Ahmed Elghawalby

Comparative study between duct to mucosa and invagination pancreaticojejunostomy after pancreaticoduodenectomy: A prospective randomized study

BACKGROUND The ideal technical pancreatic reconstruction following pancreaticoduodenectomy (PD) is still debated. The aim of the study was to assess the surgical outcomes of duct to mucosa pancreaticojejunostomy (PJ) (G1) and invagination PJ (G2) after PD. METHODS Consecutive patients treated by PD at our center were randomized into either group. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF); secondary outcomes included; operative time, day to resume oral feeding, postoperative morbidity and mortality, exocrine and endocrine pancreatic functions. RESULTS One hundred and seven patients treated by PD were randomized. The median operative time for reconstruction was significantly longer in G1 (34 vs. 30 min, P=0.002). POPF developed in 11/53 patients in G1 and 8/54 patients in G 2, P=0.46 (6 vs. 2 patients had a POPF type B or C, P=0.4). Steatorrhea after one year was 21/50 in G1 and 11/50 in G2, respectively (P=0.04). Serum albumin level after one year was 3.4 gm% in G1 and 3.6 gm in G2 (P=0.03). There was no statistically significant difference regarding the incidence of DM preoperatively and one year postoperatively. CONCLUSION Invagination PJ is easier to perform than duct to mucosa especially in small pancreatic duct. The soft friable pancreatic tissue can be problematic for invagination PJ due to parenchymal laceration. Invagination PJ was not associated with a lower rate of POPF, but it was associated with decreased severity of POPF and incidence of postoperative steatorrhea. CLINICAL TRIALS. GOV ID NCT02142517.

Biliary complications in living donor right hepatectomy are affected by the method of bile duct division

The bile duct division is a crucial step in the donor hepatectomy. Multiple small ducts will make the biliary reconstruction more difficult and may influence the outcome of the recipient. Biliary leakage, bilomas and biliary strictures are well recognized donor complications that may be directly linked to bile duct division. Biliary division still needs more standardization. This work aims to analyze our experience with two different methods of bile duct division in relation to the development of intraoperative and postoperative biliary complications. Between April 2004 and March 2013, 216 liver donors underwent right hepatectomy, in Gastro‐Enterology Surgical Center, Mansoura University, Egypt. According to the method of bile duct division, the study population was divided into 2 groups; 1‐ extrahepatic dissection group (EDG) and 2‐ fluoroscopy guided transection group (FGG), each comprised 108 patients. Data were collected from a prospectively registered database, with special emphasis on the occurrence of biliary complications. Complications were classified according to the latest version of Clavien classification. Intraoperative biliary complications did not differ between both groups, p = 0.313. The commonest postoperative complication was biliary leak/biloma accounting for 32.5% of all donor complications, followed by non‐biliary fluid collections. 24 (11.1%) donors developed 27 biliary complications. The FGG showed significantly less biliary complications (5.6%, 6 donors), when compared to EDG (15.7%, 18 donors), p = 0.015. Grade 3 complications were significantly higher in EDG, p = 0.024. On multivariate analysis, the only significant factor predicting the occurrence of biliary complications was the use of fluoroscopy guided bile duct division, p = 0.009. In conclusion, we believe that the proposed method of biliary division is safe, simple and reproducible. Liver Transpl 20:1393‐1401, 2014.

Predictors of long term survival after hepatic resection for hilar cholangiocarcinoma: A retrospective study of 5-year survivors

