A data resource from concurrent intracranial stimulation and functional MRI of the human brain

Mapping the causal effects of one brain region on another is a challenging problem in neuroscience that we approached through invasive direct manipulation of brain function together with concurrent whole-brain measurement of the effects produced. Here we establish a unique resource and present data from 26 human patients who underwent electrical stimulation during functional magnetic resonance imaging (es-fMRI). The patients had medically refractory epilepsy requiring surgically implanted intracranial electrodes in cortical and subcortical locations. One or multiple contacts on these electrodes were stimulated while simultaneously recording BOLD-fMRI activity in a block design. Multiple runs exist for patients with different stimulation sites. We describe the resource, data collection process, preprocessing using the fMRIPrep analysis pipeline and management of artifacts, and provide end-user analyses to visualize distal brain activation produced by site-specific electrical stimulation. The data are organized according to the brain imaging data structure (BIDS) specification, and are available for analysis or future dataset contributions on openneuro.org including both raw and preprocessed data.

Detection of serum melanoma-associated antigen D4 in patients with squamous cell carcinoma of the esophagus

Despite improvements in surgical techniques, perioperative management, and multidisciplinary therapy, treatment outcomes of patients with esophageal squamous cell carcinoma (ESCC) remain poor. Therefore, development of novel molecular biomarkers, which either predict patient survival or become therapeutic targets, is urgently required. In the present study, to facilitate early detection of ESCC and predict its clinical course, we investigated the relationship of the serum level of melanoma-associated antigen (MAGE)-D4 to patients' clinicopathological characteristics. Using quantitative real-time reverse transcription-polymerase chain reaction and enzyme-linked immunosorbent assays, we determined the levels of MAGE-D4 mRNA and protein in cell lysates and conditioned medium of cultures, respectively, of nine ESCC cell lines. Further, we determined MAGE-D4 levels in serum samples collected from 44 patients with ESCC who underwent radical esophagectomy without neoadjuvant therapy as well as from 40 healthy volunteers. Samples of conditioned medium and cell lysates contained comparable levels of MAGE-D4 that correlated closely with the levels of MAGE-D4 mRNA. Preoperative MAGE-D4 levels in the sera of 44 patients with ESCC, which varied from 0 to 2,354 pg/mL (314 ± 505 pg/mL, mean ± standard deviation), were significantly higher compared with those of healthy volunteers. By setting the cutoff at the highest value for healthy volunteers (50 pg/mL), the MAGE-D4-positive group of patients was more likely to have shorter disease-specific and disease-free survival compared with those of the MAGE-D4-negative group, although the differences were not statistically significant. Our results indicate that the elevation of preoperative serum MAGE-D4 levels in some patients with ESCC was possibly caused by excess production of MAGE-D4 by tumor cells followed by its release into the circulation. Clinical implications of serum MAGE-D4 levels should be validated in a large population of patients with ESCC.

Salvage pharyngolaryngectomy with total esophagectomy following definitive chemoradiotherapy

Historically, total pharyngolaryngectomy with total esophagectomy has been the standard radical surgical treatment for synchronous cancer of the thoracoabdominal esophagus and pharyngolaryngeal region, and for cancer of the cervical esophagus that has invaded as far as the thoracic esophagus. Although definitive chemoradiotherapy that enables preservation of the larynx has often been the first choice of treatment for cancers involving the cervical esophagus, total pharyngolaryngectomy with total esophagectomy is required as a salvage therapy for cases involving failure of complete remission or locoregional recurrence after chemoradiotherapy. However, salvage esophageal surgery after definitive high-dose chemoradiotherapy is generally associated with high morbidity and mortality. The aim of this study was to examine the short-term outcome of salvage total pharyngolaryngectomy with total esophagectomy. From 2001 to 2014, nine patients underwent salvage total pharyngolaryngectomy with total esophagectomy at the Department of Gastroenterological Surgery, Nagoya University. The mortality and morbidity rates were high at 22% and 89%, respectively. Four patients (44%) developed tracheal necrosis, which in two patients eventually led to lethal hemorrhage. Salvage total pharyngolaryngectomy with total esophagectomy is an uncommon and highly demanding surgical procedure that should be carefully planned and conducted in selected centers of excellence. Measures must be taken to preserve the tracheal blood supply, thus avoiding fatal complications.

High-gamma band fronto-temporal coherence as a measure of functional connectivity in speech motor control

The neural basis of human speech is unclear. Intracranial electrophysiological recordings have revealed that high-gamma band oscillations (70-150Hz) are observed in the frontal lobe during speech production and in the temporal lobe during speech perception. Here, we tested the hypothesis that the frontal and temporal brain regions had high-gamma coherence during speech. We recorded electrocorticography (ECoG) from the frontal and temporal cortices of five humans who underwent surgery for medically intractable epilepsy, and studied coherence between the frontal and temporal cortex during vocalization and playback of vocalization. We report two novel results. First, we observed high-gamma band as well as theta (4-8Hz) coherence between frontal and temporal lobes. Second, both high-gamma and theta coherence were stronger when subjects were actively vocalizing as compared to playback of the same vocalizations. These findings provide evidence that coupling between sensory-motor networks measured by high-gamma coherence plays a key role in feedback-based monitoring and control of vocal output for human vocalization.

