Amr M Aziz

Recurrent Hepatitis C Virus (Genotype 4) Infection after Living Donor Liver Transplantation: Risk Factors and Outcome

Objectives: The recurrence of HCV post liver transplantation endangers patient and graft survival. The aim of this study is to analyze the risk factors for HCV recurrence, the effect of the recurrence and its management on the outcome of liver transplantation. Materials and methods: After exclusion of the 6 months mortality, dual HCV and HCC patients, about fifty five HCV related LDLT patients were enrolled in the study and were followed up from 6 to 60 months. Demographic, preoperative, intraoperative and postoperative data were studies. HCV recurrence was defined by elevated transaminases, positive serum HCV RNA and liver biopsy findings. Univariate and multivariate analysis were done on all data to detect the favoring factors of HCV recurrence. Results: HCV recurrence occurred in 21/55 of the patients and one of them developed cirrhosis on follow up. By univariate analysis; CMV infection, mean operative time (12.490 ± 1.8952), acute cellular rejection and pulse steroids treatment were predictors of HCV recurrence (P<0.05). Multivariate analysis revealed only acute cellular rejection to be a predictor. The overall 1, 3 and 5 years’ survival of all patients was 94.5%, 90.9% and 90.9% respectively, while the overall 1, 3 and 5 years’ survival of patients with and without recurrence was 95.2%, 90.5% and 90.5% and 94.1%, 91.2%and 91.2% respectively. Conclusion: The occurrence of acute rejection was independent predictor of HCV recurrence post LDLT, so its prevention is required to decrease this recurrence. Similarly, prevention of CMV infection and decreasing operative time is important to decrease post-transplant HCV recurrence.

Analysis of Donor Motivations in Living Donor Liver Transplantation

Objectives: The introduction of the living donor liver transplantation (LDLT) in Egypt as in elsewhere, has raised important psychological conflicts and ethical questions. The objective of this study was to get better understanding of the potential donors’ motives toward LDLT. Methods: This study was conducted on consecutive 193 living-liver donors who underwent partial hepatectomy as donors for LDLT during the period between April 2003 and January 2013, at the National Liver Institute Menoufeyia University, Egypt. Potential donors were thoroughly evaluated preoperatively through a screening questionnaire and interviews as regard their demographic data, relationship to the potential recipient, and motives toward proceeding to surgery. They were assured that the information shared between them and the transplant center is confidential. Results: The donors’ mean age was 25.53 ± 6.39 years with a range of 18–45 years. Males represented 64.7% and females were 35.3%. The most common donors (32.1%, n = 62) were sons and daughters to their parents (sons: n = 43, daughters: n = 19) while parents to their offsprings represent 15% (mothers: n = 21, fathers: n = 8). Brothers and sisters represent 16.5% (brothers: n = 22, sisters: n = 10). Nephews and nieces giving their uncles or aunts were 14%. The number of wives donating to their husbands was 11 (5.7%). Interestingly, there was no single husband who donated his wife. Among the remaining donors, there were 11 cousins and 1 uncle. Unrelated donors were 20 (10.4%). Several factors seemed to contribute to motivation for donation: the seriousness of the potential recipient condition, the relationship and personal history of the donor to the potential recipient, the religious beliefs, the trust in the health care system, and family dynamics and obligations. Conclusion: Absolute absence of coercion on the living-liver donor’s motives may not be realistic because of the serious condition of the potential recipient. It is mandatory that the donor is truly willing to donate.

Risk factors impacting mortality after living related liver transplantation for hepatocellular carcinoma: a retrospective cohort study

