Mohamed Shaker

In intermediate stage hepatocellular carcinoma: radioembolization with yttrium 90 or chemoembolization?

Transarterial chemoembolization (TACE) is one of the standard treatments recommended for intermediate stage hepatocellular carcinoma (HCC). At the same time, only little is known about the use of radioembolization with Yttrium‐90 microspheres (TARE Y‐90) for this subset of patients. To perform comparative analysis between both locoregional therapies in intermediate HCCs. Primary endpoint was overall survival (OS), while safety, response rate and time‐to‐progression (TTP) were considered as secondary endpoints.

Biliary complications including single-donor mortality: experience of 207 adult-to-adult living donor liver transplantations with right liver grafts

BACKGROUND After right lobe donation, biliary complication is the main cause of morbidity. Mortality after right lobe donation has been estimated to be less than 0.5%. PATIENTS AND METHODS Between November 2001 and December 2008, 207 adult-to-adult living donor liver transplantations (ALDLT) were undertaken using right lobe grafts. Donors included 173 men and 34 women with a mean age of 28.4 +/- 5.2 years. RESULTS Siblings comprised 144 (69.6%) cases whereas unrelated donors comprised 63 (30.4%) with a mean body mass index (BMI) of 25.2 +/- 2.4. Single and multiple right hepatic ducts (RHD) were present in 82 (39.6%) and 125 (60.3%) donors, respectively. Mean operative time was 360 +/- 50 min with an estimated blood loss of 950 +/- 450 ml and returned cell-saver amount of 450 +/- 334 ml. Mean donor remnant liver volume was 33.5 +/- 3.2%. Mean intensive care unit (ICU) stay was 3 +/- 0.7 days and mean hospital stay was 14 +/- 3.5 days. Modified Clavien classifications were used to stratify all donor biliary complications The overall biliary complications occurred in 27 cases (13.0%). After modified Clavien classification, biliary complications were graded as grade I (n= 10), grade II (n= 2), grade III (n= 14) and grade V (n= 1). Grade I and II (n= 12) biliary complications were successfully managed conservatively. Grade III cases were treated using ultrasound-guided aspiration (USGA), endoscopic retrograde cholangiography (ERCP) and surgery in 10, 2 and 2 donors, respectively. Single donor mortality (Grade V) (0.4%) occurred after uncontrolled biliary leakage with peritonitis that necessitated exploration followed by ERCP with stent insertion but the donor died on day 43 as a result of ongoing sepsis. CONCLUSION Although the majority of biliary complications are minor and can be managed conservatively, uncontrolled biliary leakage is a serious morbidity that should be avoided as it could lead to mortality.

Epidemiological characteristics of hepatocellular carcinoma in Egypt: a retrospective analysis of 1313 cases.

Hepatocellular carcinoma (HCC) is one of the most common malignant tumours worldwide. Egypt has the highest prevalence of HCV in the world and the prevalence of HCC is increasing in the last years. The aim was to study epidemiological characteristics of HCC in Egypt.

Epidemiological aspects of Budd-Chiari in Egyptian patients: a single-center study.

AIM To describe the socio-demographic features, etiology, and risk factors for Budd-Chiari syndrome (BCS) in Egyptian patients. METHODS Ninety-four Egyptian patients with confirmed primary Budd-Chiari syndrome were presented to the Budd-Chiari Study Group (BCSG) and admitted to the Tropical Medicine Department of Ain Shams University Hospital (Cairo, Egypt). Complete clinical evaluation and laboratory investigations, including a thrombophilia workup and full radiological assessment, were performed to determine underlying disease etiologies. RESULTS BCS was chronic in 79.8% of patients, acute or subacute in 19.1%, and fulminant in 1.1%. Factor V Leiden mutation (FVLM) was the most common etiological cause of disease (53.1%), followed by mutation of the gene encoding methylene tetrahydrofolate reductase (MTHFR) (51.6%). Current or recent hormonal treatment was documented in 15.5% of females, and BCS associated with pregnancy was present in 17.2% of females. Etiology could not be determined in 8.5% of patients. Males had significantly higher rates of MTHFR gene mutation and Behçets disease, and females had significantly higher rates of secondary antiphospholipid antibody syndrome. A highly significant positive relationship was evident between the presence of Behçets disease and inferior vena caval occlusion, either alone or combined with occlusion of the hepatic veins (P < 0.0001). CONCLUSION FVLM is the most common disease etiology and MTHFR the second most common in Egyptian BCS patients. BCS etiology tends to vary with geographic region.

Planning and prioritizing direct-acting antivirals treatment for HCV patients in countries with limited resources: Lessons from the Egyptian experience

BACKGROUND AND AIMS The introduction of direct-acting antivirals for hepatitis C virus (HCV) in Egypt led to massive treatment uptake, with Egypts national HCV treatment program becoming the largest in the world. The aim of this paper is to present the Egyptian experience in planning and prioritizing mass treatment for patients with HCV, highlighting the difficulties and limitations of the program, as a guide for other countries of similarly limited resources. METHODS Baseline data of 337,042 patients, treated between October 2014 to March 2016 in specialized viral hepatitis treatment centers, were grouped into three equal time intervals of six months each. Patients were treated with different combinations of direct-acting antivirals, with or without ribavirin and pegylated interferon. Baseline data, percentage of patients with known outcome, and sustained virological response at week 12 (SVR12) were analyzed for the three cohorts. The outcomes of 94,258 patients treated in the subsequent two months are also included. RESULTS For cohort-1, treatment was prioritized for patients with advanced fibrosis (F3-F4 fibrosis, liver stiffness ≥9.5 kPa, or Fibrosis-4 ≥3.25). Starting cohort-2, all stages of fibrosis were included (F0-F4). The prioritization strategy in the initial phase caused delays in enrollment and massive backlogs. Cohort-1 patients were significantly older, and more had advanced fibrosis compared to subsequent cohorts. The percentage of patients with known SVR12 results were low initially, and increased with each cohort, as several methods to capture patient results were adopted. Sofosbuvir-ribavirin therapy for 24 weeks had the lowest SVR12 rate (82.7%); while other therapies were associated with SVR12 rates between 94% and 98%. CONCLUSION Prioritization based on fibrosis stage was not effective and enrollment increased greatly only after including all stages of fibrosis. The availability of generic drugs reduced costs, and helped massively increase uptake of the program. Post-treatment follow-up was initially very low, and although this has increased, further improvement is still needed. LAY SUMMARY We are presenting the largest national program for HCV treatment in the world. We clearly demonstrate that hepatitis C can be cured efficiently in large scale real-life programs. This is a clear statement that global HCV eradication is foreseeable, providing a model for other countries with limited resources and prevalent HCV. Moreover, the availability of generic products has influenced the success of this program.

