Mohammad Khalife

Organ donation after cardiac death in the Middle East.

INTRODUCTION The shortage of organ donors along with the increased number of waiting recipients have created the need for new strategies to expand the organ pool: living donors, split livers, domino livers, and organs from donations after cardiac death (DCD). The purpose of this article was to focus upon aspects of DCD application in the religious, traditional, ethical, and legal aspects of the Arab world. BACKGROUND DCD can increase the donor pool by 15%-25%. Several ethical, legal, and social concerns need to be addressed to make DCD more widely accepted by the general population in Western countries as well as in the Middle East. Organs from DCD donors have been transplanted since the 1960s. As soon as brain death criteria were published in 1968, organ retrieval from cadaveric heart-beating donors predominated. Donation after brain death (DBD) almost completely replaced DCD. In the 1990s, the organ shortage led to DCD in many countries, but not in the Arab world. DCD is still not accepted by most in the Arab world due to religious, ethical, social, and legal issues. CONCLUSION DCD in the Arab world is more complicated than in Western countries. It should be re-evaluated and thoroughly reviewed with the new criteria for DCD and its implementation in our region.

Lymph-node ratio is an independent prognostic factor in patients with stage III colorectal cancer: a retrospective study from the Middle East

BackgroundIn this retrospective study, we evaluated the prognostic effect of positive lymph-node ratio (pLNR) on patients with stage III colorectal cancer (CRC). Our paper is the first analysis, to our knowledge, to deal with such data from the Middle East.MethodsWe analyzed the clinicopathological data of 535 patients diagnosed with colorectal cancer at our institution between 1983 and 2003. The 164 patients diagnosed with stage III disease were divided into two categories based on lymph-node ratio (LNR) being the ratio of positive lymph nodes over total lymph nodes dissected: LNR ≤0.4 and LNR >0.4. We used Kaplan-Meier and Cox proportional hazard models to evaluate the prognostic effect of pLNR.ResultsThe 10-year survival rate for the patients with stage IIIA, IIIB and IIIC cancers were 76%, 56% and 0% respectively (P = 0.014). Using pLNR of 0.4 as the cutoff point was found to yield clinically and significant results, with a significant difference in the outcomes of patients with pLNR ≤0.4 compared to those with pLNR >0.4 (hazard ratio = 5.25, 95% confidence interval = 1.2 to 22.1, P = 0.02).ConclusionThe ratio-based staging (pLNR) of CRC is a more accurate and clinically useful prognostic method than the number of positive LNs resected or the total number of LNs retrieved for predicting the course of patients with stage III CRC.

Lymph node ratio is an independent prognostic factor after resection of periampullary malignancies: data from a tertiary referral center in the middle East.

Objective:The prognostic impact of nodal involvement in resected pancreatic carcinoma and biliary malignancy has been relatively well established. It has been suggested that lymph node ratio (LNR) may be a more informative way of stratifying patients with node positive disease. Our retrospective review aimed to investigate the significance of such variables and test for independent prognostic factors for survival. Methods:One hundred eighty-three pancreatic and periampullary malignancy cases were registered at the American University of Beirut Medical Center from 1990 to 2004. Of those, 80 had complete data on lymph node status. We analyzed the impact of the number of lymph nodes resected, the number of positive lymph nodes retrieved and LNR using Kaplan-Meier and Cox proportional hazard models. The measured outcome in the KM model was the survival probability at 1, 3, and 5 years while the Cox model was used to measure the hazard ratio (HR) of the previously identified predictors on survival. Results:For the 80 patients included in this analysis, overall survival rates were 65% (54 to 78), 32% (18 to 47), and 21% (8 to 34) were alive at 1, 3, and 5 years, respectively. The median number of resected lymph nodes was 9. In the node positive patients, those who had >12 nodes examined were found to have a significantly better survival (HR=0.24; P=0.013). On multivariate analysis, our model showed the following factors to be significant: age 60 years or older (HR=5.92; P=0.018), poorly differentiated tumors (HR=21.87; P=0.018), number of lymph nodes examined <12 LN (HR=6.77; P=0.022), 3 or more metastatic LN (HR=7.21; P=0.028), and LNR≥0.2 (HR=7.12; P=0.007). Conclusions:After pancreaticodudonectomy for adenocarcinoma of the pancreas and biliary malignancies, ratio-based lymph node staging is an independent and powerful prognostic factor.

Laparoscopic antral resection with Billroth I reconstruction for a gastric glomus tumor

Highlights • A 33-year-old woman presented with intermittent dull upper abdominal pain for two days. Abdominal computed tomography (CT) was performed showing a hyperdense mass in the antrum. Endoscopy and endoscopic ultrasound revealed a submucosal antral mass along the greater curvature, suspicious for a gastrointestinal (GI) stromal tumor (GIST), a laparoscopic antrectomy with Billroth I reconstruction was done.• Pathological examination revealed that the mass was a gastric glomus tumor. Gastric glomus tumors are fairly uncommon and mostly benign, with an estimated incidence of 1% of all GI soft tissue tumors.• This case may aid in improving the recognition and diagnosis of this rare entity and in differentiating it from more common GISTs and gastric carcinoids.• A built up knowledge between physicians is extremely necessary to avoid common confusion in taking the right medical approach.

