QT interval effects of cisapride in the clinical setting

PURPOSE

The clinical effect of cisapride on QT intervals was prospectively studied.

SUBJECTS

Consecutive adult patients were recruited in whom cisapride was indicated for gastroesophogeal reflux, gastric ulcer, duodenal ulcer, diabetic gastroparesis or chronic constipation refractory to laxatives. Exclusion criteria included disorders and medications affecting cardiac conduction, electrolyte homeostasis, drug clearance and membrane stability.

METHODS

Seventy-five patients were included and followed at 1 to 2 week intervals. Patients took cisapride 5 mg thrice daily for 1 to 4 weeks (lower dose stage), followed by 10 mg thrice daily for another 1 to 4 weeks (higher dose stage). Twelve-lead ECGs were performed before commencing cisapride (group B), at completion of the lower dose stage (group L) and at completion of the higher dose stage (group H).

RESULTS

No patients experienced presyncope or syncope. Seventeen patients failing to comply, and 7 complaining of abdominal discomfort or diarrhea were excluded, leaving 51 participants. Group H's corrected QT interval (QTc) was longer than group B's by 13+/-15 ms (P<0.001), and longer than group L's by 7+/-11 ms (P<0.001). Group L's QTc was longer than group B's by 7+/-21 ms (P<0.05). QT dispersion did not differ significantly among groups. Neither torsade de pointe nor ventricular tachycardia were noted in Holter monitoring of 33 patients during the higher dose stage.

CONCLUSION

cisapride dose-dependently prolongs the QT interval. Further study is needed to examine the arrhythmogenicity of cisapride in higher doses and for longer durations.

The heterogeneous nuclear ribonucleoprotein K (hnRNP K) interacts with dengue virus core protein

Heterogeneous nuclear ribonucleoprotein K (hnRNP K), a component of hnRNP particles, is involved in several steps of gene expression regulation. Dengue (DEN) virus, a member of the Flaviviridae, is the primary cause of illnesses such as dengue fever, dengue hemorrhagic fever, and dengue shock syndrome. In mature DEN virus particles, the core protein is a structural protein that forms a nucleocapsid complex with genomic RNA. Very little of its biologic functions is known. Here, using an in vitro binding assay and coimmunoprecipitation analysis, we report a protein-protein interaction between the DEN virus core protein and hnRNP K. The C-terminal hydrophilic region of the DEN virus core protein, spanning amino acid residues 73 to 100, is required for such interaction. Results of glutathione-S transferase binding assays indicated that the core protein-hnRNP K interaction might be abolished in the presence of hnRNP K cognate nucleic acids. Furthermore, in a cotransfection experiment, the repressive effect of hnRNP K on C/EBPbeta-mediated transcription activation could be reversed by full-length DEN virus core protein but not by a truncated form containing amino acids 1-72. Our results suggest that, on DEN virus infection, the multiple functions of cellular hnRNP K may be affected by the virus core protein.

Electrophysiologic characteristics of ventricular extrastimulation-induced dissipation of functional bundle branch block associated with supraventricular tachycardia

INTRODUCTION

Linking-related anterograde functional bundle branch block during supraventricular tachycardia (SVT) is due to repetitive concealed retrograde conduction of impulses from the contralateral bundle branch and can be eliminated by a critically timed premature ventricular beat (PVB). We assessed the electrophysiologic characteristics of PVB-induced dissipation of functional bundle branch block during SVT.

METHODS AND RESULTS

During SVT with functional bundle branch block, PVB was delivered from the right ventricular apex, scanning the tachycardia cycle length (CL) with 10-msec decrements in the coupling interval in 14 patients (3 AV nodal reentrant tachycardia and 11 orthodromic AV reciprocating tachycardia). Dissipation was achieved in group 1: functional right bundle branch block (RBBB) in 4, functional left bundle branch block (LBBB) in 4, and both functional RBBB and LBBB in 1 with a dissipation zone occupying 4% to 13% (mean 8.5%) of the tachycardia CL. The outer limits were 22+/-16 msec and 68+/-14 msec < tachycardia CL; the inner limits were 56+/-18 msec and 90+/-24 msec < tachycardia CL for RBBB and LBBB, respectively (both P < 0.05). Dissipation could not be achieved in group 2 (4 RBBB and 1 LBBB) due to CL-dependent bundle branch block and/or local ventricular refractoriness.