Objective Liver transplantation is an optimal form of radical therapy for selected patients with hepatocellular carcinoma (HCC). Yet, risk factors determining outcome after living donor liver transplantation (LDLT) are still lacking and need to be well identified to maximize recipient benefit and minimize donor risk. Aim The aim of this study was to retrospectively identify and analyze the factors impacting mortality in HCC patients after LDLT. Patients and methods This is a single-center retrospective analysis of data collected from 205 patients who underwent LDLT in the Department of Surgery, National Liver Institute, Menoufia University, between May 2004 and December 2013. Of these patients, 53 proved to have an HCC in the explanted liver. Preoperative data such as demographic criteria of the patients, liver status, tumor burden, and downstaging or bridging procedures, and all intraoperative and postoperative data were collected and compared against mortality outcome. Mortality was divided into three periods: hospital mortality, which occurred within 30 days after operation; early mortality, which occurred between 2 and 6 months postoperatively; and late mortality, which occurred 6 months after transplantation. Results The mean age of all patients was 48±6.1 years; 50 (94.3%) patients were male. During the follow-up period, 22 (41.5%) patients died. The majority of mortality cases (10; 18.9%) were in the perioperative period; six (11.3%) patients died in the early period and six (11.3%) in the late period. There was a statistically significant relation between mortality rate and cytomegalovirus immunoglobulin (CMV-IgG) negativity and TNM classification (IIIB). Concerning the operative data, there was a significant statistical relation between mortality and actual graft weight, actual graft/recipient weight ratio, and number of blood and plasma transfused units. Postoperatively, there was a significant statistical relation between mortality and the grade of tumor differentiation. In multivariate analysis, CMV-IgG negativity, TNM stage (stage III), actual graft weight, and number of blood transfusion units were independent predictors of mortality. Conclusion Several factors have an independent significant effect on post-liver transplantation mortality. CMV-IgG negativity, advanced tumor stage (IIIB), actual graft weight, volume of intraoperative blood transfusion, poor tumor grade of differentiation, and tumor recurrence have an influence on post-transplantation mortality. Because LDLT can be performed regardless of Child–Pugh classification, model of end-stage liver disease score, and portal hypertension, only tumor factors, graft volume, and technical complications should be considered when selecting HCC patients for LDLT.

Evaluation of surgical complications in 204 live liver donors according to the modified clavien classification system

Background Several large centers have reported outstanding outcomes of living donor liver transplantation in decreasing mortality on the liver transplant waiting list. Nevertheless, living donor liver transplantation is not without risk to the volunteer donors. The rate of complications differs widely among transplant centers. Yet, there is no consensus on how to define and stratify complications by severity. Participants and methods This retrospective study to identify and analyze the surgical outcomes of 204 consecutive living donor hepatectomies was carried out between April 2003 and October 2013 by using the modified Clavien classification system, according to which grade I=minor complications, grade II=any deviation from the normal postoperative course requiring pharmacologic treatment, grade III=complications requiring invasive treatment, grade IV=complications causing organ dysfunction requiring ICU management, and grade V=complications resulting in death. Results The present study included 129 (63.2%) males and 75 (36.8%) females, with the donor’s mean age being 27.72±6.4 years (range: 19–45 years). There were 64 (31.4%) donors who developed postoperative complications, with a total of 74 complications. Ten (4.9%) donors had more than one complication. Twenty-nine (39.2%) donors had Clavien’s grade I complications, 38 (51.3%) donors had Clavien’s grade IIIa, six (8.1%) donors had Clavien’s grade IIIb complications, and there was one (0.5%) case of mortality (Clavien’s grade V). Conclusion Donor hepatectomy is a relatively safe procedure when performed by a dedicated and well-trained team. A prompt diagnosis and meticulous intervention is considered the first priority whenever a donor complication is expected. Furthermore, a continuous standardized reporting and a comprehensive database are crucial to precisely define true donor morbidity.

Influence of technical refinement on biliary complications of donors of living donor liver transplantation: a retrospective comparative study