Laparoscope-assisted Hassab's operation for esophagogastric varices after living donor liver transplantation: a case report

This is the first successful report of a laparoscope-assisted Hassab's operation for esophagogastric varices after living donor liver transplantation (LDLT). A 35-year-old man underwent LDLT using a right lobe graft as an aid for primary sclerosing cholangitis (PSC) in 2005. Follow-up endoscopic and computed tomography (CT) examinations showed esophagogastric varices with splenomegaly in 2009 that increased (esophageal varices [EV]: locus superior [Ls], moderator enlarged, beady varices [F2], medium in number and intermediate between localized and circumferential red color signs [RC2]; gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], moderator enlarged, beady varices [F2], absent red color signs [RC0]). A portal venous flow to the esophagogastric varices through a large left gastric vein was also confirmed. Preoperative Child-Pugh was grade B and score was 9. Because these esophagogastric varices had a high risk of variceal bleeding, we proceeded with a laparoscope-assisted Hassab's operation. Operative time was 464 minutes. Blood loss was 1660 mL. A graft liver biopsy was also performed and recurrence of PSC was confirmed histologically. It was suggested that portal hypertension and esophagogastric varices were caused by recurrence of PSC. Postoperative complications were massive ascites and enteritis. Both of them were treated successfully. This patient was discharged on postoperative day 43. Follow-up endoscopic study showed improvement in the esophagogastric varices (esophageal varices [EV]: locus superior [Ls], no varicose appearance [F0], absent red color signs [RC0], gastric varices [GV]: adjacent to the cardiac orifice [Lg-c], no varicose appearance [F0], absent red color signs [RC0]) at 6 months after the operation. We also confirmed the improvement of esophagogastric varices by serial examinations of CT.

Apparatus for simulating dynamic interactions between the spinal cord and soft-coupled intradural implants

We have designed, built, and tested an apparatus used for investigating the biomechanical response of a novel intradural spinal cord stimulator to the simulated physiological movement of the spinal cord within the thecal sac. In this apparatus, the rostral-caudal displacements of an anthropomorphic spinal cord surrogate can be controlled with a resolution of approximately 0.1% of a target value for up to 10(7) lateral movement cycles occurring at a repetition rate of 2 Hz. Using this system, we have been able to determine that the restoring force of the stimulator's suspension system works in concert with the frictional coupling between the electrode array and the surrogate to overcome the 0.42 μN inertial force associated with the lateral motion of the array. The result is a positional stability of the array on the surrogate (in air) of better than 0.2 mm over ~500,000 movement cycles. Design modifications that might lead to improved physiological performance are discussed.

Overexpression of melanoma-associated antigen D4 is an independent prognostic factor in squamous cell carcinoma of the esophagus

To pursue an urgently needed treatment target for esophageal cancer (EC), we investigated the function of the recently discovered melanoma-associated antigen (MAGE)-D4 in squamous cell EC. MAGE-D4 messenger RNA (mRNA) expression was analyzed in nine EC cell lines using quantitative reverse transcription polymerase chain reaction. In 65 surgical specimens of squamous cell EC with no prior neoadjuvant therapy, MAGE-D4 mRNA expression in EC tissues and corresponding normal tissues was analyzed and compared, and evaluated in terms of clinicopathological factors. In representative cases, MAGE-D4 protein distribution was analyzed immunohistochemically. The heterogeneity of MAGE-D4 mRNA expression was confirmed in EC cell lines by quantitative reverse transcription polymerase chain reaction. In surgical specimens, MAGE-D4 mRNA expression was significantly higher in EC tissues than in corresponding normal tissues (P < 0.001). Patients with the highest MAGE-D4 mRNA expression in EC tissues (top quartile, n = 17) had significantly shorter overall survival than patients with low expression (2-year survival: 44% and 73%, respectively, P = 0.006). Univariate analysis identified age (≥65 years), lymphatic involvement, and high MAGE-D4 mRNA expression as significant prognostic factors; high MAGE-D4 mRNA expression was also an independent prognostic factor in multivariable analysis (hazard ratio: 2.194; P = 0.039) and was significantly associated with Brinkman index (P = 0.008) and preoperative carcinoembryonic antigen level (P = 0.002). Immunohistochemical MAGE-D4b expression was consistent with MAGE-D4 mRNA profiling. Our results suggest that MAGE-D4 overexpression influences tumor progression, and MADE-D4 can be a prognostic marker and a potential molecular target in squamous cell EC.

Functional connection between posterior superior temporal gyrus and ventrolateral prefrontal cortex in human

The connection between auditory fields of the temporal lobe and prefrontal cortex has been well characterized in nonhuman primates. Little is known of temporofrontal connectivity in humans, however, due largely to the fact that invasive experimental approaches used so successfully to trace anatomical pathways in laboratory animals cannot be used in humans. Instead, we used a functional tract-tracing method in 12 neurosurgical patients with multicontact electrode arrays chronically implanted over the left (n = 7) or right (n = 5) perisylvian temporal auditory cortex (area PLST) and the ventrolateral prefrontal cortex (VLPFC) of the inferior frontal gyrus (IFG) for diagnosis and treatment of medically intractable epilepsy. Area PLST was identified by the distribution of average auditory-evoked potentials obtained in response to simple and complex sounds. The same sounds evoked little if there is any activity in VLPFC. A single bipolar electrical pulse (0.2 ms, charge-balanced) applied between contacts within physiologically identified PLST resulted in polyphasic evoked potentials clustered in VLPFC, with greatest activation being in pars triangularis of the IFG. The average peak latency of the earliest negative deflection of the evoked potential on VLPFC was 13.48 ms (range: 9.0-18.5 ms), providing evidence for a rapidly conducting pathway between area PLST and VLPFC.

