Cihan Agalar

Complications in Donors Using Right Liver Graft: Analysis of 280 Consecutive Cases

INTRODUCTION Living donor liver transplantation (LDLT) is performed with increasing frequency worldwide due to the shortage of donated organs. It is a life-saving procedure for the recipient, but, on the other hand, a major surgical procedure for healthy donors and it may cause morbidity and even mortality. PATIENTS AND METHODS This research was completed at Dokuz Eylül University Faculty of Medicine Hospital General Surgery Department Liver Transplant Unit and included 280 cases (4 with simultaneous liver and kidney transplants from living donors) who underwent donor right hepatectomy for LDLT from June 2000 to June 2016. We analyzed the data of patients retrospectively. RESULTS Of 280 donor right hepatectomies for LDLT, 181 were male (M; 64.6%) and 99 were female (F; 35.4%) (M/F: 1.82). Mean donor age was 31.2 ± 0.9 years (range, 18-56). Mean donor monitoring duration was 45 ± 2.4 months (range, 3-192 months). Mean body mass index (BMI) was 24.28 ± 2.96 kg/m2 (range, 18.1-32.42 kg/m2). In our study 72 cases (25.7%) developed postoperative complications. There were 17 Clavien grade 3A, 1 grade 3B, and 5 grade 4A complications and also 1 death due to pulmonary embolism. CONCLUSION Together with the increase in living donor surgery, the morbidity and mortality of these cases are becoming controversial. Full donor safety is only possible with appropriate donor choice requiring very detailed studies, a problem-free hepatectomy process, and close postoperative donor monitoring.

En Bloc Pancreaticoduodenectomy for Locally Advanced Right Colon Cancers

Locally advanced right colon cancer may invade adjacent tissue and organs. Direct invasion of the duodenum and pancreas necessitates an en bloc resection. Previously, this challenging procedure was associated with high morbidity and mortality; however, today, this procedure can be done more safely in experienced centers. The aim of this study is to report our experience on en bloc right colectomy with pancreaticoduodenectomy for locally advanced right colon cancers. Between 2000 and 2012, 5 patients underwent en bloc multivisceral resection. No major morbidities or perioperative mortalities were observed. Median disease-free survival time was 24.5 months and median overall survival time was 42.1 (range: 4.5–70.4) months in our series. One patient lived 70 months after multivisceral resection and underwent cytoreductive surgery and total pelvic exenteration during the follow-up period. In locally advanced right colon tumors, all adhesions should be considered as malign invasion and separation should not be done. The reasonable option for this patient is to perform en bloc pancreaticoduodenectomy and right colectomy. This procedure may result in long-term survival with acceptable morbidity and mortality rates. Multidisciplinary teamwork and multimodality treatment alternatives may improve the results.

Solid-Pseudopapillary neoplasm of the pancreas: A clinicopathological review of 20 cases including rare examples

AIMS Solid-pseudopapillary neoplasm (SPN) is an uncommon malignant tumor of the pancreas with a favorable prognosis unlike other pancreatic neoplasms. We investigated the clinicopathological features of 20 patients with SPN in details. METHODS The patients diagnosed as SPN in Dokuz Eylul University Hospital between January 2005 and March 2016 were reviewed in terms of clinical and histopathological data. RESULTS Mean age of the patients was 33. Three of our cases were male and 4 were children. Some patients had synchronuous malignancies. Nine patients were diagnosed by fine needle aspiration cytology (FNAC). One of our tumors had 2×1mm of pancreas endocrine neoplasm in addition to SPN. One case had foci of atypical and multinucleated giant cells. All cases were positive for vimentin and CD10 antibodies and most were positive for PR and β-catenin. The mean follow-up duration was 40 mo (range 2-110 mo). Only one case showed liver metastasis. CONCLUSION Herein we present a series of 20 patients with 3 male and 4 pediatric cases, almost half of which were diagnosed with FNAC findings, and most of which are clinically being followed with one patient showing progression. Our series includes rare examples like collision tumor of SPN and pancreas endocrine neoplasm, SPN with multinucleated giant cells. Also cases with no surgical treatment and no progression, as well as cases with synchronous malignancies are presented. We believe that FNAC findings of any pancreatic mass should be investigated in detail for the designation of a therapy plan especially for the patients with high operation risks. The findings in our series also show that extensive necrosis, angioinvasion, perineurial invasion and larger tumor size might be predictive for worse prognosis and these patients should be more closely followed up.

