Hazem Zakaria

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).

Impact of Preoperative Endoscopic Biliary Drainage on Postoperative Outcome after Pancreaticoduodenectomy

Background: The value of preoperative biliary drainage (PBD) on the surgical outcome after pancreaticoduodenectomy (PD) is still a point of controversy. The aim of this study was to identify the impact of biliary drainage (BD) prior to PD on the postoperative outcome. Methods: The data of patients, who underwent PD from February 2009 to February 2017, were retrospectively studied. A comparison was performed between 2 groups of patients; group A (with PBD) and group B (without PBD), according to preoperative, operative and postoperative data. Results: PD was performed in 158 patients with periampullary lesions. Group A, included 76 patients (48.1%) while 82 patients were included in group B (51.9%). The incidence of major postoperative complications was significantly higher in group A (P=0.04). The infectious complications were higher in group like; positive intraoperative bile culture (P=0.06), intraabdominal abscess (P=0.07) and wound infection (P=0.04). Also, hospital stay and mortality were higher in group A (P=0.05 and 0.08, respectively). High preoperative bilirubin level was not a risk factor for major postoperative complications (P=0.12). Conclusion: Patients with PBD had a significantly higher incidence of major postoperative complications mainly of infectious ones, thus PBD should be performed only in selected patients, not as a routine prior PD.

Living Donor Liver Transplantation for Patients with Pre-existent Portal Vein Thrombosis

Background: Portal vein thrombosis (PVT) in living donor liver transplantation (LDLT) is a surgical challenge with technical difficulty. The aim of this study was to analyze the operative planning for management of PVT in LDLT and the impact of PVT on the outcome in comparison to patients without PVT. Methods: Between July 2003 to August 2016, 213 patients underwent LDLT. The patients were divided into two groups with and without PVT. The preoperative, operative, and postoperative data were analysed. Results: Thirty six patients (16.9%) had different grades of PVT at time of liver transplantation (LT); grades I, II, III and IV were 18 (50%), 14 (38.9%), 3 (8.3%) and 1 patient (2.8%) respectively. The management of PVT was by; thrombectomy in 31 patients (86%), bypass graft in 2 patients (5.6%), portal replacement graft in 1 patient (2.8%), anastomosis with the left renal vein in 1 patient (2.8%) and with large collateral vein in 1 patient (2.8%). Overall postoperative PVT occurred in 10 patients (4.7%), 4 patients of them had preoperative PVT. The perioperative mortality in patients with PVT, and patients without PVT was 33.3%, and 20.3%, respectively (P=0.17). The 1-, 3-, 5-, and 7y survival in patients with PVT was 49.7%, 46.2%, 46.2%, 46.2% respectively and in patients without PVT it was 65%, 53.7%, 50.8%, 49% respectively (P=0.29). Conclusions: Preoperative PVT may not keep a patient from undergoing successful LT with comparable outcome to patients without PVT specially with partial PVT.

Nonparasitic liver cysts: different treatment strategies

Objective The aim of this work was to study the clinicopathological data of nonparasitic liver cysts (NPLCs), its different management modalities, and outcome. Patients and methods This retrospective study included patients who were diagnosed as having NPLCs from January 2000 to the start of 2016. The clinicopathological data, surgical and nonsurgical treatment, and outcomes of these patients were studied. Results NPLC was present in 118 patients. There were 78 (66.1%) female patients and the median age was 48 years. The majority of cases (95; 80.5%) were of simple liver cysts and its management was conservative treatment with follow-up (51 patients; 53.7%), percutaneous aspiration, puncture aspiration injection and reaspiration or pig-tail catheter drainage (26 patients; 27.4%), and surgical treatment (18 patients; 18.9%) with either laparoscopic deroofing (12 patients) or open surgery (six patients). Six (5.1%) patients with intrahepatic biloma underwent percutaneous aspiration or pig-tail drainage. Five (4.2%) patients had cystadenoma and underwent resection or pericystectomy. Five (4.2%) patients had post-traumatic hematoma and underwent conservative treatment. Three (2.5%) patients had polycystic liver disease; one of them underwent laparoscopic deroofing of large ones and two patients underwent conservative treatment. Two (1.7%) patients had Caroli’s disease and were prepared for liver transplantation. Two (1.7%) patients had cysts with biliary atresia and underwent Kasai operation with excision of the cyst. Conclusion Most of the NPLCs are simple liver cyst that can be managed conservatively if it is asymptomatic and small, or with percutaneous radiological intervention or laparoscopic deroofing for large symptomatic or recurrent ones. Open or laparoscopic resection or pericystectomy is reserved for cystic neoplasms which is not common.

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.

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.

Hepatic Resection for Hepatocellular Carcinoma in Cirrhotic Patients with Portal Hypertension

Hepatic resection (HR) in cirrhotic patients with hepatocellular carcinoma (HCC) and portal hypertension (PHT) is not recommended, according to international guidelines. The aim of the present study was to determine the outcome of HR for HCC in cirrhotic patients with PHT.

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.

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.