CONCLUSION

During SVT, functional bundle branch block due to "linking" often can be dissipated by timely PVB delivered from the right ventricular apex within a narrow zone of the tachycardia CL. Our findings suggest that the dissipation zone is affected by the pattern of functional bundle branch block relative to the site of PVB delivery.

Susceptibility of thyroid cancer cells to 7-hydroxystaurosporine-induced apoptosis correlates with Bcl-2 protein level

7-Hydroxystaurosporine (UCN-01) is a selective protein kinase C (PKC) inhibitor and is being developed as a novel anticancer agent. Because of reports that PKC may be involved in the pathogenesis of some forms of thyroid cancers, we examined four thyroid carcinoma lines (FRO, KAT5, NPA, and WRO). These cells were found to have different susceptibility to UCN-01 treatment, and there appeared to be a correlation between UCN-01-induced death and expression levels of endogenous Bcl-2. KAT5 cells, which normally express a low amount of Bcl-2, exhibited significantly higher sensitivity to UCN-01-induced death than the other cell lines. Of interest, susceptibility did not relate to PKC activity or its inhibition by UCN-01. In order to investigate the role of Bcl-2 in UCN-01-induced death, KAT5 cells were transfected to overexpress Bcl-2. KAT5/Bcl-2 cells were capable of conferring resistance to UCN-01-induced death. Furthermore, upregulating of Bcl-2 by 1alpha,25-dihydroxyvitamin D3 (VD3) could protect primary thyroid cell from death induced by UCN-01. Both in situ TUNEL staining and the flow cytometric analysis of cytokeratin-18 (CK18) cleavage confirmed that UCN-01 was indeed inducing apoptosis, and that this effect was inhibited by increased expression of Bcl-2. These results suggest that the Bcl-2 can block the UCN-01-activated cell death pathway and that the expression of Bcl-2 is inversely related to thyroid carcinoma cell susceptibility to UCN-01. Therefore, the analysis of the expression of apoptosis suppressors provides a basis for the use of UCN-01 in the treatment of thyroid cancer.

Interventional radiologic procedures in liver transplantation

Postoperative biliary and vascular complications contribute significantly to morbidity and mortality in liver transplantation. Interventional radiologists are an integral part of the multidisciplinary team necessary for optimizing the management of these complications. During a 15-year period, 39 cadaveric and 25 living related liver transplantations were performed at the Chang Gung Memorial hospital, Taiwan. Of 64 liver transplant recipients, 9 (3 adult and 6 pediatric) underwent 13 interventional radiological procedures for the treatment of biliary sludge-casts (n = 2), bile duct occlusion or stenosis (n = 2), hepatic veins thrombosis (n = 1), hepatic veins stenosis (n = 1), portal vein stenosis with splenorenal shunting (n = 1), biloma (n = 1), and infected fluid collection or ascites (n = 4). Antegrade or retrograde interventional approach was used to successfully treat all biliary complications, and all percutaneous drainage procedures were effective in the control of intra-abdominal fluid collections. Portal vein stenosis was treated by balloon dilatation, and the associated splenorenal shunt was closed by metallic coil embolization via transhepatic catheterization of the portal vein. Hepatic vein stenosis was effectively treated by balloon dilatation and expandable metallic stent deployment via transfemoral and jugular venous approaches, respectively. Hepatic vein thrombosis was only partially lysed by transvenous streptokinase administration, and surgical thrombectomy was needed to achieve complete recanalization. The total success rate of the interventional procedures was 92 % with no procedure-related complications. The overall survival rate in this series is 89 %, and all patients who underwent living related liver transplantation maintain to date a 100 % survival rate. We can conclude that interventional radiological procedures are very useful for managing biliary and vascular complications after liver transplantation. These techniques provide a cure in most situations, thus obviating the need for further surgical intervention or re-transplantation.