Adult morgagni hernia: A single-center experience of five cases and a review of literature

Morgagni hernia is a rare congenital anomaly arising from the fusion defect between the septum transversum and sternum. The diagnosis is usually difficult since the presentation may be asymptomatic or with respiratory symptoms, abdominal and/or retrosternal pain, abdominal fullness, or gastrointestinal obstruction. In this report, we discuss the clinical presentation and management of this rare condition in five consecutive cases. Between 2009 and 2015, five cases underwent surgery for Morgagni hernia (three laparoscopic and two open repair surgeries); one patient developed recurrent hernia 7 months after the laparoscopic surgery. This case is the first reported recurrence in literature following laparoscopic repair in adults. Surgery is the only treatment option for Morgagni hernias, which can be performed through transthoracic, transabdominal, laparoscopic, or thoracoscopic approach. The issues of using mesh and reducing the hernial sac remain controversial.

Reply to Comment to: Preventing parastomal hernia with modified stapled mesh stoma reinforcement technique (SMART) in patients who underwent surgery for rectal cancer: a case–control study. Li J, Zhang W

We read with interest the comments of Dr. Li and Dr. Zhang on our paper preventing parastomal hernia with modified stapled mesh stoma reinforcement technique (SMART) in patients who underwent surgery for rectal cancer: a case–control study. We believe that the determination “a method that is less effective for the treatment would be less effective for prevention and used with caution” is not appropriate for comparison of keyhole parastomal hernia (PSH) repair and prevention, because they are anatomically different scenarios. During the key hole repair of the PSH, the fascial defect is the main reason for the failure; however, in PSH prevention with keyhole mesh technique, there is no fascial defect. Current trials on PSH prevention have diverse results. The authors discussed two prospectively randomized trials. The cited reference 3 should be replaced by the latest update of the PREVENT trial in Annals of Surgery [1], because the cited one did not mention the parastomal hernia prevention rate; instead that, manuscript is focused on the safety of the prophylactic mesh and method. We also included the result of this study in our discussion. STOMAMESH trial [2] which was not published when we submitted our manuscript. However, as this study is a prospective randomized trial, discussion of its result will be valuable. Recent European Hernia Society (EHS) guidelines on prevention and treatment of parastomal hernias strongly recommend the use of prophylactic synthetic non-absorbable mesh when constructing an elective permanent end colostomy to reduce the parastomal hernia rate [3]. We also believe that when using the keyhole technique, the diameter or creation of the mesh hole is important and should be standardized especially in multicenter randomized trials. In the SMART [4] method, creation of the mesh hole by the use of a circular stapler gun device may contribute to standardizing the technique. We like to thank for the author(s) valuable comments and we believe that STOMAMESH trial [2] which was not published when we submitted our manuscript will be a new discussion point in prevention of parastomal hernias. Best regards.

Comparison of Resection and Liver Transplant in Treatment of Hepatocellular Carcinoma

OBJECTIVES Hepatic resection and liver transplant are regarded as 2 potentially curative treatments for hepatocellular carcinoma. Here, we compared both options in patients with hepatocellular carcinoma secondary to cirrhosis seen at a single center over 12 years. MATERIALS AND METHODS We evaluated early complications and survival of patients with hepatocellular carcinoma treated with liver transplant (57 patients) or hepatic resection (36 patients) at our center between 1998 and 2010. RESULTS The 34-month mean follow-up period was similar for both treatment groups. The liver transplant group had a longer hospital stay than the hepatic resection group (P ⟨ .001). Patients with Child-Turcotte-Pugh A stage were treated by hepatic resection more than by liver transplant (P ⟨ .001),with Child-Turcotte-Pugh B stage patients treated by liver transplant more than by hepatic resection (P = .03). All patients with Child-Turcotte-Pugh C stage had liver transplant. Both treatment groups had similar postoperative complications and early postoperative mortality rates, but liver transplant resulted in longer overall (P = .001) and higher event-free (P = .001) survival than hepatic resection. Among the liver transplant group, 57.8% of patients met the Milan criteria. Patients who met Milan criteria were treated by liver transplant statistically more than hepatic resection, and these patients had longer overall survival (P = .01) and higher event-free survival (P ⟨ .001) than patients who had hepatic resection. Hepatocellular carcinoma recurrence rates were higher after hepatic resection (P = .232). CONCLUSIONS In patients with hepatocellular carcinoma, hospital stay was longer after liver transplant, but morbidity and mortality rates for liver transplant versus hepatic resection were similar. However, overall and event-free survival rates were better after liver transplant than after hepatic resection. These results suggest that liver transplant should be considered as the primary treatment option for patients with hepatocellular carcinoma secondary to cirrhosis.

