O. Hegazy

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).

Iatrogenic Biliary Injuries: Multidisciplinary Management in a Major Tertiary Referral Center

Background. Iatrogenic biliary injuries are considered as the most serious complications during cholecystectomy. Better outcomes of such injuries have been shown in cases managed in a specialized center. Objective. To evaluate biliary injuries management in major referral hepatobiliary center. Patients & Methods. Four hundred seventy-two consecutive patients with postcholecystectomy biliary injuries were managed with multidisciplinary team (hepatobiliary surgeon, gastroenterologist, and radiologist) at major Hepatobiliary Center in Egypt over 10-year period using endoscopy in 232 patients, percutaneous techniques in 42 patients, and surgery in 198 patients. Results. Endoscopy was very successful initial treatment of 232 patients (49%) with mild/moderate biliary leakage (68%) and biliary stricture (47%) with increased success by addition of percutaneous (Rendezvous technique) in 18 patients (3.8%). However, surgery was needed in 198 patients (42%) for major duct transection, ligation, major leakage, and massive stricture. Surgery was urgent in 62 patients and elective in 136 patients. Hepaticojejunostomy was done in most of cases with transanastomotic stents. There was one mortality after surgery due to biliary sepsis and postoperative stricture in 3 cases (1.5%) treated with percutaneous dilation and stenting. Conclusion. Management of biliary injuries was much better with multidisciplinary care team with initial minimal invasive technique to major surgery in major complex injury encouraging early referral to highly specialized hepatobiliary center.

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±2.1u2009cm. 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±75u2009ml. Mean surgical time was 160±40u2009min. 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.

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.

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.

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]