Superior rectal artery injury following lumbar disc surgery. Case report

Traumatic injury of the aorta, inferior vena cava, and iliac vessels due to penetration of the anterior anulus fibrosus and anterior longitudinal ligament is a recognized complication of lumbar disc surgery. The authors report, to the best of their knowledge, the first case of discectomy-related superior rectal artery injury treated by endovascular intervention.

Collection efficiency and capacity of three samplers for acidic and basic gases

This paper compares the collection efficiency and capacity of a coated porous metal disk with those of a silica gel tube and an impinger at the acid or basic aerosol concentration of two times the permissible exposure limitation (Taiwan IOSH, Institute of Occupational Safety and Health), relative humidity of 80 +/- 5%, and temperature of 30 +/- 3 degrees C in the laboratory. Using 5% sodium carbonate/glycerin coating, the collection efficiencies of the porous metal disk for nitric acid, hydrogen chloride, and hydrogen fluoride are found to be higher than those of the silica gel tube and the impinger when the sampling time is less than 3.0 h. The gas collection capacity of the porous metal disk coated with 5% sodium carbonate is calculated to be 3.9, 5.8, and >2.5 mg for nitric acid, hydrogen chloride, and hydrogen fluoride, respectively. For ammonia, the porous metal disk coated using 4% citric acid performs slightly better than the impinger, and the corresponding capacity is slightly greater than 33.6 mg.

In vivo measurements of ultrasonic backscattering in blood

Ultrasonic backscattering in blood including its dependence on the hematocrit, plasma proteins, shear rate, and flow disturbance, has been studied extensively theoretically and experimentally in vitro. However, much of the result has never been validated in vivo. To do so, backscattering measurements were made on pigs using a 10-MHz non-focused intravascular transducer in direct contact with blood. The probe was placed in either the abdominal aorta or the inferior vena cava. The backscattering coefficient (BSC) of blood flowing in these vessels as well as downstream from a stenosis was measured using an approach that was originally developed for measurements with focused transducers. With this approach, 6% porcine red cell saline suspensions prepared immediately after each in vivo measurement were used as the reference medium. Result from seven pigs at hematocrits ranging from 29 to 36% (31.9 +/- 2.5%) demonstrated that BSC of blood in the vena cava, (4.62 +/- 2.06) x 10(-5) cm-sr-1, is consistently higher than that in the aorta, (2.65 +/- 1.22) x 10(-5) cm-sr-1. The difference has been attributed to the lower shear rate and the formation of red cell aggregation in venous blood. These in vivo results are in agreement with those obtained in vitro. In response to stenoses created by ligating the aorta, backscattering of the blood measured downstream from the stenosis showed that the closer the site of measurement relative to the stenosis, the higher the backscatter, presumably resulting from the higher degree of flow disturbance. In vitro backscattering results on porcine whole blood were also acquired at 20 MHz with a Diasonics intravascular scanner.

Biliary complications in living related liver transplantation

BACKGROUND

Biliary tract reconstruction has long been considered the Achilles' heel of liver transplantation as biliary complications can increase morbidity and mortality especially in partial liver graft transplantation.

METHODS

Thirty-four living related liver transplants were performed at Chang Gung Memorial Hospital in Kaohsiung for 33 children and 1 adolescent during a 5.5-year period. All potential donors underwent a detailed preoperative imaging study of the vascular and biliary anatomy, including three-dimensional helical computed tomographic cholangiography (n = 20), magnetic resonance cholangiography (n = 14), and intra-operative cholangiography (n = 31) before graft retrieval. All hepatic artery anastomoses were performed in the standard microsurgery fashion and their patency was confirmed intra-operatively using Doppler ultrasound.