De novo ulcerative colitis and autoimmune hepatitis after living related liver transplantation from cytomegalovirus-positive donor to cytomegalovirus-negative recipient: a case report

BACKGROUND

De novo autoimmune hepatitis (AIH) after liver transplantation (OLT) has been reported; however, de novo ulcerative colitis (UC) combined with AIH after OLT is rare.

MATERIALS AND METHODS

We report a patient who suffered de novo UC with AIH after living related OLT (LRLT) due to fulminant hepatitis using a cytomegalovirus (CMV)-positive donor to a CMV-negative recipient.

RESULTS

A 32-year-old man underwent LRLT due to fuluminant hepatis 4 years prior. He was admitted for colitis with diarrhea, abdominal pain, and high fever in March 2010. The abdominal computed tomography revealed severe jejunal edema. Anti-infectious therapies for bacterial, fungal, and CMV cases were ineffective. Small bowel endoscopy demonstrated erosion, redness, ulceration, and edema from the stomach to the jejunum. However, the origin of the colitis was not clear. Thereafter he displayed melena with a high fever and abdominal pain. The colon revealed diffuse inflammation with pseudopolyposis. De novo UC or CMV infection was suspected. His symptoms improved upon administration of salazopyrin and denosine. Moreover, he suffered de novo AIH, which was diagnosed by liver biopsy 3 months after the de novo UC. Steroid therapy improved the AIH.

CONCLUSIONS

It has been reported that CMV is involved with UC and rejection. Our case suggested that CMV might induce de novo UC or AIH in CMV-negative recipients.

Regulatory T-cell activation among patients who displayed operational tolerance following intra-portal administration of donor-specific antigens in living donor liver transplantation

Immunologic tolerance is the goal for all transplant surgeons. We have reported that repeated donor-specific antigen transfusion (DST) via the portal vein allowed rapid reduction of immunosuppressants with decreased acute cellular rejection episodes among living donor liver transplantations (LDLT). Moreover, we demonstrated that intraportal DST induced macrochimerism of donor type CD56+ T cells in the liver graft. We examined the impact of FoxP3+CD4+CD25+ T cells in recipients who acquired almost tolerance after LDLT with intraportal DST. We defined the amount of immunosuppressants administered less than one time per week as "almost tolerance" after LDLT, which occurred among 14% of DST patients after adult-to-adult LDLT. Two patients (4%) have gotten been we used from immunosuppressants more than 2 years after LDLT 4 years prior. We examined the impact of FoxP3+CD4+CD25+ T cells both in recipients with almost daily immunosuppressants and those who acquired almost tolerance. The proportion of FoxP3+/CD4+CD25+ T cells in the almost tolerance group was significantly higher than that in the almost daily immunosuppressant group (P<.05). The increased proportion of FoxP3+/CD4+CD25+ T cells significantly correlated with time after LRLT (y=0.0964x+42.02, R2=0.8854). Repeated intraportal DST may be a goot tool to induce immunologic tolerance after LDLT. Both donor type CD56+ T cells and FoxP3+/CD4+CD25+ T cells may act as important regulatory cells for tolerance. The period after LDLT is important for acquiring immunologic tolerance.

The inferior mesenteric vein to the left gonadal vein shunt for gastroesophageal varices and extrahepatic portal vein thrombosis after living donor liver transplantation: a case report

This 59-year-old woman underwent living donor liver transplantation using a left lobe graft as an aid for autoimmune hepatitis in 2003. Splenectomy was also performed because of blood type incompatibility. Follow-up endoscopic and computed tomography examinations showed gastroesophageal varices with extra hepatic portal vein thrombosis in 2007 that increased (esophageal varices [EV]: locus superior [Ls], moderately enlarged, beady varices [F2], Blue varices [Cb], presence of small in number and localized red color sign [RC1] and telangiectasia [TE+], gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], moderately enlarged, beady varices [F2], white varices [Cw], absence of red color sign [RC-]). Portal venous flow to the gastroesophageal varices was also confirmed from a large right gastric vein. The splenic vein was thrombosed. Blood flow to the liver graft was totally supplied from the hepatic artery. The graft was functioning well. Because these gastroesophageal varices had a high risk of variceal bleeding, we decided to proceed with a portal reconstruction of a surgical portosystemic shunt in 2008. Severe adhesions were observed around the portal vein. It was impossible to perform portal reconstruction. There were relatively fewes adhesious in the left lower side of the abdominal cavity. We decided to create an inferior mesenteric vein to left gonadal vein shunt. The portal vein pressure decreased from 31.0 to 21.5 cm H2O thereafter. The postoperative course was smooth without any complication. This patient was discharged on the postoperative day 15. Follow-up endoscopic study showed the improvement in the gastroesophageal varices (EV: Ls, F2, Cb, RC(-), GV: Lg-c, F2, Cw, RC-) at 3 months after the operation. We also comfirmed the patency of the shunt by serial computed tomography examinations.