AIM To determine predictors of long term survival after resection of hilar cholangiocarcinoma (HC) by comparing patients surviving > 5 years with those who survived < 5 years. METHODS This is a retrospective study of patients with pathologically proven HC who underwent surgical resection at the Gastroenterology Surgical Center, Mansoura University, Egypt between January 2002 and April 2013. All data of the patients were collected from the medical records. Patients were divided into two groups according to their survival: Patients surviving less than 5 years and those who survived > 5 years. RESULTS There were 34 (14%) long term survivors (5 year survivors) among the 243 patients. Five-year survivors were younger at diagnosis than those surviving less than 5 years (mean age, 50.47 ± 4.45 vs 54.59 ± 4.98, P = 0.001). Gender, clinical presentation, preoperative drainage, preoperative serum bilirubin, albumin and serum glutamic-pyruvic transaminase were similar between the two groups. The level of CA 19-9 was significantly higher in patients surviving < 5 years (395.71 ± 31.43 vs 254.06 ± 42.19, P = 0.0001). Univariate analysis demonstrated nine variables to be significantly associated with survival > 5 year, including young age (P = 0.001), serum CA19-9 (P = 0.0001), non-cirrhotic liver (P = 0.02), major hepatic resection (P = 0.001), caudate lobe resection (P = 0.006), well differentiated tumour (P = 0.03), lymph node status (0.008), R0 resection margin (P = 0.0001) and early postoperative liver cell failure (P = 0.02). CONCLUSION Liver status, resection of caudate lobe, lymph node status, R0 resection and CA19-9 were demonstrated to be independent risk factors for long term survival.

Hepatic venous outflow obstruction after living donor liver transplantation managed with ectopic placement of a foley catheter: A case report.

Highlights • Hepatic venous outflow obstruction is a rare serious complication after liver transplantation.• Hepatic venous outflow obstruction may result in graft loss and recipient death.• We report the use of the foley catheter to temporary fix the graft and correct the hepatic venous outflow obstruction.• It is a simple, cheap and safe device to correct the hepatic venous outflow obstruction.• It could be easily monitored and removed under Doppler US without any device related complications.

Ligation of huge spontaneous porto-systemic collaterals to avoid portal inflow steal in adult living donor liver transplantation: A case-report

Highlights • Maintenance of adequate portal inflow is essential for the graft regeneration in adult LDLT.• Portal inflow steal may occur due to presence of huge spontaneous porto-systemic collaterals.• If the portal inflow to the liver graft is inadequate after adult LDLT, post-transplant impairment of the graft regeneration and eventually graft failure would occur.• A surgical procedure to increase the portal inflow is rarely necessary in adult LDLT.• We report a case of prophylactic surgical interruption of spontaneous huge porto-systemic collateral to prevent PFS during adult LDLT procedure.

Outcomes of Living Donor Liver Transplantation for Patients with Preoperative Portal Vein Problems

BackgroundPortal vein thrombosis (PVT) is a common complication for patients with end-stage liver disease. The presence of PVT used to be a contraindication to living donor liver transplantation (LDLT). The aim of this study is to evaluate the influence of preoperative PVT on perioperative and long-term outcomes of the recipients after LDLT.MethodsWe reviewed the data of patients who underwent LDLT during the period between 2004 till 2017.ResultsDuring the study period, 500 cases underwent LDLT. Patients were divided into three groups. Group I included non-PVT, 446 patients (89.2%); group II included attenuated PV, 26 patients (5.2%); and group III included PVT, 28 patients (5.6%). Higher incidence of hematemesis and encephalopathy was detected in PVT (p = 0.001). Longer anhepatic phase was found in PVT (p = 0.013). There were no significant differences between regarding operation time, blood loss, transfusion requirements, ICU, and hospital stay. The 1-, 3-, and 5-year overall survival (OS) rates of non-PVT were 80.5%, 77.7%, and 75%, and for attenuated PV were 84.6%, 79.6%, and 73.5%, and for PVT were 88.3%, 64.4%, and 64.4%, respectively. There was no significant difference between the groups regarding OS rates (logrank 0.793).ConclusionPreoperative PVT increases the complexity of LDLT operation, but it does not reduce the OS rates of such patients.

Internal hernia of the small intestine around biliary catheter after living-donor liver transplantation: A case report

Highlights • Biliary reconstruction is a cornerstone of LDLT.• The use of trans-anastomotic biliary catheters is controversial.• We describe a rare case of intestinal obstruction due to internal herniation around biliary catheter.• Awareness of this complication plus early surgical intervention can prevent postoperative morbidity and mortality.