RESULTS

The biliary complication rate was 8.8% (3/34), including multiple intrahepatic biliary stenosis of unknown origin (n = 1), bile leakage from the Roux-en-Y loop (n = 1), and a missed biliary radicle (n = 1) which were treated via interventional radiological and surgical procedures. The overall graft and patient survival rates were 100%.

CONCLUSION

The biliary complication rate in this series was low compared to those of other experienced centers. Complete study of the variations of intrahepatic duct ramification pre-and-intra-operatively provided adequate information on the appropriate transection plane. Furthermore, intra-operative Doppler ultrasound verification of vessel patency helps prevent vascular complications, which has been identified as a cause of biliary complications.

[Development of a canine adenovirus type 1 vaccine strain E3-deleted based expression vector]

OBJECTIVE

To evaluate canine adenovirus type 1 vaccine strain (Cannaught Laboratory Limited, CLL) as recombinant vaccine and gene transfer vector.

METHODS

Recombinant virus CLLEGFP which contains enhanced green fluorescent protein(EGFP) reporter gene was constructed. CLLEGFP was used to infect various human derived cell lines(293, Hela, CO, SW, Hep-2 and CAM) by inoculating intraperitoneally(i.p.), intravenously(i.v.) and intramuscularly (i.m.) to Kunming mice other than oral administration. Various tissue samples of the mice were collected at multi-time point for observing EGFP green fluorescence. Anti-EGFP antibodies were detected by Western blot analysis in the sera after 4 weeks.

RESULTS

CLLEGFP can infect various human derived cell lines and express EGFP. EGFP green fluorescence were observed in liver tissue cells after i.p. transducing 3 days. All immune inoculation ways above could induce Kunming mice producing anti-EGFP antibodies which were identified by Western blot analysis.

CONCLUSIONS

These results indicate that CLL possess powerful potential as recombinant vaccine and gene transfer vector.

A linear relation between the compressibility and density of blood

By considering the blood as a mixture of ultrafiltrate and protein concentrate, the additive nature of compressibility and density from the components is utilized to deduce a linear relation between the compressibility and density for blood. This deduction also indicates that the intercept and slope of the linear relation are independent of the hematocrit, plasma protein concentration, and hemoglobin concentration of red blood cells. To verify experimentally this linear relation, saline and plasma dilutions on porcine or canine blood flowing in an extracorporeal circuit were carried out. The hematocrit of the experiments ranges from 0% to 55% and the plasma protein concentration ranges from 10 to 90 g/l. A resonance device in the circuit measured the density rhob of blood at 37 degrees C and an ultrasound system measured the sound velocity cb. The range of density is from 1,010 to 1,060 g/l and that of sound velocity is from 1,530 to 1,580 m/s. The linear relation that best fits the data of compressibility [computed as (rhob cb(2))-1] and density has a correlation coefficient of 0.9978. The linear relation is found to fit well the dependence of compressibility on density derived from the sound velocity data of human, horse, and porcine blood in the literature.

Differential roles of iNOS and nNOS at rostral ventrolateral medulla during experimental endotoxemia in the rat

We investigated the differential contribution of inducible and neuronal nitric oxide synthase (iNOS and nNOS) at the rostral ventrolateral medulla (RVLM) to endotoxemia induced by E. coli lipopolysaccharide (LPS). In Sprague-Dawley rats maintained under propofol anesthesia, i.v. administration of LPS (15, 30, or 45 mg/kg) induced a reduction (phase I), followed by an augmentation (phase II) and a secondary decrease (phase III) in the power density of the vasomotor components (0-0.8 Hz) in systemic arterial pressure (SAP) signals. LPS also induced an immediate hypotension, followed by a rebound increase and a secondary decrease in SAP. In addition, the level of iNOS mRNA exhibited a significant surge that began with phase I endotoxemia, reaching progressively its peak at phase III. Discernible down-regulation of nNOS mRNA was not detected until the last phase of endotoxemia. Pretreatment with microinjection of the selective iNOS inhibitor, aminoguanidine (250 pmol), into the bilateral RVLM significantly prolonged phases II and III endotoxemia, blunted the initial and secondary hypotension, and antagonized the upregulation of iNOS mRNA. Similar pretreatment with the selective nNOS inhibitor, 7-nitroindazole (1 pmol), on the other hand, discernibly shortened phase II and prolonged phase III endotoxemia, and induced progressive hypotension by antagonizing the rebound increase in SAP. We conclude that the relative prevalence of functional expression and molecular synthesis of iNOS over nNOS in the RVLM may be a crucial determinant for the reduction or loss in power density of the vasomotor components of SAP signals during experimental endotoxemia.