Magnetic compression anastomosis for bile duct stenosis after donor left hepatectomy: a case report

Magnetic compression anastomosis (MCA) provides a minimally invasive treatment creating a nonsurgical, sutureless enteric anastomosis in conjunction with an interventional radiologic technique by using 2 high-power magnets. Recently, the MCA technique has been applied to bile duct strictures after living donor liver transplantation or major hepatectomy. Herein we described use of MCA for bile duct stenosis 5 months after donor left hepatectomy in a 24-year-old man who presented with a stricture at the porta hepatis and intrahepatic bile duct dilatation. Unsuccessful transpapillary biliary drainage and balloon dilatation through a percutaneous transhepatic biliary drainage (PTBD) route led to the MCA. A 4-mm-diameter cylindrical samarium-cobalt (Sm-Co) daughter magnet with a long nylon wire was placed at the superior site of the obstruction through the PTBD route. A 5-mm-diameter Sm-Co parent magnet with an attached nylon handle was endoscopically inserted into the common bile duct and placed at the inferior site of obstruction. The 2 magnets were attracted, sandwiching the stricture and establishing a reanastomosis. In conclusion, the MCA technique was a unique procedure for choledochocholedochostomy in a patient with bile duct stenosis after donor hepatectomy.

The new method of time-lag ligation for portosystemic shunt using coronary artery bypass graft occluder for adult living donor liver transplantation

We performed a living donor liver transplantation (LDLT) for a 57-year-old man who had end-stage liver failure with portal hypertension and an inferior mesenteric vein-left testicular vein (IMV-LTV) shunt. At operation, we did not clamp the shunt but encircled it with a coronary artery bypass graft (CABG) occluder (Sumitomo Bakelite K.K., Japan), which was passed outside the body through the abdominal wall to time-lag ligation (TLL). On postoperative day (POD) 5, we observed decreased portal flow. We performed TLL of the shunt using the CABG occluder without re-laparotomy. The portal flow increased, while the portal vein pressure increased slightly. In LDLT, portosystemic shunt has been reported to be a cause of portal thrombus formation or graft liver atrophy due to decreased PV flow in the mid postoperative period. However, perioperative ligation of a portosystemic shunt may prevent regeneration of the grafted liver because of excessive portal hypertension. Therefore the technique of time-lag ligation of a portosystemic shunt using a CABG occluder may be a minimally invasive, useful method to achieve physiological liver graft regeneration.

Feasibility of auxiliary partial living donor liver transplantation for fulminant hepatic failure as an aid for small-for-size graft: single center experience

Auxiliary partial orthotopic liver transplantation (APOLT) or heterotopic auxiliary partial liver transplantation (HAPLT) was initially indicated for potentially reversible fulminant hepatic failure (FHF). We started auxiliary partial living donor liver transplantation (LDLT) for FHF in February 2002. Since then, 5 FHF patients (3 females and 2 males) underwent auxiliary partial LDLT: 3 cases of APOLT and 2 cases of HAPLT. All of them received a small-for-size graft: graft-to-recipient weight ratio (GRWR) < or = 1.0%. The etiologies of FHF were hepatitis B virus (HBV) in 1, Wilson's disease in 1, and unknown origin in 3 cases. Three were the acute type and 2 the subacute type of FHF. Median age was 45 years (range, 14-54 years). Blood type was identical in all cases. A left lobe graft was used in 4 instances and a right lobe graft in 1 case. Median GRWR was 0.74 (range, 0.42-0.85). Median follow-up was 42 months (range, 3 days to 70 months). Three of 5 patients (60%) were alive (at 42, 67, and 70 months) and 1 was free of immunosuppression after sufficient recovery of the native liver. Two cases succumbed: 1 at postoperative day 3 because of cytomegalovirus pneumonia and 1 at 10 months after APOLT because of sepsis. Complications were seen in all 5 patients: Relaparotomy for hemostasis in 3, decompression surgery of the abdominal cavity in 1, rehepaticojejunostomy in 1, and biliary strictures in 2 cases. Auxiliary partial LDLT may be a choice as an aid for a small-for-size graft in FHF.

De novo autoimmune hepatitis after living donor liver transplantation in a 25-day-old newborn baby: a case report

De novo autoimmune hepatitis (AIH) has been described recently as a new type of graft dysfunction in pediatric patients receiving liver transplantation. Herein we have reported the case of a boy, diagnosed as neonatal hemochromatosis, who received a reduced left lateral graft 25 days after birth. Pretransplantation autoantibodies and serological tests were negative. The postoperative course was smooth. No episode of vascular or biliary complication or acute cellular rejection was observed. The maintenance immunosuppressant was tacrolimus only. Liver dysfunction occurred 13 months after living donor liver transplantation. Liver biopsies showed no acute cellular rejection, but severe apoptosis and regeneration of liver cells at the centrolobular area. At that time, various autoantibodies including anti-nuclear, anti-double-stranded DNA, and anti-smooth muscle antibodies were positive. In addition, serum immunoglobulin G (IgG) was elevated. Based on these findings, he was diagnosed as de novo AIH. The treatment consisted of reducing the tacrolimus dose and reintroduction of steroids. After 12 months of treatment, liver dysfunction improved, serum autoantibodies became negative, and serum IgG level normalized. Currently his immunosuppressive therapy consists of low-dose tacrolimus and prednisolone. In conclusion, the present case demonstrated that de novo AIH can appear in living donor liver transplant patients despite appropriate immunosuppression. Reducing the tacrolimus dose and reintroduction of prednisolone sustained the graft and prevented retransplantation.