Background Biliary complications (BCs) of living liver donors are of serious concern as they threaten the donor’s health and life. Technical problems are the main cause of these complications. Aim We conducted a retrospective analysis of the incidence, types, and management polices of BCs in our cohort of donors of living donor liver transplantation, with special emphasis on the impact of technical refinement of bile duct stump closure. Patients and methods Data were reviewed from a prospectively maintained database of all donors who underwent hepatectomy. The incidence and types of and management options for BCs in living liver donors were compared in two successive phases of our program of living donor liver transplantation. The first period included 140 donors in a procedure in which the bile duct stump was closed using continuous sutures or interrupted sutures, whereas the second period comprised 100 donors in a procedure in which the bile duct stump was closed using a newly designed technique by combining suturing and reinforcement with a metallic clip just below the suture line. Before abdominal closure, the intraoperative cholangiogram was repeated. Results The overall incidence of BCs among donors was 14.2%. On comparison of BCs in the two studied phases we found significant differences in the rate of BCs: 20% in the first phase and 6% in the second phase. Further, a significant difference was documented in the two periods with respect to age less than 30 years, male donors, BMI more than 25%, left lobe or left lateral graft, and one duct (P Conclusion Our newly adopted technique of bile duct stump closure as well as the performance of two intraoperative cholangiographies before cutting and after closure of the stump resulted in significant improvement in and reduction of BCs. This new technique is safe, simple, and reproducible and does not prolong the surgery.

The safety and adequacy of liver resection for large hepatocellular carcinoma: A retrospective single institute study

Background: Most major hepatocellular carcinoma (HCC) staging systems recommend hepatic resection only for patients with early-stage of HCC. Still there is controversial about resection of patients with large HCC (defined as >5 cm). The aim of this retrospective study is to investigate the clinicopathological features that impacted the long-term outcomes of 1 year after hepatectomy of large HCC >5 cm in cirrhotic patients. Materials and Methods: From February 2012 to December 2015, a total of 92 patients with resection of large HCC on liver cirrhosis were reviewed retrospectively and considered for clinicopathological features that impacted the long-term outcomes. Time to recurrence (recurrence-free survival) and overall survival (OS) were determined by Kaplan-Meier analysis. Results: Twenty-nine (31.5%) patients developed tumor recurrence. The mean time until tumor recurrence was 12.4 ± 6.6 months. The cumulative 1-, 2-, and 3-year disease-free survival rates were 73%, 28%, and 18%, respectively. On multivariate analysis, male gender, α-fetoprotein >400, bilobed tumors, patients with portal hypertension, plasma transfusion, and absence of tumor capsule remained independent predictors for recurrence of HCC. The OS rates at 1, 2, and 3 years were 73%, 31%, and 16%, respectively. On multivariate analysis, α-fetoprotein >400 and plasma transfusion remained independent predictors for death. Conclusions: Liver resection is suggested in patients with large HCC and can be performed with acceptable overall and disease-free survival and morbidity rates. Identification of risk factors and close postresection follow-up with early detection are mandatory measures for prompt treatment of tumor recurrence which is reflected by a beneficial survival rate for this group of patients.

Iatrogenic bile duct injury: A retrospective analysis of short- and long-term outcomes after surgical repair

Background: Iatrogenic bile duct injuries (IBDIs) remain an important problem in gastrointestinal surgery and represent a big challenge for surgeons. Aim: To review the management of IBDI and describe short- and long-term postoperative complications of surgical repair at our tertiary referral institute. Patients and Methods: This was a retrospective review of the medical record of all patients referred for the management of IBDIs between January 2005 and January 2015. One hundred patients formed the study cohort. Preoperative data including patient demographics, mechanism of injury, operative details, and postoperative outcomes were extracted. Research Ethics Board approval was obtained. Results: There were 36 men and 64 women, with a mean age 45.4 ΁ 11.5 years. Open cholecystectomy was the most common procedure in 61 patients, whereas laparoscopic surgery was the primary treatment in 39 patients. Twenty-nine patients treated by nonsurgical management in the form of endoscopic retrograde cholangiopancreatography (ERCP) and stenting and percutaneous abdominal drainage. Seventy patients underwent operative surgery in the form of Roux-en-Y H.J, and T-tube insertion in the common bile duct in two cases. Short-term complications encountered in 15 (20.8%) cases, with a significant correlation with a previous ERCP intervention (P = 0.047). Long-term complications encountered in 12 (16.6%) patients, with a significant relation with the intermediate timing (within 2 weeks) of repair (P = 0.037). Conclusions: Prompt diagnosis of the type and grade of injury is mandatory before deciding management. Intermediate time for surgical intervention was significantly related to stricture complications. ERCP should be done only in cases that can benefit from conservative management (Strasberg from A-D) as the incidence of postoperative complication is high after surgical repair.