Outflow tract reconstruction in living donor liver transplantation

BACKGROUND

Hepatic venous reconstruction is critical in living donor liver transplantation because outflow obstruction may lead to graft dysfunction or loss. We describe our experience and analyze outcomes with a technique of creating a single outflow tract using venoplasties of the graft and recipient hepatic veins.

PATIENTS AND METHODS

A retrospective study was done on 38 consecutive living donor liver transplants performed from June 1994 to March 2000. The grafts included 36 left-side grafts and 2 right-side grafts. Nine grafts had multiple hepatic veins and required a venoplasty of two or three hepatic veins to create a single outflow orifice. Triple recipient hepatic venoplasty was performed in 32 patients, double venoplasty in 5 and none in 1.

RESULTS

There were four cases of outflow obstruction, three occurring in patients with a double recipient venoplasty. Two of the problems were remedied intraoperatively by adjusting the position of the graft although two were structural in nature and required the insertion of expandable metallic vascular stents. All donors and recipients with their original grafts are alive at a mean follow-up period of 27 months.

CONCLUSION

A triple recipient venoplasty with a matching venoplasty of multiple graft hepatic veins to create a single wide outflow orifice is recommended in living donor liver transplantation using left side grafts.

Dual role for Drosophila epidermal growth factor receptor signaling in early wing disc development

Cell fate decisions in the early Drosophila wing disc assign cells to compartments (anterior or posterior and dorsal or ventral) and distinguish the future wing from the body wall (notum). Here we show that EGF-receptor (EGFR) signaling stimulated by its ligand, Vein, has a fundamental role in regulating two of these cell fate choices: (1) Vn/EGFR signaling directs cells to become notum by antagonizing wing development and by activating notum-specifying genes; (2) Vn/EGFR signaling directs cells to become part of the dorsal compartment by induction of apterous, the dorsal selector gene, and consequently also controls wing development, which depends on an interaction between dorsal and ventral cells.

Distinct accumbal subareas are involved in place conditioning of amphetamine and cocaine

In considering the heterogeneous function of the nucleus accumbens (NAC), the present work evaluated the conditioned place preference (CPP) after local infusion of d-amphetamine (AMP; 10, 15 microg/side) or cocaine (COC; 50, 100 microg/side) into two subareas of NAC, core and shell. A regular two-compartment CPP apparatus was used to test the place conditioning effects after 6 pairings of drug in one compartment and 6 pairings of vehicle in the other one. Significant CPP was observed with either AMP infused in the core area or COC infused into the shell area. Neither AMP in shell nor COC in core significantly produced CPP. These results indicate important differences between two neural substrates within NAC for the rewarding effects of AMP and COC on the CPP task.