Early regular examination of biliary strictures by endoscopic retrograde cholangiography for duct-to-duct biliary reconstruction after adult living donor liver transplantation

In September 2006, we initiated regular screening of biliary strictures (BS) by endoscopic retrograde cholangiography (ERC) within 6 months after removal of external stents among duct-to-duct biliary reconstructed adult living donor liver transplantations (LDLT). From March 2000 to January 2008, we retrospectively evaluated 45 primary adult LDLTs who had survived >1 month. We separated the cases into 2 groups-the early cases (March 2000 to August 2006: n = 34) and the late cases (September 2006 to January 2008: n = 11)-to compare the incidences of BS and the success rates of endoscopic treatments. Median follow-up of the late cases (8.0 months) was shorter than that of the early cases (38.5 months; P = .0003). The overall incidence of BS was 36% (16/45), with 32% (11/34) among the early and 45% (5/11) among the late cases (P = .18). BS was successfully treated by endoscopic management in 4/5 (80%) late cases and 3/11 (27%) early cases (P = .049). Two early patients required operative biliary reconstructions. Endoscopic procedure-related complications developed in 2 patients among the early cases. Early postoperative regular screening of BS by ERC for duct-to-duct biliary reconstructions may be effective to avoid surgical interventions after adult LDLT. However, repeat ERCs have a risk for pancreatitis and other complications. Further investigations and longer follow-up are needed to confirm the efficacy and safety of a regular examination by ERC for duct-to-duct biliary reconstructions in LDLT.

Impact of intraportal donor-specific leukocyte transfusion for adult ABO-incompatible liver transplantation

INTRODUCTION

We have reported that repeated donor-specific leukocyte transfusions (DSLT) via the portal vein allow rapid reduction of immunosuppressants and decrease the occurrence of acute cellular rejection. Herein, we examined the immunological benefits of DSLT in adult ABO-incompatible living donor liver transplantation (LDLT).

MATERIALS AND METHODS

Ten adult patients (MELD score, 19.4 +/- 7.3; range, 12-29) underwent LDLT from ABO-incompatible donors from August 2003 to November 2007. The antirejection therapy included multiple perioperative plasmaphereses, splenectomy, and quadruple immunosuppression. In addition to these conventional approaches, we performed 4 intraportal administrations of DSLT after transplantation.

RESULTS

There was no humoral rejection in any patient. Two patients experienced mild cellular rejection requiring steroid pulse therapy. Both donor-specific immunoglobulin (Ig)M and IgG A/B antibodies in all patients decreased following transplantation by 16 fold. By flow cytometry, donor type of CD56+NK T cells existed in the liver graft showing macrochimerism at 1 month after liver transplantation. Furthermore, interleukin (IL)-10 production of Th2 type cytokines was up-regulated after transplantation. Three patients died of sepsis and infection. The 5-year survival rate was 70% by the Kaplan-Meier method.

CONCLUSION

Adult ABO-incompatible liver transplantation can be performed with acceptable patient and graft survival rates with a low risk of antibody-mediated rejection using intraportal administration of DSLT. Donor type CD56+NK T cells may induce tolerance by a veto or an anti-idiotype network mechanism.

Temporary cardiac pacing for fatal arrhythmia in living-donor liver transplantation: three case reports

Cardiac pacing often turns out to be the only effective treatment of severe, life-threatening arrhythmias. We performed 77 living-donor liver transplantations (LDLT) from 1999 to 2007. In these cases, three recipients experienced fatal arrhythmia and required temporary cardiac pacing during the perioperative period. The first case was a 68-year-old woman diagnosed with liver cirrhosis and hepatocellular carcinoma (HCC). Her Model for End-Stage Liver Disease (MELD) score was 34. We performed LDLT using a right lobe graft. She showed complete atrioventricular block with cardiac arrest at postoperative day (POD) 42 after a bacterial infection. We performed a resuscitation and instituted temporary cardiac pacing. However, she was dead at POD 43. Pathologic findings at autopsy showed a diffuse myocardial abscess, which caused the fatal arrhythmia. The second case was a 58-year-old man diagnosed with HCC and liver cirrhosis; his MELD score was 9. We performed LDLT using a right lobe graft. He showed atrial fibrillation after septic shock. He also showed sinus bradycardia with a cardiac arrest at POD 10. We performed resuscitation and emergent temporary pacing. He recovered and was alive without recurrence of arrhythmia or infection. The third case was a 58-year-old woman diagnosed with multiple HCC. During preoperative regular check-up, she was diagnosed to have cardiac hypertrophy and was started on beta-blockers as treatment for cardiac hypertrophy. However, severe bradycardia necessitated temporary cardiac pacing. LDLT was performed safely after implantation of a pacemaker. Early use of temporary cardiac pacing for severe arrhythmias may be effective to maintain the hemodynamic state in LDLT.

Thrombotic microangiopathy after ABO-incompatible living donor liver transplantation: a case report

