Veysel Ersan

Acute traumatic diaphragmatic ruptures: A retrospective study of 48 cases

PurposeTraumatic diaphragmatic rupture (TDR) is associated with high rates of morbidity and mortality, and the preoperative diagnosis is difficult.MethodsForty-eight patients with TDR were treated in our department between January 2000 and May 2009. The cause, location, size of rupture, associated morbidity and mortality, surgical material for repair, and predictive factors for overall outcome were evaluated.ResultsThere were 41 male patients (85%) and 7 female patients (15%) with a mean age of 33.8 years (range 17–69 years). Blunt trauma accounted for the injuries of 15 patients (31%) and 33 patients (68%) had penetrating injuries. The diagnosis was preoperatively established in 12 patients (25%) with a plain chest X-ray or/and computed tomography. The location of rupture was on the left side of the diaphragm in 35 patients (73%), on the right side in 10 (21%), and was bilateral in 3 patients (6%). Traumatic diaphragmatic rupture was repaired with interrupted nonabsorbable sutures or polypropylene mesh (8 patients). Postoperative complications were observed in 18 patients (38%). Overall mortality was observed in 7 patients (15%). The mortality was associated with hemorrhagic shock (P = 0.002), a high injury severity score (P = 0.002), and having additional injuries (P = 0.015).ConclusionThe outcome of the patients is associated with presence of hemorrhagic shock, a high injury severity score, and additional organ injury.

Chronic Graft-Versus-Host Disease After Liver Transplantation: A Case Report

Graft-versus-host disease (GVHD) after orthotopic liver transplantation (OLT) is a rare but significant complication, occurring in 1%-2% of cases with a mortality rate of 85%- 90%. It occurs when donor passenger lymphocytes mount an alloreactive response against the hosts histocompatibility antigens. It presents as fever, rash, and diarrhea with or without pancytopenia. Between March 2002 and September 2011, among 656 OLT patients 1 (0.15%) had acute GVHD. A biopsy at the 7th posttransplantation month revealed chronic GVHD. Consequently, in the cases that had fever, rash, and/or desquamation of the any part of body after liver transplantation, GVHD must be considered and skin biopsies must be planned for the diagnosis.

Biliary Complications in 106 Consecutive Duct-to-Duct Biliary Reconstruction in Right-Lobe Living Donor Liver Transplantation Performed in 1 Year in a Single Center: A New Surgical Technique

OBJECTIVE Biliary complications remain a major source of morbidity after living donor liver transplantation (LDLT). Of 109 consecutive right lobe (RL)-LDLTs performed in 1 year in our institution, we present the biliary complications among 106 patients who underwent a new duct-to-duct anastomosis technique known as University of Inonu. METHODS Of 153 liver transplantations performed in 1 year from January to December of 2008, 128 were LDLTs including 109 RL-LDLTs. The others were left or left lateral grafts. All RL-LDLT patients were adults, all of whom except three included a duct-to-duct anastomosis. RESULTS All, but three, biliary reconstructions were completed with a surgical technique, so called UI, in which 6-0 prolene sutures were used. Nine bile leaks were seen in 106 recipients (8.49%) performed in a duct-to-duct fashion in a time period of 1 to 4 weeks. Seventeen patients (16.03%) posed bile duct stricture (BDS). Five patients had both. Although endoscopic stent placement and percutaneous balloon dilatation, 4 patients continued to suffer from BDS on whom a permanent access hepatico-jejunostomy (PAHJ) procedures were performed. CONCLUSION We recommend a duct-to-duct biliary reconstruction because of its de facto advantages over other types of anastomosis provided the native duct is not diseased. After almost 2 years, the bile tract complication rate was 22.64%.

Can an extended right lobe be harvested from a donor with Gilbert's syndrome for living-donor liver transplantation? Case report.

Gilberts syndrome (GS) is a common cause of inherited benign unconjugated hyperbilirubinemia that occurs in the absence of overt hemolysis, other liver function test abnormalities, and structural liver disease. GS may not affect a patients selection for living-donor liver transplantation (LDLT). Between February 2005 and April 2011, 446 LDLT procedures were performed at our institution. Two of the 446 living liver donors were diagnosed with GS. Both donors underwent extended right hepatectomies, and donors and recipients experienced no problem in the postoperative period. Their serum bilirubin levels returned to the normal range within 1-2 weeks postoperatively. In our opinion, extended right hepatectomy can be performed safely in living liver donors with GS if appropriate conditions are met and remnant volume is >30%. Livers with GS can be used successfully as grafts in LDLT recipients.

