Moustafa Mabrouk Mourad

Etiology and management of hepatic artery thrombosis after adult liver transplantation

Hepatic artery thrombosis (HAT) represents a major cause of graft loss and mortality after liver transplantation. It occurs in up to 9% of adult recipients. The early diagnosis of HAT decreases septic complications, multiorgan failure, and graft loss, and there are better outcomes after treatment. In this study, we reviewed 102 episodes of HAT, which were classified as early hepatic artery thrombosis (E‐HAT) when they were diagnosed within the first 21 days after transplantation. The overall incidence of HAT was 7%: 31 episodes (30.4%) were identified as E‐HAT, and 71 episodes (69.6%) were identified as late hepatic artery thrombosis (L‐HAT). Graft dysfunction was the commonest presentation (30 cases or 29%). Most E‐HAT cases were managed with retransplantation (74%), whereas early revascularization was carried out for only 13% with a 75% success rate. The incidence of retransplantation for L‐HAT was only 41%, whereas 32% were too ill for relisting and eventually died. Successful conservative management was noted for 13 of the 102 patients (13%) with collateralization and good hepatic perfusion, with biliary complications encountered in 7 cases (54%) subsequently. A multivariate analysis showed that previous episodes of HAT, the number of arterial anastomoses, and a low donor weight were independent risk factors for E‐HAT, whereas a history of upper abdominal operations (non‐HAT), a previous history of HAT, a low donor weight, and a recipient ageu2009<u200950 years were independent risk factors for L‐HAT. The graft survival rates for HAT patients were 52%, 36.6%, and 27.4% at 1, 3, and 5 years, whereas the corresponding rates were 81.4%, 81.2%, and 76.4% for non‐HAT patients. In conclusion, prompt revascularization for E‐HAT patients decreases the incidence of serious, irreversible septic complications and graft loss and improves overall outcomes. A significant number of L‐HAT patients do not require further intervention despite the high incidence of ischemic cholangiopathy. Liver Transpl 20:713‐723, 2014.

Aetiology and risk factors of ischaemic cholangiopathy after liver transplantation

Liver transplantation (LT) is the best treatment for end-stage hepatic failure, with an excellent survival rates over the last decade. Biliary complications after LT pose a major challenge especially with the increasing number of procured organs after circulatory death. Ischaemic cholangiopathy (IC) is a set of disorders characterized by multiple diffuse strictures affecting the graft biliary system in the absence of hepatic artery thrombosis or stenosis. It commonly presents with cholestasis and cholangitis resulting in higher readmission rates, longer length of stay, repeated therapeutic interventions, and eventually re-transplantation with consequent effects on the patients quality of life and increased health care costs. The pathogenesis of IC is unclear and exhibits a higher prevalence with prolonged ischaemia time, donation after circulatory death (DCD), rejection, and cytomegalovirus infection. The majority of IC occurs within 12 mo after LT. Prolonged warm ischaemic times predispose to a profound injury with a subsequently higher prevalence of IC. Biliary complications and IC rates are between 16% and 29% in DCD grafts compared to between 3% and 17% in donation after brain death (DBD) grafts. The majority of ischaemic biliary lesions occur within 30 d in DCD compared to 90 d in DBD grafts following transplantation. However, there are many other risk factors for IC that should be considered. The benefits of DCD in expanding the donor pool are hindered by the higher incidence of IC with increased rates of re-transplantation. Careful donor selection and procurement might help to optimize the utilization of DCD grafts.

Vasculobiliary complications following adult right lobe split liver transplantation from the perspective of reconstruction techniques

Split liver transplantation (SLT) compensates for the organ shortage and provides an alternative solution for recipients disadvantaged by a smaller body size. Variations in the hepatic arterial anatomy and reconstructive techniques may lead to more technical complications, and we sought to analyze the incidence and risk factors of vasculobiliary complications with respect to reconstructive techniques. We identified 171 adult right lobe SLT procedures and 1412 whole liver transplantation (WLT) procedures between January 2000 and June 2012 and compared the results of these 2 groups. In the SLT group, arterial reconstruction techniques were classified into 4 subgroups (I‐IV), and biliary reconstruction was classified into 2 groups [duct‐to‐duct (DD) anastomosis and Roux‐en‐Y hepaticojejunostomy (RH)]. Specific surgical complications were analyzed against reconstruction techniques. The overall incidence of vascular and biliary complications in the SLT group was greater than that in the WLT group (Pu2009=u20090.009 and Pu2009=u20090.001, respectively). There was no difference in hepatic artery thrombosis (HAT), but we saw a tendency toward early HAT in the presence of multiple hepatic arteries supplying the right lobe graft (group IV; 20%) in comparison with the other arterial reconstruction groups (Pu2009=u20090.052). No difference was noticed in the overall incidence of biliary complications in either DD or RH recipients across 4 arterial reconstruction groups. When the arterial reconstruction involved a right hepatic artery (groups II and III) combined with a DD biliary anastomosis, there was a significant preponderance of biliary complications (Pu2009=u20090.04 and Pu2009=u20090.01, respectively). There was no survival difference between SLT and WLT grafts. In conclusion, the complications of SLT are directly related to arterial and biliary reconstruction techniques, and this classification helps to identify high‐risk reconstructive techniques. Liver Transpl 21:63‐71, 2015.

Anticoagulation and antiplatelets as prophylaxis for hepatic artery thrombosis after liver transplantation.