Thrombotic microangiopathy (TMA) has rarely been reported in the setting of liver transplantation. Herein we have reported a successful case of TMA after ABO-incompatible living donor liver transplantation (LDLT) treated with plasma exchange and high-dose intravenous gamma-globulin infusion. A 50-year-old woman was diagnosed with hepatitis C virus-related cirrhosis. We performed an ABO-incompatible LDLT (group B to O) with preoperative plasma exchange to reduce the anti-B hemagglutinin titers to 1:8. The immunosuppressants consisted of tacrolimus, mycophenolate mofetil, and steroid. On postoperative day (POD) 8, her anti-B hemagglutinin titer suddenly increased to 1:64. The serum lactate dehydrogenase (LDH) level was grossly elevated (1518 IU/L). On POD 13, we suspected infection of an intra-abdominal hematoma (Serratia marcescens) which was drained surgically. On day 5 after the reoperation, thrombocytopenia developed with a platelet count of 3 x 10(4)/mm3. A peripheral blood film showed severe red blood cell (RBC) fragmentation. Thus, we made a clinical diagnosis of TMA and reduced the tacrolimus dose. We started intensive daily plasma exchange (4 L/d) with fresh frozen plasma and high-dose intravenous gamma-globulin infusions. One week thereafter, thrombocytopenia improved with reduced transfusion requirements. The peripheral blood film showed normal RBC morphology. The serum LDH returned to baseline levels. Four factors were considered to have caused TMA in this case: the prescription of tacrolimus, ABO-incompatible liver transplantation, bacterial infection, and surgical stress. These factors may have all contributed by causing significant endothelial injury and TMA.

Successful super-small-for-size graft liver transplantation by decompression of portal hypertension via splenectomy and construction of a mesocaval shunt: a case report

We performed a successful super-small-for-size graft liver transplantation by decompressing portal hypertension via splenectomy and a mesocaval shunt. A 46-year-old woman with Child-Pugh class C liver cirrhosis associated with Wilson's disease underwent a living donor liver transplantation (LDLT). The donor had an anomalous portal vein, hepatic vein, and bile duct, so we had to use the right lateral segment for the graft. Preoperative computed tomographic (CT) volumetry showed the volume of this area to be 433 mL; graft-to-recipient weight ratio (GRWR) was 0.72; and graft-to-standard liver volume (GV/SLV) was 39.0%. However, the real volume of the resected right lateral segment was 281 g; GRWR was 0.47; and GV/SLV was 25.3%--a super-small-for-size graft. After implantation, congestion of the small graft was severe due to excessive portal hypertension. Therefore, we tried decompressing the portal vein. First, we performed splenectomy which reduced the portal pressure which remained excessive. Second, a mesocaval shunt was constructed decreasing the portal pressure from 38 to 30 cm H2O. Additionally, we initiated continuous portal injection of prostaglandin E1. The postoperative course was not smooth, but the general status slowly recovered. Over 25 cm H2O of portal hypertension was observed until postoperative day 21 when it improved. At last, the recipient was discharged on postoperative day 156. Accurate preoperative CT volumetry is important to obtain sufficient graft volume. Our case may be one of the smallest-for-size grafts that was successfully transplanted. Management of excessive portal hypertension is important for LDLT, especially using a small-for-size graft. Splenectomy and construction of a mesocaval shunt may be useful strategies to decompress the portal vein.

Adult ABO-incompatible liver transplantation by intraportal transfusion of donor-specific antigen: a case report

A 55-year-old-woman suffering from fluminant hepatitis owing to autoimmune hepatitis underwent ABO-incompatible liver transplantation (LRLD) of blood type A to B. In this study, we investigated whether a new immunosuppressive strategy by intraportal transfusion of donor-specific leukocytes (DSLT) separated from whole blood would yield immunological benefit in adult ABO-LRLD. The operative course was uneventful; she was discharged at 46 days postoperatively without humoral or cellular rejection. On immunologic analysis, 54.6% intrahepatic macrochimerism of donor type CD56+ T cells was recognized at 1 month after transplantation. The interleukin-10 Th2 cytokine level was increased on postoperative day 1. Adult ABO-incompatible liver transplantation can be performed with acceptable patient and graft survival rates with a low risk of antibody-mediated rejection with our strategy of immunosuppression by intraportal administration of DSLT. Donor type CD56+ NKT cells may induce tolerance by a veto mechanism and/or an anti-idiotype network. ABO-incompatible liver transplantation may be improved by this strategy.

Living related pancreas transplantation alone with enteric drainage in Japan: case report

In this study, we report a living donor partial pancreas transplantation using intraportal donor-specific leukocyte transfusion (DSLT). The recipient was a 38-year-old woman who had type I diabetes mellitus for 17 years. Hypoglycemia occurred 2 or 3 times per week. Her hemoglobin A1c level was 9.0%, and she required 70 U of insulin almost every day. The donor was her 64-year-old father. The steroid-minimized immunosuppressive protocol included 1.5mg of thymoglobulin administered with a steroid bolus on days 0, 4, and 7 postoperatively. Steroids were never prescribed thereafter. Postoperative maintenance therapy included tacrolimus (FK506) and mycophenolate mofetil. In addition to these conventional approarches, we administered intraportal DSLT on days 0, 1, 4, and 7 after transplantation. The donor-specific leukocytes (40mL) had been separated from donor whole blood using an apheresis filter (Cellsorba EX; Asahi Kasei medical Co, Ltd, Tokyo, Japan). In the recipient operation, a segmental pancreas graft was transplanted into the right iliac cavity with enteric drainage with a pancreatic duct stent. Operation time was 6 hours. The postoperative course was uneventful. The patient was discharged on day 15 after transplantation. There was no acute rejection for six months after transplantation. The hemoglobin A1c level recovered to 5.1% with 6 U of insulin per day. At immunologic analysis, only interleukine-10 cytokine production was elevated at 7 days after transplantation. At flow cytometry cross-match analysis, the immunoglobulin M antibody decreased from day 7 after transplantation. We conclude that intraportal DSLT may be an effective adjunct to a steroid-free regimen.