Hepatic Artery Reconstruction With Autologous Inferior Mesenteric Artery Graft in Living Donor Liver Transplant Recipients

INTRODUCTION In living donor liver transplantation (LDLT), hepatic arterial continuity is crucial to avoid biliary leakage, biliary stricture, cholangitis, and graft and patient loss. Sometimes there exist factors making anastomosis difficult or even impossible. In these cases, a vascular graft may be needed to bridge the two arteries for revascularization. METHOD Medical records of 297 patients who underwent LDLT between June 2000 and July 2016 at the Hepatopancreatobiliary Surgery and Liver Transplantation Unit of Dokuz Eylul University Hospital were reviewed retrospectively. Twenty-eight (9%) patients younger than the age of 18 were excluded from the study. The remaining 269 patients were included in the study. We analyzed data of patients who developed hepatic arterial complications during or after LDLT and underwent revascularization using autologous interposed inferior mesenteric artery (IMA) grafts. RESULTS In 8 (2.9%) of the 269 patients who underwent LDLT and were included in the study, autologous interposed IMA grafts were used for the hepatic artery revascularization. All of the patients were males. Their mean age was 42 (range, 25-57). The mean duration of follow-up was 83.25 months (range, 3-144 months). One patient developed intraoperative hepatic arterial thrombosis (HAT) after autologus IMA reconstruction and this patient needed retransplantation. No arterial complications developed in the other 7 patients. CONCLUSION Autologous interposed IMA graft could be used as an alternative vascular graft in hepatic artery revascularization to provide tension-free hepatic arterial continuity.

Long-term Results of Living Donors in Simultaneous Kidney and Liver Transplantations

INTRODUCTION Because of the shortage of organs available for transplantation, living related sequential transplantation with the use of liver and a kidney from the same donor has emerged as a reasonable therapeutic alternative. However, there is insufficient literature about the complications that living donors experience after simultaneous kidney and liver transplantations. METHODS From December 2001 to October 2009, 5 living donors provided simultaneous donation of livers and kidneys and 1 living donor donated first her kidney and then her liver. Demographic data of the donors and information concerning the surgery and postoperative observation were collected prospectively. RESULTS All of the donors were female. The median age was 27.5 (range, 19-36) years. Indications requiring the simultaneous transplantation of livers and kidneys were primary hyperoxaluria type 1 (PH1) in 5 potential recipients and cirrhosis due to chronic hepatitis B infection and idiopathic chronic renal insufficiency in 1 potential recipient. Four recipients underwent right hepatectomy (segments 5-8) and right nephrectomy; 1 recipient underwent left hepatectomy (segments 2-4) and right nephrectomy; and 1 recipient underwent left lobectomy (segments 2-3) and right nephrectomy. There were no complications except in 1 donor (postoperative ileus). No donor developed hypertension or microalbuminuria. CONCLUSIONS With the right indications, appropriate preoperative evaluation, meticulous surgical technique, proper postoperative care, and long-term close monitoring to minimize morbidity and mortality risks, liver and kidney donation from the same donor can be considered for simultaneous kidney and liver transplantation.

Porcine Dermal Collagen Prevents Seroma Formation After Mastectomy and Axillary Dissection in Rats

OBJECTIVE Seroma occurs as a result of accumulation lymphovascular liquid in the dead space forming after tissue dissection. It is the most common complication after breast surgery. Collagens are the common component of extracellular matrix and have an important role in wound healing. In this study, we aimed to investigate the efficiency of the Porcine Dermal Collagen in preventing Seroma. MATERIALS AND METHODS Eighteen young female Wistar rats were used and divided into three groups. Mastectomy and axillary dissection were performed in each group. No other procedures were performed in Group 1 (Control group). Porcine dermal collagen was applied to 50% of the mastectomy field in Group 2 and to 100% of the mastectomy field in Group 3. RESULTS Seroma volume was significantly decreased in Group 3 in contrast to Groups 1 and 2 (p<0.001) and in Group 2 in contrast to Group 1 (p<0.001). Vascular proliferation, granulation tissue formation and congestion were significantly increased in Group 3 (p<0.05). CONCLUSION We conclude that the use of Porcine Dermal Collagen reduces the formation of seroma in the model of experimental mastectomy and axillary dissection. As the amount of Porcine Dermal Collagen applied increases the formation of seroma reduces.