Pancreatitis-associated pseudoaneurysm of the splenic artery presenting as lower gastrointestinal bleeding: treatment with transcatheter embolisation.

Pancreatitis is a known cause of pseudoaneurysms of the peripancreatic arteries, which can rarely rupture into various adjacent structures and become a source of life-threatening bleeding. The management is challenging and requires an individualised approach and multidisciplinary care. Herein, we present the case of a 24-year-old man in whom a splenic pseudoaneurysm ruptured into the adjacent infected pseudocyst, communicating with the colon by a fistulous tract, causing massive lower gastrointestinal bleeding. This was successfully managed by transcatheter arterial embolisation (TAE).

Spontaneous intraperitoneal haemorrhage from short gastric artery avulsion secondary to forceful retching

Spontaneous intraperitoneal haemorrhage can occur in any age group. It is defined as presence of free blood in the peritoneal cavity which can results from a non-traumatic and non-iatrogenic cause. Common causes are visceral, coagulopathy related and vascular. The clinical presentation is usually non-specific; it can vary from mild abdominal pain to a shock status. We report a very rare case of a 17-year-old male patient who presented to our institution with spontaneous intraperitoneal bleeding secondary to avulsion of one of the short gastric artery following forceful retching.

Assessment of surgical portosystemic shunts and associated complications: The diagnostic and therapeutic role of radiologists

Surgical portosystemic shunting, the formation of a vascular connection between the portal and systemic venous circulation, has been used as a treatment to reduce portal venous pressure. Although the use of portosystemic shunt surgery in the management of portal hypertension has declined during the past decade in favour of alternative therapies, and subsequently surgeons and radiologists became less familiar with the procedure, it remains a well-established treatment. Knowledge of different types of surgical portosystemic shunts, their pathophysiology and complications will help radiologists improve communication with surgeons and enhance their understanding of the diagnostic and therapeutic role of radiology in the assessment and management of these shunts. Optimal assessment of the shunt is essential to determine its patency and allow timely intervention. Both non-invasive and invasive imaging modalities complement each other in the evaluation of surgical portosystemic shunts. Interventional radiology plays an important role in the management of complications, such as shunt thrombosis and stenosis. This article describes the various types of surgical portosystemic shunts, explains the anatomy and pathophysiology of these shunts, illustrates the pearls and pitfalls of different imaging modalities in the assessment of these shunts and demonstrates the role of radiologists in the interventional management of complications.

Congestive hepatopathy secondary to large renal arteriovenous malformation

A 75-year-old woman presented with acute onset dyspnoea, and was found to have signs of pulmonary congestion on clinical examination. Imaging revealed cardiomegaly and coincident congestive hepatopathy, secondary to a left renal arteriovenous malformation. The presence of a high flow vascular shunt in the left kidney was possibly the causative factor behind both the high-output cardiac failure and congestive hepatopathy.

Triple thrombophilic simultaneous mutations in patients after bariatric surgery: is there a role for screening in the Eastern Mediterranean?

Abstract Background and purpose: Thrombophilia is a hypercoagulable state that predisposes to thrombosis. Several genetic risk factors have been shown to predispose to thromboembolic events. Homozygosity to a thrombophilic mutation certainly predisposes the affected patient to more serious symptoms. Materials and methods: Here we present a case of a 56-year-old male patient who underwent sleeve gastrectomy for morbid obesity, presenting to our institution with abdominal pain. Investigations revealed thrombosis of the splenic, axillary vein as well as the right pulmonary artery. The patient was found to have triple thrombophilic mutations. Results: To our knowledge, this is the first reported case of three specific simultaneous thrombophilic mutations in a patient from the Eastern Middle East. Conclusion: We suggest a role for screening for thrombophilic mutations in the Eastern Mediterranean patients undergoing bariatric surgeries for morbid obesity due to the increased risk of thrombosis in this group of patients

Clinical review of liver hydatid disease and its unusual presentations in developing countries

Human hydatid cyst disease is an international public health issue that particularly affects the developing countries. In this article, we discuss the epidemiology of hydatid disease in third world countries, the life cycle of echinococcus granulosus and how to make the clinical diagnosis of the disease, including laboratory tests and imaging modalities as well as uncommon presentation of this entity that we have encountered at the American University of Beirut Medical Center (AUBMC). We emphasize on the new World Health Organization classification of hepatic echinococcosis with examples from our clinical practice at AUBMC, and finally we describe the treatment, including medical and interventional therapies.