Auditory-visual processing represented in the human superior temporal gyrus

In natural face-to-face communication, speech perception utilizes both auditory and visual information. We described previously an acoustically responsive area on the posterior lateral surface of the superior temporal gyrus (field PLST) that is distinguishable on physiological grounds from other auditory fields located within the superior temporal plane. Considering the empirical findings in humans and non-human primates of cortical locations responsive to heard sounds and/or seen sound-sources, we reasoned that area PLST would also contain neural signals reflecting audiovisual speech interactions. To test this hypothesis, event related potentials (ERPs) were recorded from area PLST using chronically implanted multi-contact subdural surface-recording electrodes in patient-subjects undergoing diagnosis and treatment of medically intractable epilepsy, and cortical ERP maps were acquired during five contrasting auditory, visual and bimodal speech conditions. Stimulus conditions included consonant-vowel (CV) syllable sounds alone, silent seen speech or CV sounds paired with a female face articulating matched or mismatched syllables. Data were analyzed using a MANOVA framework, with the results from planned comparisons used to construct cortical significance maps. Our findings indicate that evoked responses recorded from area PLST to auditory speech stimuli are influenced significantly by the addition of visual images of the moving lower face and lips, either articulating the audible syllable or carrying out a meaningless (gurning) motion. The area of cortex exhibiting this audiovisual influence was demonstrably greater in the speech-dominant hemisphere.

Comparison between human-telomerase reverse transcriptase mRNA and alpha-fetoprotein mRNA as a predictive value for recurrence of hepatocellular carcinoma in living donor liver transplantation

OBJECTIVE

In this study we compared the potential roles of preoperative human-telomerase reverse transcriptase (h-TERT) mRNA versus alpha-fetoprotein (AFP) mRNA expression in the peripheral blood as a tool to predict prognosis and tumor recurrence after living donor liver transplantation (LDLT) in hepatocellular carcinoma (HCC) patients.

PATIENTS AND METHODS

We examined 14 patients with unresectable HCC who underwent LDLT. Six patients displayed stage IVA HCC that deviated from the Milan criteria, while the rest of the patients fell within the limitations of the Milan criteria. We analyzed the relationship between preoperative h-TERT mRNA or AFP mRNA expression in the peripheral blood and survival without recurrence.

RESULTS

There was no significant difference between the survival curves without recurrence of those patients who did versus did not meet the Milan criteria. There was also no significant difference between the survival curves without recurrence among patients with positive versus negative AFP mRNA expression. However, there was a significant difference (P = .005) between the survival curves without recurrence of those patients with positive preoperative h-TERT mRNA expression versus those who either had an initially negative preoperative h-TERT mRNA or who converted from positive to negative after neoadjuvant immunochemotherapy.

CONCLUSIONS

h-TERT mRNA seemed to prove more valuable than AFP mRNA not only to assess preoperative treatment modalities and postoperative patient surveillance, but also to evaluate prospective LDLT patients with HCC. Moreover, use of h-TERT mRNA could potentially expand the indications for transplantation to patients outside the Milan criteria.

Serum LECT2 level as a prognostic indicator in acute liver failure

In the present study, we investigated the relationship between serum leukocyte cell-derived chemotaxin2 (LECT2) levels and liver function in patients with acute liver failure, and its use as a prognostic indicator. We studied six acute liver failure patients (two women, four men; 49.8 +/- 20.7 years old) admitted to our hospital in 2002. These patients had diagnoses of fulminant hepatitis due to acute liver failure (1) from congestive heart failure; (2) from portal venous gas, and (3) from postoperative disseminated intravascular coagulation (DIC). We measured serum LECT2, GOT, and GPT levels, the last two being inversely proportionate to the serum LECT2 levels. When the serum GPT levels peaked, the serum LECT2 levels were the lowest. When the liver function recovered, serum LECT2 levels increased. Three of four patients died due to liver failure, one to congestive heart failure. Maximum serum LECT2 levels among the expired group were significantly lower than those among the alive group (0.96 +/- 0.8 ng/mL vs 12.9 +/- 4.3 ng/mL). Serum LECT2 levels may be a prognostic indicator of recovery from liver failure. The present study suggests that in clinical medicine LECT2 participates in regeneration after injury of hepatocytes.

Changes in serum LECT 2 levels during the early period of liver regeneration after adult living related donor liver transplantation

We investigated changes in serum leukocyte cell-derived chemotaxin2 (LECT2) levels between donors and recipients in the early period during liver regeneration following adult living related donor liver transplantation (LRDLT). Five recipients (three women, two men; 37.0 +/- 15.8 years old), all of whom had end-stage liver failure, underwent LRDLT from healthy five donors (two women, three men; 41.6 +/- 14.3 years old) between June 2000 and February 2001. FK506 and methylprednisolone were used as immunosuppressants for recipients. Serum LECT2 levels decreased immediately after both the hepatectomy in all donors and the implantation of liver graft in all recipients. Donors showed a nadir at 3 to 12 hours, increasing at 24 to 48 hours. The nadir in recipients occurred several hours after the donors. The serum LECT2 levels of donors were significantly higher than those of recipients on day 5 (9.5 +/- 5.9 ng/mL vs 3.1 +/- 2.2 ng/mL, P = .04) and on day 7 (9.3 +/- 3.8 ng/mL vs 3.5 +/- 1.1 ng/mL, P = .04). Serum GPT and GOT levels were inversely proportionate to the serum LECT2 levels. The present studies suggest that LECT2 participates in liver regeneration and injury following hepatectomy.