International sharing of split liver grafts in Asia: initial experience

The donor shortage problem is particularly serious in Asia and has markedly limited progress in liver transplantation. The increasing demand has, in fact, made it necessary to resort to living donor liver transplantation in both pediatric and adult recipients. Nevertheless, expanding the use of split liver allografts is yet another option to increase the supply. This has a wide potential application on a regional level because most liver transplant programs are still small and may have limited resources in terms of being able to do two transplants in one sitting. The first experience of overseas sharing of split liver grafts in Asia took place in January 1999. The graft was from a 35-yr-old donor from Kaohsiung, Taiwan, who sustained irreversible brain damage in a vehicular accident and had optimal conditions for multiorgan donation. The liver was split ex vivo and the left lateral segment was given to a 3-yr-old girl with biliary atresia at the Chang Gung Memorial Hospital. The extended right lobe split graft was transported to Hong Kong and transplanted into a 51-yr-old male patient with end-stage hepatitis C cirrhosis who was then in a state of acute failure with hepatorenal syndrome. Graft function was excellent in both recipients and the patient from Taiwan was discharged without any complications. Unfortunately, the Hong Kong recipient developed a cerebrovascular accident and required a reoperation for bile leakage from the cut surface of the liver in the early postoperative period. He has made a steady recovery since then; graft function has remained good and his kidneys have recovered. Both patients are currently alive and well 11 months post-transplant. This initial experience of overseas sharing of split liver grafts in Asia demonstrates its feasibility. It has a potentially wide applicability and could lead to the establishment of a formal organ-sharing network in the region. Established competence and mutual trust among the participating liver transplant teams would be essential in perpetuating such a graft-multiplying strategy on an organized basis.

2-Methoxyestradiol, an endogenous estrogen metabolite, induces thyroid cell apoptosis

The etiology of autoimmune thyroid diseases is unclear; however, the extreme female predominance suggests that sex hormones may have a pathogenic role. 2-Methoxyestradiol (2-ME) is present in the serum of women during the ovulatory and luteal phases of the menstrual cycle, and during pregnancy. We investigated the actions of 2-ME and estrogen on thyroid follicular cells. 2-ME induced dramatic changes in cell morphology and decreased the viability of the cells, as well as disrupted the structural integrity of cultured thyroid follicles. Flow cytometric analysis showed that 2-ME halted cell proliferation by arresting the cells in the G2/M cell-cycle compartment. Prolonged exposure to 2-ME led to apoptosis and to increased release of the autoantigen thyroid peroxidase (TPO). 17beta-estradiol failed to produce a similar effect even in 40-fold molar excess to 2-ME. Co-treatment with estrogen receptor antagonists did not alter the 2-ME effect, indicating that 2-ME was not operating through a classic nuclear estrogen receptor. In conclusion, this study indicates that 2-ME induces G2/M cycle arrest, apoptosis and the disruption of thyroid follicles. This process results in the release of thyroid antigens that may play a role in high incidence of thyroid autoantibodies and autoimmune thyroid disease in women.

Position 13 analogs of the tridecapeptide mating pheromone from Saccharomyces cerevisiae: design of an iodinatable ligand for receptor binding

Analogs of the alpha-factor tridecapeptide mating pheromone (WHWLQLKPGQPMY) from Saccharomyces cerevisiae in which Tyr13 was replaced with Phe, p-F-Phe, m-F-Phe, p-NO2-Phe, p-NH2-Phe or Ser were synthesized and purified to >99% homogeneity. These analogs were bioassayed using a growth arrest assay and a gene induction assay and evaluated for their ability to compete with binding of tritiated alpha-factor to its receptor Ste2p. The results showed that the phenolic OH of Tyr13 is not required for either biological activity or receptor recognition. Analogs containing fluorine, amino, nitro or a hydrogen in place of OH had 80-120% of the biological activity of the parent pheromone in the gene induction assay and had receptor affinities from nearly equal to 6-fold lower than that of alpha-factor. In contrast, substitution of Ser or Ala at position 13 resulted in a >100-fold decrease in receptor affinity suggesting that the aromatic ring is involved in binding to the receptor. The lack of a strict requirement for Tyr13 allowed the design of several multiple replacement analogs in which Phe or p-F-Phe were substituted at position 13 and Tyr was placed in other positions of the peptide. These analogs could then be iodinated and used in the development of a highly sensitive receptor-binding assay. One potential receptor ligand [Tyr(125I)1,Nle12, Phe13] alpha-factor exhibited saturable binding with a KD of 81 nM and was competed by alpha-factor for binding in a whole-cell assay. Thus a new family of radioactive ligands for the alpha-factor receptor has been revealed. These ligands should be extremely useful in defining active site residues during mutagenesis and cross-linking studies.