Venous malformations of the head and neck: A diagnostic approach and a proposed management approach based on clinical, radiological, and histopathology findings

There is no easy road map for venous malformations (VMs) of the head and neck according to which treatment modality can be chosen. The purpose of this study was to identify different types of VMs of the head and neck based on clinical, histopathology, MRI, and venography findings that help in specification of different treatment modalities.

Outcome of non surgical hepatic decompression procedures in Egyptian patients with Budd-Chiari

AIM To evaluate outcome of patients with Budd-Chiari syndrome after balloon angioplasty ± stenting or transjugular intrahepatic portosystemic shunt (TIPS). METHODS Twenty five patients with Budd-Chiari syndrome admitted to Ain Shams University Hospitals, Tropical Medicine Department were included. Twelve patients (48%) with short segment occlusion were candidates for angioplasty; with stenting in ten cases and without stenting in two. Thirteen patients (52%) had Transjugular Intrahepatic Portosystemic Shunt. Patients were followed up for 12-32 mo. RESULTS Patency rate in patients who underwent angioplasty ± stenting was 83.3% at one year and at end of follow up. The need of revision was 41.6% with one year survival of 100%, dropped to 91.6% at end of follow up. In patients who had Transjugular Intrahepatic Portosystemic Shunt, patency rate was 92.3% at one year, dropped to 84.6% at end of follow up. The need of revision was 38.4% with one year and end of follow up survival of 100%. Patients with patent shunts showed marked improvement compared to those with occluded shunts. CONCLUSION Morbidity and mortality following angioplasty ± stenting and TIPS are low with satisfactory outcome. Proper patient selection and management of shunt dysfunction are crucial in improvement.

Annexin A2 as a biomarker for hepatocellular carcinoma in Egyptian patients

AIM To investigate the clinical utility of serum annexin A2 (ANXA2) as a diagnostic marker for early hepatocellular carcinoma (HCC). METHODS This study was performed in HCC Clinic of Ain Shams University Hospitals, Cairo, Egypt and included: Group 1: Fifty patients with early stage HCC (Barcelona Clinic Liver Cancer stage A); Group 2: Twenty five patients with chronic liver disease; and Control Group: Fifteen healthy, age- and sex-matched subjects who were seronegative for viral hepatitis markers. The following laboratory investigations were done: Viral hepatitis markers [hepatitis B surface antigen and hepatitis C virus (HCV) antibodies], HCV RNA in HCV antibody-positive patients, serum alpha fetoprotein (AFP), and serum ANXA2 levels. RESULTS In this study, 88% of HCC patients (n = 44) were HCV-positive, while HBV infection represented only 8% of all HCC patients (n = 4); and two patients were negative for both viral markers. A highly significant difference was found between patients with HCC and chronic liver disease as well as controls with regard to serum ANXA2 levels (130, IQR 15-240; 15, IQR 15-17; and 17, IQR 15-30 ng/mL, respectively). The area under the curve of ANXA2 was 0.865; the cut-off value was established to be 18 ng/mL with a diagnostic sensitivity of 74% and a specificity of 88%, while the sensitivity and specificity of AFP at the cut-off value of 200 ng/dL were 20% and 100%, respectively. CONCLUSION Serum ANXA2 may serve as a biomarker for the early detection of HCC.

Characteristics of hepatocellular carcinoma in Egyptian patients with primary Budd‐Chiari syndrome

Budd‐Chiari syndrome (BCS) is caused by hepatic venous outflow obstruction. This work aimed at analyzing characteristics and factors associated with development of hepatocellular carcinoma (HCC) in patients with primary BCS.

Combined radiofrequency and chemoembolization vs. chemoembolization in management of hepatocellular carcinoma

Aim: Hepatocellular carcinoma (HCC) is one of the most common cancers in the world. If left untreated, liver cancer has a poor prognosis with more than 90% of patients dying of the disease within 5 years of diagnosis. The aim of this study is to assess the value of combined radiofrequency ablation (RFA), followed by trans-arterial chemoembolization (TACE) in the management of HCC. Methods: Fifty HCC patients with chronic liver disease were categorized into two groups according to the modality of locoregional treatment: 25 HCC patients treated with RFA followed by TACE within 5 days and 25 HCC patients treated with TACE only. Results: Complete response was achieved in 100% and 84% of the HCC patients after 1 month from combined RFA-TACE therapy and TACE only respectively. The rate of objective response after 7 months was 84% and 44% in the RFA-TACE and TACE groups respectively. One year disease free survival rate was 56% and 24% in RFA-TACE and TACE groups respectively, and overall survival rate was 88% in the RFA-TACE group and 80% in the TACE only group. Conclusion: Combined RFA-TACE appears to be an effective modality and superior to TACE only for the treatment of HCC.