T. Ibrahim

Live donor hepatectomy for liver transplantation in Egypt: Lessons learned

Purpose: To retrospectively review anesthesia and intensive care management of 145 consented volunteers subjected to right lobe or left hepatectomy between 2003 and 2011. Methods: After local ethics committee approval, anesthetic and intensive care charts, blood transfusion requirements, laboratory data, complications and outcome of donors were analyzed. Results: One hundred and forty-three volunteers successfully tolerated the surgery with no blood transfusion requirements, but with a morbidity rate of (50.1%). The most frequent complication was infection (21.1%) (intraabdominal collections), followed by biliary leak (18.2%). Two donors had major complications: one had portal vein thrombosis (PVT) treated with vascular stent. This patient recovered fully. The other donor had serious intraoperative bleeding and developed postoperative PVT and liver and renal failure. He died after 12 days despite intensive treatment. He was later reported among a series of fatalities from other centers worldwide. Epidural analgesia was delivered safely (n=90) with no epidural hematoma despite significantly elevated prothrombin time (PT) and international normalization ratio (INR) postoperatively, reaching the maximum on Day 1 (16.9±2.5 s and 1.4±0.2, P<0.05 when compared with baseline). Hypophosphatemia and hypomagnesemia were frequently encountered. Total Mg and phosphorus blood levels declined significantly to 1.05±0.18 mg/dL on Day 1 and 2.3±0.83 mg/dL on Day 3 postoperatively. Conclusions: Coagulation and electrolytes need to be monitored perioperatively and replaced adequately. PT and INR monitoring postoperatively is still necessary for best timing of epidural catheter removal. Live donor hepatectomy could be performed without blood transfusion. Bile leak and associated infection of abdominal collections requires further effort to better identify biliary leaks and modify the surgical closure of the bile ducts. Donor hepatectomy is definitely not a complication-free procedure; reported complication risks should be available to the volunteers during consenting.

Recurrent Hepatitis C Virus (Genotype 4) Infection after Living Donor Liver Transplantation: Risk Factors and Outcome

Objectives: The recurrence of HCV post liver transplantation endangers patient and graft survival. The aim of this study is to analyze the risk factors for HCV recurrence, the effect of the recurrence and its management on the outcome of liver transplantation. Materials and methods: After exclusion of the 6 months mortality, dual HCV and HCC patients, about fifty five HCV related LDLT patients were enrolled in the study and were followed up from 6 to 60 months. Demographic, preoperative, intraoperative and postoperative data were studies. HCV recurrence was defined by elevated transaminases, positive serum HCV RNA and liver biopsy findings. Univariate and multivariate analysis were done on all data to detect the favoring factors of HCV recurrence. Results: HCV recurrence occurred in 21/55 of the patients and one of them developed cirrhosis on follow up. By univariate analysis; CMV infection, mean operative time (12.490 ± 1.8952), acute cellular rejection and pulse steroids treatment were predictors of HCV recurrence (P<0.05). Multivariate analysis revealed only acute cellular rejection to be a predictor. The overall 1, 3 and 5 years’ survival of all patients was 94.5%, 90.9% and 90.9% respectively, while the overall 1, 3 and 5 years’ survival of patients with and without recurrence was 95.2%, 90.5% and 90.5% and 94.1%, 91.2%and 91.2% respectively. Conclusion: The occurrence of acute rejection was independent predictor of HCV recurrence post LDLT, so its prevention is required to decrease this recurrence. Similarly, prevention of CMV infection and decreasing operative time is important to decrease post-transplant HCV recurrence.

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±2.1 cm. 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±75 ml. Mean surgical time was 160±40 min. 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.

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.

Influence of technical refinement on biliary complications of donors of living donor liver transplantation: a retrospective comparative study

Background Biliary complications (BCs) of living liver donors are of serious concern as they threaten the donor’s health and life. Technical problems are the main cause of these complications. Aim We conducted a retrospective analysis of the incidence, types, and management polices of BCs in our cohort of donors of living donor liver transplantation, with special emphasis on the impact of technical refinement of bile duct stump closure. Patients and methods Data were reviewed from a prospectively maintained database of all donors who underwent hepatectomy. The incidence and types of and management options for BCs in living liver donors were compared in two successive phases of our program of living donor liver transplantation. The first period included 140 donors in a procedure in which the bile duct stump was closed using continuous sutures or interrupted sutures, whereas the second period comprised 100 donors in a procedure in which the bile duct stump was closed using a newly designed technique by combining suturing and reinforcement with a metallic clip just below the suture line. Before abdominal closure, the intraoperative cholangiogram was repeated. Results The overall incidence of BCs among donors was 14.2%. On comparison of BCs in the two studied phases we found significant differences in the rate of BCs: 20% in the first phase and 6% in the second phase. Further, a significant difference was documented in the two periods with respect to age less than 30 years, male donors, BMI more than 25%, left lobe or left lateral graft, and one duct (P Conclusion Our newly adopted technique of bile duct stump closure as well as the performance of two intraoperative cholangiographies before cutting and after closure of the stump resulted in significant improvement in and reduction of BCs. This new technique is safe, simple, and reproducible and does not prolong the surgery.

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.