Living related donor liver transplantation for primary sclerosing cholangitis with hepatocellular carcinoma and Crohn's disease: a case report

INTRODUCTION

Primary sclerosing cholangitis (PSC) is a premalignant condition associated with a risk of developing cholangiocarcinoma in 10% to 20% of patients. However, the prevalence of hepatocellular carcinoma (HCC) in patients with PSC is estimated to be only 2%. In addition, PSC often occurs in association with inflammatory bowel disease. Ulcerative colitis occurs in 60% of PSC patients and Crohn's disease occurs in about 10%. We diagnosed a patient as having PSC with HCC and concomitant Crohn's disease prior to living related donor liver transplantation (LRDLT).

PATIENTS AND METHODS

A 63-year-old woman was diagnosed as having PSC with solitary HCC. Preoperative liver condition was Child-Pugh grade C. Colonoscopic findings showed an active longitudinal ulcer in the terminal ileum and clinically diagnosed Crohn's disease. The medical treatment was 5'-aminosalicylates. She received a left lobe graft from her daughter. The immunosuppressants were tacrolimus and azathioprine, which was changed to predonisolone because of leukopenia and moderate acute cellular rejection, after which the postoperative course was uneventful. Colonoscopic findings revealed disappearance of the longitudinal ulcer in the terminal ileum at 15 months after LRDLT. There was no evidence of PSC or HCC recurrence.

CONCLUSIONS

Generally, PSC with HCC is rare with a poor prognosis; however, LRDLT may be a treatments option although the patient with PSC had a combined HCC. Moreover, aminosalicylates together with the immunosuppressants may be effective for the clinical management of concomitant Crohn's disease.

Biliary reconstruction and complications of left lobe living donor liver transplantation

Postoperative biliary tract complications remain one of the most serious problems facing patients who undergo living donor liver transplantation. The aim of this study was to analyze the clinical implications of three methods of biliary reconstruction in left lobe adult living donor liver transplantation. We retrospectively compared three groups of patients who underwent various biliary reconstructions: those who had Roux-en-Y hepaticojejunostomy (HJ) (n = 11); duct to duct hepaticohepaticostomy (HH) with an external stent (n = 11); or HH with T-tube (n = 6). The median follow-up for each group was 29, 28, and 8 months, respectively. Bile leaks were observed in 45.5% of both the HJ and the HH with external stent groups. Biliary anastomotic strictures occurred in 9.1% of the Roux-en-Y HJ patients and in 27.2% of those who had HH with an external stent. No biliary complications were observed in the HH over a T-tube group (P = .049). Biliary reconstruction using HH with a T-tube may decrease the incidence of biliary complications. Despite the relatively short follow-up, these encouraging preliminary results warrant further studies of this biliary reconstruction technique for left lobe adult living donor liver transplantations.

Surgical Procedures for Decompression of Excessive Shear Stress in Small-For-Size Living Donor Liver Transplantation—New Hepatic Vein Reconstruction

We have reported that acute elevation of portal pressure, reflecting wall shear stress of sinusoidal endothelial cells, triggers liver regeneration after partial hepatectomy and that excessive portal hypertension induces liver failure. For prevention of excessive shear stress in small-for-size living donor liver transplantation (LDLT), we developed a new hepatic vein reconstruction to expand the anastomotic site. Fourteen adult patients, who underwent LDLT, were divided into two groups: previous end-to-end hepatic vein reconstruction in nine patients (group P) and the new method in five patients (group N). The outside middle and left hepatic veins of the graft were incised and enlarged to 40 mm. The vena cava was cut 40 mm longitudinally. The graft was positioned a quarter turn counterclockwise with the hepatic vein of the graft anastomosed end-to-side to the vena cava longitudinally. Postoperative portal pressures and serum total bilirubin levels of these two groups showed portal pressure in group N to rapidly decrease below 25 cm H2O following LDLT. No cases showed posttransplanted hyperbilirubinemia above 10 mg/dL in group N; however, all cases were small-for-size grafts. Moreover, serum total bilirubin levels in group N were significantly lower than those in group P. This procedure is simple despite not using a venous patch. If the hepatic vein is narrow or obstructed, such as in Budd-Chiari syndrome, the procedure is applicable. Even in small-for-size grafts, excessive tension did not occurred at the portal vein or hepatic artery anastomoses. Moreover, it is possible to avoid outflow block and posttransplanted hyperbilirubinemia.

Inferior mesenteric venous left renal vein shunting for decompression of excessive portal hypertension in adult living related liver transplantation

In the present study, we investigated the effect of decompression of excessive portal hypertension by inferior mesenteric venous (IMV) left renal vein shunting in 7 cirrhotic patients with esophago-gastric varices and 2 patients who underwent adult living related donor liver transplantation (ALRDLT). The portal pressure remarkably decreased after shunting in all patients with esophago-gastric varices (388 +/- 42 mm H2O vs. 247 +/- 57 mm H2O; P < .05). It also decreased after a shunt operation in patients who had undergone liver transplantation. We report that the excessive shear stress by portal hypertension after small-for-size LRDLT induces a liver injury and the decompression of portal hypertension by splenic arterial ligation or splenectomy prevents postoperative liver injury following massive hepatectomy and small-for-size LRDLT. Our present studies suggested that IMV left renal vein shunting might prevent postoperative liver injury by partial decompression of excessive portal hypertension following small-for-size LRDLT.