High-frequency backscatter and attenuation measurements of selected bovine tissues between 10 and 30 MHz

There are now diagnostic ultrasonic imaging devices that operate at very high frequencies (VHF) of 20 MHz and beyond for clinical applications in ophthalmology, dermatology, vascular surgery, endoluminal imaging and small animal imaging. To be able to better interpret these images and to further the development of these devices, knowledge of ultrasonic attenuation and scattering of biological tissues in this frequency range is crucial. Attenuation and backscatter coefficients (BSCs) of bovine tissues in the frequency range of 10 to 30 MHz were measured, respectively, using a standard substitution method for attenuation measurements and a modified narrow-band substitution method for scattering measurements. A modified substitution method for scattering measurements has to be used at high frequencies because unfocused transducers due to their decreased sensitivity cannot be used in the simple substitution method. In the modified method, the flat reflector is substituted by a particulate reference medium whose BSC is well-known and documented; in this case, a red cell suspension. In this paper, experimental results on BSC and attenuation coefficient measured between 10 and 30 MHz are reported. The frequency dependence of backscatter of the selected bovine tissues ranges from 2.4 to 3.5, whereas attenuation is observed to be still approximately linearly proportional to frequency. The BSC measured with the modified method is in good agreement with those obtained with the standard method between 10 and 20 MHz.

Minimal blood loss living donor hepatectomy

BACKGROUND

Donor hepatectomy with maximal safety while preserving graft viability is of principal concern in living donor liver transplantation. There are compelling reasons for avoiding blood transfusion, even with autologous blood, to avoid the potential risks it imposes on healthy donors. This study aims to describe the surgical technique and clinical outcomes of living donor hepatectomy with minimal blood loss requiring no blood transfusion.

METHODS

Donor hepatectomy was performed in 30 living donors according to a detailed preoperative imaging study of the vascular and biliary anatomy. Liver parenchymal transection was carried out with strict adherence to a meticulous surgical technique without vascular inflow occlusion to either side of the liver. Pre-, intra-, and postoperative data were gathered, and factors related to blood loss were analyzed retrospectively.

RESULTS

The intraoperative blood loss ranged from 20 to 300 ml with a mean of 72.0+/-58.9 ml (median, 55 ml), and neither homologous nor autologous blood transfusion was required in any of the donors intra- and postoperatively. All 30 donors were discharged with minimal complications, and remain well at a mean follow-up of 24 months after donation. Excellent graft viability was verified by the fact that all 30 recipients are alive and well with a few manageable complications. The actual graft and patient survival are both 100% at the time of writing.

CONCLUSIONS

Regardless of the extent of donor hepatectomy, blood loss can and should be kept to a minimum, and living donor hepatectomy without blood transfusion is a realistic objective.

Repeated hypotensive episodes due to hepatic outflow obstruction during liver transplantation in adult patients

We report two cases of unusual repeated hypotension, decreased cardiac output, decreased mixed venous oxygen saturation, decreased central venous pressure, pulmonary artery pressure, and pulmonary wedge pressure after the completion of all vascular anastamoses of liver transplantation. These unstable hemodynamics appear to reflect a clinically relevant picture of hypovolemia. However, the real cause was partial hepatic outflow obstruction. The obstruction was suspected because hypotension was alleviated by elevating the full-sized liver graft ventrally and to the left. Doppler ultrasound examination confirmed that the flow velocity of the hepatic vein outflow was insufficient when the liver fell to its resting position in the right hepatic fossa. An additional side-to-side cavo-caval anastomosis resolved the problem in one patient, whereas the other required not only the additional anastomosis, but also application of a tissue expander filled with 770 mL normal saline beneath the liver to eliminate the obstruction. We emphasize that obstruction of the hepatic outflow causes only temporal hypovolemia because of a decrease of venous return and that treatment of this complication should be surgical intervention to relieve the obstruction. Blind resuscitation with fluids will not solve the problem and, in fact, may result in fluid overload with subsequent complications.