Ahmed Eldorry

Biliary complications including single-donor mortality: experience of 207 adult-to-adult living donor liver transplantations with right liver grafts

BACKGROUND After right lobe donation, biliary complication is the main cause of morbidity. Mortality after right lobe donation has been estimated to be less than 0.5%. PATIENTS AND METHODS Between November 2001 and December 2008, 207 adult-to-adult living donor liver transplantations (ALDLT) were undertaken using right lobe grafts. Donors included 173 men and 34 women with a mean age of 28.4 +/- 5.2 years. RESULTS Siblings comprised 144 (69.6%) cases whereas unrelated donors comprised 63 (30.4%) with a mean body mass index (BMI) of 25.2 +/- 2.4. Single and multiple right hepatic ducts (RHD) were present in 82 (39.6%) and 125 (60.3%) donors, respectively. Mean operative time was 360 +/- 50 min with an estimated blood loss of 950 +/- 450 ml and returned cell-saver amount of 450 +/- 334 ml. Mean donor remnant liver volume was 33.5 +/- 3.2%. Mean intensive care unit (ICU) stay was 3 +/- 0.7 days and mean hospital stay was 14 +/- 3.5 days. Modified Clavien classifications were used to stratify all donor biliary complications The overall biliary complications occurred in 27 cases (13.0%). After modified Clavien classification, biliary complications were graded as grade I (n= 10), grade II (n= 2), grade III (n= 14) and grade V (n= 1). Grade I and II (n= 12) biliary complications were successfully managed conservatively. Grade III cases were treated using ultrasound-guided aspiration (USGA), endoscopic retrograde cholangiography (ERCP) and surgery in 10, 2 and 2 donors, respectively. Single donor mortality (Grade V) (0.4%) occurred after uncontrolled biliary leakage with peritonitis that necessitated exploration followed by ERCP with stent insertion but the donor died on day 43 as a result of ongoing sepsis. CONCLUSION Although the majority of biliary complications are minor and can be managed conservatively, uncontrolled biliary leakage is a serious morbidity that should be avoided as it could lead to mortality.

Epidemiological aspects of Budd-Chiari in Egyptian patients: a single-center study.

AIM To describe the socio-demographic features, etiology, and risk factors for Budd-Chiari syndrome (BCS) in Egyptian patients. METHODS Ninety-four Egyptian patients with confirmed primary Budd-Chiari syndrome were presented to the Budd-Chiari Study Group (BCSG) and admitted to the Tropical Medicine Department of Ain Shams University Hospital (Cairo, Egypt). Complete clinical evaluation and laboratory investigations, including a thrombophilia workup and full radiological assessment, were performed to determine underlying disease etiologies. RESULTS BCS was chronic in 79.8% of patients, acute or subacute in 19.1%, and fulminant in 1.1%. Factor V Leiden mutation (FVLM) was the most common etiological cause of disease (53.1%), followed by mutation of the gene encoding methylene tetrahydrofolate reductase (MTHFR) (51.6%). Current or recent hormonal treatment was documented in 15.5% of females, and BCS associated with pregnancy was present in 17.2% of females. Etiology could not be determined in 8.5% of patients. Males had significantly higher rates of MTHFR gene mutation and Behçets disease, and females had significantly higher rates of secondary antiphospholipid antibody syndrome. A highly significant positive relationship was evident between the presence of Behçets disease and inferior vena caval occlusion, either alone or combined with occlusion of the hepatic veins (P < 0.0001). CONCLUSION FVLM is the most common disease etiology and MTHFR the second most common in Egyptian BCS patients. BCS etiology tends to vary with geographic region.

Outcome of non surgical hepatic decompression procedures in Egyptian patients with Budd-Chiari

AIM To evaluate outcome of patients with Budd-Chiari syndrome after balloon angioplasty ± stenting or transjugular intrahepatic portosystemic shunt (TIPS). METHODS Twenty five patients with Budd-Chiari syndrome admitted to Ain Shams University Hospitals, Tropical Medicine Department were included. Twelve patients (48%) with short segment occlusion were candidates for angioplasty; with stenting in ten cases and without stenting in two. Thirteen patients (52%) had Transjugular Intrahepatic Portosystemic Shunt. Patients were followed up for 12-32 mo. RESULTS Patency rate in patients who underwent angioplasty ± stenting was 83.3% at one year and at end of follow up. The need of revision was 41.6% with one year survival of 100%, dropped to 91.6% at end of follow up. In patients who had Transjugular Intrahepatic Portosystemic Shunt, patency rate was 92.3% at one year, dropped to 84.6% at end of follow up. The need of revision was 38.4% with one year and end of follow up survival of 100%. Patients with patent shunts showed marked improvement compared to those with occluded shunts. CONCLUSION Morbidity and mortality following angioplasty ± stenting and TIPS are low with satisfactory outcome. Proper patient selection and management of shunt dysfunction are crucial in improvement.

Donor rejection before living donor liver transplantation: causes and cost effective analysis in an egyptian transplant center.

