H. Shoreem

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.

Small for size syndrome difficult dilemma: Lessons from 10 years single centre experience in living donor liver transplantation

AIM To analyze the incidence, risk factors, prevention, treatment and outcome of small for size syndrome (SFSS) after living donor liver transplantation (LDLT). METHODS Through-out more than 10 years: During the period from April 2003 to the end of 2013, 174 adult-to-adults LDLT (A-ALDLT) had been performed at National Liver Institute, Menoufiya University, Shibin Elkoom, Egypt. We collected the data of those patients to do this cohort study that is a single-institution retrospective analysis of a prospectively collected database analyzing the incidence, risk factors, prevention, treatment and outcome of SFSS in a period started from the end of 2013 to the end of 2015. The median period of follow-up reached 40.50 m, range (0-144 m). RESULTS SFSS was diagnosed in 20 (11.5%) of our recipients. While extra-small graft [small for size graft (SFSG)], portal hypertension, steatosis and left lobe graft were significant predictors of SFSS in univariate analysis (P = 0.00, 0.04, 0.03, and 0.00 respectively); graft size was the only independent predictor of SFSS on multivariate analysis (P = 0.03). On the other hand, there was lower incidence of SFSS in patients with SFSG who underwent splenectomy [4/10 (40%) SFSS vs 3/7 (42.9%) no SFSS] but without statistical significance, However, there was none significant lower incidence of the syndrome in patients with right lobe (RL) graft when drainage of the right anterior and/or posterior liver sectors by middle hepatic vein, V5, V8, and/or right inferior vein was done [4/10 (28.6%) SFSS vs 52/152 (34.2%) no SFSS]. The 6-mo, 1-, 3-, 5-, 7- and 10-year survival in patients with SFSS were 30%, 30%, 25%, 25%, 25% and 25% respectively, while, the 6-mo, 1-, 3-, 5-, 7- and 10-year survival in patients without SFSS were 70.1%, 65.6%, 61.7%, 61%, 59.7%, and 59.7% respectively, with statistical significant difference (P = 0.00). CONCLUSION SFSG is the independent and main factor for occurrence of SFSS after A-ALDLT leading to poor outcome. However, the management of this catastrophe depends upon its prevention (i.e., selecting graft with proper size, splenectomy to decrease portal venous inflow, and improving hepatic vein outflow by reconstructing large draining veins of the graft).

Laparoscopic left lateral bisegmentectomy for hepatocellular carcinoma: moving from peripheral to anatomical

Context The use of the laparoscopic approach for liver resections became popular worldwide and is now of increasing popularity in Egypt. The growing experience in laparoscopic liver resections has made it more applicable in cirrhotic livers with hepatocellular carcinoma. Aim The aim of this study was to assess the feasibility and safety of laparoscopic left lateral liver resections in a tertiary centre in Egypt. Patients and methods A retrospective analysis of laparoscopic liver resections was undertaken in patients with preoperative diagnoses of a hepatocellular carcinoma with compensated cirrhosis. Surgical technique included CO2 pneumoperitoneum and liver transection with a harmonic scalpel and laparoscopic Habib 4X sealer without portal triad clamping or hepatic vein control. Portal pedicles and large hepatic veins were stapled. Resected specimens were placed in a bag and removed through a separate incision, without fragmentation. Nonparametric data were presented as medians (range), and categorical data as frequency and proportion (%). P value less than 0.05 was considered statistically significant. Statistical analyses were performed using the IBM SPSS software, version 23. Results From August 2008 to February 2016, 38 liver resections were included. Eleven patients with a diagnosis of HCC were planned for laparoscopic left lateral resection. The mean tumour size was 5.6±2.1 cm. There were five conversions to laparotomy: two cases because of bleeding, one because of stapler failure, one because of accessibility failure, and one because of failure to extract the specimen. Mean blood loss was 150±75 ml. Mean surgical time was 160±40 min. There were no deaths. Complications occurred in two patients: only one patient developed postoperative ascites and the other developed bile leak. Conclusion Laparoscopic left lateral bisegmentectomy is feasible and safe in selected patients with adequate training and preparation.

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.

Pattern of Hepatocellular Carcinoma Recurrence Following Living Donor Liver Transplantation

Living donor liver transplantation (LDLT) is a promising treatment option for patients with hepatocellular carcinoma (HCC), but tumour recurrence can affect long‐term survival. The aim of the present study was to identify the pattern of HCC recurrence after LDLT for early detection and management.

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.

Early (<6 months) Mortality after Adult to Adult Living Donor Liver Transplantation,Single Centre Experience: A Retrospective Cohort Study

Objectives: Both complications and mortality of recipients are annoying problems after living donor liver transplantation (LDLT). The aim to analyze early (<6 months) mortality of patients after adult to adult LDLT (A-ALDLT) in a single center. Methods: Between April 2003 and February 2013, we performed 167 A-ALDLT in National Liver Institute, Egypt. We retrospectively analyzed early mortality in recipients. Results: The overall incidence of early mortality was 34.1% (n=57), it was classified into in hospital (28.7%) and post-hospital discharge (5.4%) mortalities. The most frequent causes of in hospital and post hospital discharge mortalities were SFSS (10/48) and sepsis (5/9) respectively. On univariate analysis, the following factors were significant predictors of early mortality (Female gender, Lt Lobe graft, GRWR<0.8, mean blood transfusion 10.8 ± 9.8 units,(vascular, renal, chest, neurological, bacterial infection and small for size syndrome (SFSS)) complications. While on multivariate analysis by Cox regression, mean blood transfusion 10.8 ± 9.8 units, vascular and neurological complications were independent predictors. Conclusion: Reduction of blood transfusion units, prevention and management of vascular and neurological complications is required for better early outcome after A-A LDLT.

Secondary Liver Tumors

The liver is a common site of metastases. The most relevant metastatic tumor of the liver to the surgeon is colorectal cancer because of the well-documented potential for long-term sur‐ vival after complete resection. However, a large number of other tumors commonly meta‐ stasize to the liver, including cancers of the upper gastrointestinal system (stomach, pancreas, biliary), genitourinary system (renal, prostate), neuroendocrine system, breast, eye (melanoma), skin (melanoma), soft tissue (retroperitoneal sarcoma), and gynecologic system (ovarian, endometrial, cervix). [1]