Hepatic artery thrombosis (HAT) is the most serious vascular complication after liver transplantation. Multiple risk factors have been identified to impact its development. Changes in haemostasis associated with end stage liver disease and the disturbance of the coagulation and anticoagulation cascades play an important role in development of this lethal complication. Early recognition and therapeutic intervention is mandatory to avoid its consequences. Pharmacological prophylaxis, by the use of antiplatelet or anticoagulant agents, is an important tool to reduce its incidence and prevent graft loss. Only a few studies have shown a clear benefit of antiplatelet agents in reducing HAT occurrence, however, these studies are limited by being retrospective and by inhomogeneous populations. The use of anticoagulants such as heparin is associated with an improvement in the outcomes mainly when used for a high-risk patients like living related liver recipients. The major concern when using these agents is the tendency to increase bleeding complications in a setting of already unstable haemostasis. Hence, monitoring of their administration and careful selection of patients to be treated are of great importance. Well-designed clinical studies are still needed to further explore their effects and to formulate proper protocols that can be implemented safely.

Primary hepatic tuberculosis in immunocompetent adults: a UK case series

Primary hepatic tuberculosis (TB) is very rare in the UK, but the incidence may be rising. Three cases of primary hepatic TB in immunocompetent patients without evidence of pulmonary involvement are reported. The diagnosis was challenging as two patients had liver space-occupying lesions, and the third patient presented with liver abscess. All of them responded well to standard anti-tubercular treatment. Hepatic TB should be considered in the differential diagnosis of space-occupying lesions of the liver and liver abscesses.

Acute pancreatitis: current perspectives on diagnosis and management

The last two decades have seen the emergence of significant evidence that has altered certain aspects of the management of acute pancreatitis. While most cases of acute pancreatitis are mild, the challenge remains in managing the severe cases and the complications associated with acute pancreatitis. Gallstones are still the most common cause with epidemiological trends indicating a rising incidence. The surgical management of acute gallstone pancreatitis has evolved. In this article, we revisit and review the methods in diagnosing acute pancreatitis. We present the evidence for the supportive management of the condition, and then discuss the management of acute gallstone pancreatitis. Based on the evidence, our local institutional pathways, and clinical experience, we have produced an outline to guide clinicians in the management of acute gallstone pancreatitis.

Hepatic and Intra-abdominal Tuberculosis: 2016 Update

Mycobacterium tuberculosis (TB) infection affects nearly 10xa0million people a year and causes 1.5xa0million deaths. TB is common in the immunosuppressed population with 12xa0% of all new diagnoses occurring in human immune deficiency virus (HIV)-positive patients. Extra-pulmonary TB occurs in 12xa0% of patients with active TB infection of which 3.5xa0% is hepatobiliary and 6–38xa0% is intra-abdominal. Hepatobiliary and intra-abdominal TB can present with a myriad of non-specific symptoms, and therefore, diagnosis requires a high level of suspicion. Accurate and rapid diagnosis requires a multidisciplinary team (MDT) approach using radiology, interventional radiology, surgery and pathology services. Treatment of TB is predominantly medical, yet surgery plays an important role in managing the complications of hepatobiliary and intra-abdominal TB.

Internal Herniation Through Foramen of Winslow: A Diagnosis Not to Be Missed.

Introduction Hernias through the foramen of Winslow are extremely rare, accounting for 0.1% of all abdominal hernias. Delayed diagnosis is often observed, resulting in bowel strangulation and high mortality. Method We present a case of a patient with strangulated ileum herniated through the foramen of Winslow. Recent literature review was undertaken on “PubMed” as a search platform using the keywords “foramen of Winslow” and “hernia”. Case Summary A 66-year-old man presented acutely with severe epigastric pain and vomiting. An emergency computed tomography scan revealed a loop of ileum in the lesser sac. At emergency laparotomy, a herniated loop of ileum that had become strangulated at its entry to the lesser sac via the foramen of Winslow was confirmed. The loop of ileum was reduced but was nonviable, which had to be resected with a primary anastomosis. The patients postoperative recovery was uneventful. Conclusion Herniation through the foramen of Winslow is a difficult diagnosis and must not be missed. Early cross-sectional imaging and surgical intervention are advised in order to reduce morbidity.

Patient with liver dysfunction while maintained on veno‐venous extracorporeal membrane oxygenation should not be overlooked as a potential donor

This report describes transplantation of liver allograft from a circulatory death donor who was supported by veno‐venous extracorporeal membrane oxygenation (ECMO) for 14 days and presented with severely altered liver functions. Successful liver transplant was done in a patient with hepatocellular carcinoma (HCC) in the background of primary sclerosing cholangitis. There was immediate graft function and uneventful recovery with stable graft function at 1‐year follow‐up. This case illustrates the ability of veno‐venous ECMO to resuscitate organs in the presence of severe dysfunction, and perhaps, lessons from this case may be incorporated to optimize the condition of organs rescued from these marginal donors and exemplify the use of ECMO in normothermic regional perfusion in donors after circulatory death.

Pancreatitis: Preventing catastrophic haemorrhage

Pancreatitis represents nearly 3% of acute admissions to general surgery in United Kingdom hospitals and has a mortality of around 1%-7% which increases to around 10%-18% in patients with severe pancreatitis. Patients at greatest risk were those identified to have infected pancreatic necrosis and/or organ failure. This review seeks to highlight the potential vascular complications associated with pancreatitis that despite being relatively uncommon are associated with mortality in the region of 34%-52%. We examine the current evidence base to determine the most appropriate method by which to image and treat pseudo-aneurysms that arise as the result of acute and chronic inflammation of pancreas. We identify how early recognition of the presence of a pseudo-aneurysm can facilitate expedited care in an expert centre of a complex pathology that may require angiographic, percutaneous, endoscopic or surgical intervention to prevent catastrophic haemorrhage.