Background: In the living donor liver transplant setting, the preoperative assessment of potential donors is important to ensure the donor safety. Objectives: The aim of this study was to identify causes and costs of living liver-donors rejection in the donation process. Materials and Methods: From June 2010 to June 2012, all potential living liver donors for 66 liver transplant candidates were screened at the Ain Shams Center for Organ Transplantation. Potential donors were evaluated in 3 phases, and their data were reviewed to determine the causes and at which phase the donors were rejected. Results: One hundred and ninety two potential living liver donors, including 157 (81.7%) males, were screened for 66 potential recipients. Of these, 126 (65.6%) were disqualified for the donation. The causes of rejection were classified as surgical (9.5 %) or medical (90.5 %). Five donors (3.9 %) were rejected due to multiple causes. Factor V Leiden mutation was detected in 29 (23 %) rejected donors (P = 0.001), 25 (19.8 %) donors had positive results for hepatitis serology (P = 0.005), and 16 (12.7 %) tested positive for drug abuse. Portal vein trifurcation (n = 9, 7.1%) and small size liver graft estimated by CT volumetric analysis (n = 6, 4.8 %) were the main surgical causes which precluded the donation. Conclusions: Among potential Egyptian living liver donors, Factor V Leiden mutation was a significant cause for live donor rejection. A stepwise approach to donor assessment was found to be cost-effective.

Characteristics of hepatocellular carcinoma in Egyptian patients with primary Budd‐Chiari syndrome

Budd‐Chiari syndrome (BCS) is caused by hepatic venous outflow obstruction. This work aimed at analyzing characteristics and factors associated with development of hepatocellular carcinoma (HCC) in patients with primary BCS.

Pattern of Vascular Involvement in Egyptian Patients with Budd-Chiari Syndrome: Relation to Etiology and Impact on Clinical Presentation

INTRODUCTION AND AIM Budd-Chiari syndrome (BCS) is caused by hepatic venous outflow obstruction. This work aims to analyze the pattern of vascular involvement in Egyptian patients with BCS, demonstrates its relation to etiology and shows its impact on clinical presentation. MATERIAL AND METHODS The current retrospective study was conducted at The Tropical Medicine Department, Ain Shams University on one hundred Egyptian patients with confirmed diagnosis of primary BCS who were presented to the Budd-Chiari Study Group (BCSG) from April 2014 to May 2016 by collecting clinical, laboratory and radiological data from their medical records. RESULTS Isolated hepatic vein occlusion (HVO) was the most common pattern of vascular involvement (43%), followed by combined HVO and inferior vena cava (IVC) compression by enlarged caudate lobe (32%), then combined HVO and IVC stenosis/webs (21%), and lastly isolated IVC occlusion (4%). Ascites was more significantly encountered in BCS patients with HVO than in those with isolated inferior vena cava (IVC) occlusion and patent HVs (P = 0.005). Abdominal pain was significantly encountered in patients with occluded three major HVs (P = 0.044). Behcets disease was significantly detected in isolated IVC occlusion. Protein C deficiency was significantly detected in patients with combined HVO and IVC compression. CONCLUSION Isolated HVs occlusion was the most common pattern of vascular involvement in Egyptian patients with primary BCS. Vascular pattern of involvement affected the clinical presentation and was related to the underlying thrombophilia in those patients.INTRODUCTION AND AIM Budd-Chiari syndrome (BCS) is caused by hepatic venous outflow obstruction. This work aims to analyze the pattern of vascular involvement in Egyptian patients with BCS, demonstrates its relation to etiology and shows its impact on clinical presentation. MATERIAL AND METHODS The current retrospective study was conducted at The Tropical Medicine Department, Ain Shams University on one hundred Egyptian patients with confirmed diagnosis of primary BCS who were presented to the Budd-Chiari Study Group (BCSG) from April 2014 to May 2016 by collecting clinical, laboratory and radiological data from their medical records. RESULTS Isolated hepatic vein occlusion (HVO) was the most common pattern of vascular involvement (43%), followed by combined HVO and inferior vena cava (IVC) compression by enlarged caudate lobe (32%), then combined HVO and IVC stenosis/webs (21%), and lastly isolated IVC occlusion (4%). Ascites was more significantly encountered in BCS patients with HVO than in those with isolated inferior vena cava (IVC) occlusion and patent HVs (P = 0.005). Abdominal pain was significantly encountered in patients with occluded three major HVs (P = 0.044). Behcets disease was significantly detected in isolated IVC occlusion. Protein C deficiency was significantly detected in patients with combined HVO and IVC compression. CONCLUSION Isolated HVs occlusion was the most common pattern of vascular involvement in Egyptian patients with primary BCS. Vascular pattern of involvement affected the clinical presentation and was related to the underlying thrombophilia in those patients.