Management of difficult hepatic artery anastomosis in living donor liver transplantation: mansoura experience

Background One of the most difficult and important procedure in living donor liver transplantation (LDLT) is hepatic artery reconstruction. Difficult hepatic artery reconstruction may be because of pathological factor such as intimal dissection (ID) and anatomical variation. Difficult hepatic artery reconstruction is a risk factor for hepatic artery complications. This study was done to evaluate difficult hepatic artery reconstruction in LDLT at our center and its surgical outcomes. Patient and methods Consecutive patients who were treated for end-stage liver cirrhosis by LDLT were retrospectively reviewed. The management of hepatic artery with ID is carried out according to the extent of ID. Results Hepatic artery ID was found in 21/375 (5.6%) cases. Overall, seven (33%) cases were reconstructed with the graft hepatic artery after trimming the edge until reaching a healthy segment. A total of 11 (52.4%) cases were reconstructed with the graft hepatic artery after intimal fixation of ID. Moreover, three (14.3%) cases had severe ID and failed intimal fixation and were reconstructed with the recipient splenic artery. Biliary stricture developed in two patients who had severe ID, and three patients developed transient bile leak. No hepatic artery complications, graft failure, or mortality occurred. Conclusion Intimal fixation technique proved to be an effective technique in most of the cases, with good short-term and long-term follow-up results. In severe ID or failure of intimal fixation, alternative recipient arteries other than hepatic artery can be used.

Short-term effects of extracorporeal graft rinse versus circulatory graft rinse in living donor liver transplantation. A prospective randomized controlled trial

Living donor liver transplantation has shorter cold ischemia time, less preservative volume, and lower metabolic load compared to transplantation from deceased donors. We investigated the impact of rinsing the graft contents into the systemic circulation on operative course and postoperative outcomes. Donors had right hepatectomy, and grafts were preserved with cold histidine‐tryptophan‐ketoglutarate solution. On ending portal vein anastomosis, grafts were flushed by patients portal blood either through incompletely anastomosed hepatic vein (extracorporeal rinse group, EcRg, n = 40) or into systemic circulation (circulatory rinse group, CRg, n = 40). The primary outcome objective was the lowest mean arterial blood pressure within 5 min after portal unclamping as a marker for postreperfusion syndrome (PRS). Secondary objectives included hemodynamics and early grafts and patients outcomes. Within 5 min postreperfusion, mean arterial blood pressure was significantly lower in the CRg compared to the EcRg, yet this was clinically insignificant. Postoperative graft functions, early biliary and vascular complications, and three‐month survival were comparable in both groups. Rinsing the graft into the circulation increased the incidence of PRS without significant impact on early graft or patient outcome in relatively healthy recipients.

Spray Diathermy Versus Harmonic Scalpel Technique for Hepatic Parenchymal Transection of Living Donor

BackgroundLiver parenchymal transection is the most invasive and challenging part in the living donor operation. The study was planned to compare the safety, efficacy, and outcome of harmonic scalpel versus spray diathermy as a method of parenchymal liver transection in donor hepatectomy.Patient and MethodEighty consecutive patients, who were treated by living donor liver transplantation (LDLT), were included in the study. The study population was divided into two groups according to the method of liver transection: group A by harmonic scalpel (HS) and group B by spray diathermy (SD). The primary outcome was the volume of blood loss during transection. Secondary outcomes were time of transection, number of ligatures needed during transection, pathological changes at cut surface, postoperative morbidities, cost, and hospital stayResultsBlood loss during overall liver transection and in each zone was significantly less in the SD than in the HS group (P = 0.015). The number of ligatures was significantly less in the SD than in the HS group (P = 0.0001). The SD group had significantly higher level of serum bilirubin, serum glutamic pyruvic transaminase (SGPT), and international normalized ratio (INR) levels on postoperative day 3 than the HS group. Lateral tissue coagulation and hepatic necrosis are significantly less in HS group. The overall incidence of postoperative morbidities was the same in both groups. The cost was higher in HS group than SD group (US