Validation of prognostic indices in Egyptian Budd-Chiari syndrome patients: A single-center study

AIM To compare predictive ability of Budd-Chiari syndrome (BCS) prognostic indices (PIs) for one-year survival and Transjugular intrahepatic portosystemic shunt (TIPS) patency. METHODS This retrospective study enrolled 194 Egyptian patients with primary BCS who presented to the Budd-Chiari Study Group of Ain Shams University Hospital. Calculation of the available PIs was performed using Child-Pugh and model for end-stage liver disease scores, BCS-specific PIs (Clichy, New Clichy and Rotterdam) for all patients, and BCS-TIPS PI only for patients who underwent TIPS. The overall one-year survival rate and the one-year shunt patency rate for TIPS were reported. RESULTS The overall one-year survival rate was 69.6%, and the New Clichy PI revealed the best validity for its prediction at a cut-off value of 3.75, with sensitivity and specificity of 78% and 73.3%, respectively [area under receiver operating characteristic curve (AUC) = 0.806]. The one-year survival rate post-TIPS was 89.7%, and the BCS-TIPS score demonstrated validity for its prediction at a cut-off value of 3.92 (sensitivity and specificity were 71.4% and 64.5%, respectively) (AUC = 0.715). Logistic regression analysis revealed that the New Clichy PI (P = 0.030), high serum total bilirubin (P = 0.047) and low albumin (P < 0.001) were independent factors for predicting mortality within one year. The one-year shunt patency rate in TIPS was 80.2%, and none of the PIs exhibited significant validity for its prediction. CONCLUSION The New Clichy score could independently predict the one-year survival in Egyptian BCS patients.

Prevalence of portal vein thrombosis in Egyptian patients with Budd-Chiari syndrome

Editor, Portal vein thrombosis (PVT) and Budd-Chiari syndrome (BCS) are caused by thrombosis and/or obstruction of the portal vein and the hepatic venous outflow tract, respectively [1, 2]. The mean survival of patients with PVT compared to patients without PVT may be shorter [3]. We evaluated the prevalence of PVT among Egyptian patients with BCS. All patients with BCS presenting to the Budd-Chiari Study Group (BCSG), Ain Shams University Hospital, Egypt, during the period from May 2005 to December 2011 were evaluated after signing an informed consent. One hundred and thirty-eight patients were included, and BCS and PVT were confirmed with color-pulsed Doppler ultrasonography. The mean age of the included patients was 26.6 years. The distribution of BCS cases was as follows: Cairo (n=60) followed by Delta (n=43) then upper Egypt (n=35). They mostly presented with the chronic BCS presentation (n=126) vs. 12 with acute presentation. Abdominal enlargement and abdominal pain were the most common symptoms (n=122, 113). The most common clinical signs were ascites and hepatomegaly (n=115, 114). The etiology could not be identified in 48 patients. Factor V Leiden mutation (FVLM) and methylene tetrahydrofolate reductase (MTHFR) gene mutation were the most common etiological factors being responsible for (n=26) and (n=25), respectively. Rare etiological factors include hemolytic uremic syndrome, Churg-Strauss disease, and congenital web and vasculitis (only one cause for each). One etiological factor was found in 60 patients, 2 factors in 21 patients, and 3 factors in 8 patients. Only one patient had four etiological factors (0.7 %). Esophageal varices were present in 97 cases, while gastric extensions (12 cases) and fundal varices (5 cases) were not common findings. Portal hypertensive gastropathy (PHG) was present in 63 cases. There was no significant difference between patients with (n=15) and without PVT (n=123) as regards sociodemographic data and the underlying etiology of BCS. Hepatic tenderness was more frequent in patients with PVT as well as increased direct bilirubin and white blood cells (p<0.05). Doppler ultrasound findings were similar in patients with PVT and others (Table 1). In our study, we identified a combined etiology in 21.7 % of the patients and FVLM was the most common. Denninger et al. documented combined etiology of BCS in at least 25 % of their patients [4]. Mohanty et al. concluded that FVLM was the most common risk factor in BCS (26 %) [5]. In our study, MTHFR gene mutation was documented in 18.1 % of patients. Others have reported high prevalence (45.1 %) of the MTHFR 677/T genotype in patients with BCS [6]. In the current study, Behcet’s disease (BD) was found in 8.7 %, like Turkey which reported 9 % prevalence in BCS [7]. As regards the frequency of PVT in Egyptian patients with BCS, we found that 10.9 % (15 of 138) of the studied patients had PVT including 10 males and 5 females (without significant difference) with median age of 26.93 years. In a multicenter European study in BCS patients [8], the estimated frequency of PVT was 14 %. In our cases, the etiology of combined BCS-PVT could not be defined in 4 patients (26. 7 %). Seven patients had unifactorial etiology (46.6 %), and the remaining 4 had multifactorial etiology (26.7 %), while in the European study, the etiology was unifactorial in 18 % and multifactorial in 58 % with no definitive etiology in 24 % of cases. The authors reported that three of the affected patients had a local cause of PVT, while none of our patients had such a cause. The main presenting sign in the studied patients was M. A. Sakr :N. Abdelkader :H. Dabbous (*) :A. Eldorry Tropical Medicine Department, Ain Shams University, Cairo, Egypt e-mail: drhdabbous@yahoo.com Indian J Gastroenterol (September–October 2014) 33(5):489–491 DOI 10.1007/s12664-014-0483-x