Reconstruction of Anomalous Portal Venous Branching in Right Lobe Living Donor Liver Transplantation: Malatya Approach

Reconstruction of anomalous portal vein branching (APVB) during right lobe living donor liver transplantation (LDLT) can be challenging. The goal of this article is to describe our surgical technique, named the Malatya Approach, in case of APVB during right lobe LDLT. The technique unifies the APVB and obtains a funnel‐shaped common extension with a circumferential fence by a saphenous vein conduit. In total, 126 (10.6%) of 1192 right lobe grafts had APVB that were divided into 2 groups according to the adopted surgical techniques: the Malatya Approach group (n = 91) and the previously defined other techniques group (n = 35). Both groups were compared regarding portal vein thrombosis (PVT), postoperative 90‐day mortality and survival. PVT developed in 3 patients (3.3%) in the Malatya Approach group and developed in 10 (28.6%) patients for the other group (P < 0.001). There were 8 (8.8%) 90‐day mortalities in the Malatya Approach group (1 PVT related) and 15 patients (9 PVT related) died in the other techniques group (P < 0.001). Mean follow‐up time for both groups was similar (999.1 days for the Malatya Approach group versus 1024.7 days for the other group; P = 0.47), but longterm survival in the Malatya Approach group was better than in the other group (84.6% versus 40%; P < 0.001). Multivariate analysis revealed that the Malatya Approach group showed less PVT development and longer survival (P < 0.001). This technique is promising to avoid PVT and mortalities in cases of APVB during right lobe LDLT. Liver Transplantation 23 751–761 2017 AASLD.

A pancreatic pseudopapillary tumor enucleated curatively.

Highlights • Pancreatic pseudopapillary tumor is an rarely problem.• Tumor may be more aggressive at males relatively to females.• Complete resection is the main treatment option for these tumors.

Hepatic vein stenosis developed during living donor hepatectomy and corrected with peritoneal patch technique: a case report.

An 18-year-old male living donor for his father with end-stage liver cirrhosis due to hepatitis B underwent an extended right lobe donor hepatectomy. The middle hepatic vein was visualised on the cut surface of the graft and dissected up to the confluence of the middle and left hepatic veins. After vascular clamping, right and middle hepatic veins were cut to removed the graft. While starting the stump closure, the clamp over the middle hepatic vein slipped and the vein stump sutured quickly under suboptimal exposure. Soon after this closure, the remnant liver showed increasing congestion. Intraoperative Doppler ultrasound revealed obstruction of venous outflow at the remnant left liver due to stenosis in the left hepatic vein. Under total hepatic vascular occlusion, the sutures were removed from the narrowed left hepatic vein. A 2 × 2 cm peritoneal patch from the subcostal area that was prepared to close the defect was sutured to the edges of the left hepatic vein defect. Venous congestion of the liver disappeared when the clamps were removed. Intraoperative Doppler ultrasound confirmed normal hepatic venous flow. The postoperative course of the donor was uneventful. There was no clinical, biochemical, or radiological problems at 47 months of follow-up. An autogenous peritoneal patch may be a good option to repair vascular defects, which are not suitable for primary sutures, due to easy accessibility and size adjustment, cost effectiveness, as well as relatively low risk of infection and thrombosis. Close dissection of the left hepatic vein during parenchymal transection over the middle hepatic vein can result in narrowing, particularly at the bifurcation of the middle/left hepatic veins that can cause congestion in the remnant liver. When we include the middle hepatic vein with the right graft, we now believe that dissection away from the left hepatic vein seems much more secure for donors.

Management of Acute Sleeve Gastrectomy Leaks by Conversion to Roux-en-Y Gastric Bypass: a Small Case Series

Management of early sleeve gastrectomy leak remains challenging. The recommended approach is endoscopic stenting and abdominal drainage. Conversion to a Roux-en-Y gastric bypass (RYGB) is a common procedure used for late fistulas with distal obstruction. Here, we have presented three cases of early staple line leaks treated by conversion to RYGB. These patients had uncontrolled abdominal infections despite intensive medical treatments, and surgery was elected for abdominal drainage as well as to control the source of sepsis. All the patients were discharged without problems, and successful weight loss processes continued. Conversion to RYGB of a sleeve gastrectomy leak in an acute setting can be a feasible method in the case of inevitable surgical drainage for abdominal sepsis.

Colorectal stenting for obstruction due to retrorectal tumor in a patient unsuitable for surgery

Abstract Fund of knowledge on palliative treatment of unresectable retrorectal tumors is scare. Here, we reported a non-surgical treatment of a huge retrorectal malignant tumor in an aged and debilitated patient complicated with colorectal obstruction. An 86-year-old male with severe comorbidities was admitted with acute colorectal obstruction owing to an untreated retrorectal malign epithelial tumor. There was a lobulated retrorectal mass, 20 cm × 15 cm at largest size, extending to the superior iliac bifurcation level, caused an obstruction of the rectal lumen. He was not suitable for surgical excision because of the severe comorbidities. Rectal obstruction was palliated by two self-expandable metallic stents. He tolerated the procedures well and post-procedural course was uneventful. After four months, stents were patent and the patient was continent. Stenting for colorectal obstruction owing to a retrorectal tumor can be feasible in patients who are not suitable for surgery (aged, debilitated, advanced tumor). It avoided the surgical trauma to a high-risk patient and ensured the continuity of continence. As far as we know, this was the first report on colorectal stenting for a retrorectal tumor.

Living-Donor Liver Transplantation for Budd-Chiari Syndrome—Resection and Reconstruction of the Suprahepatic Inferior Vena Cava With the Use of Cadaveric Aortic Allograft: Case Report

BACKGROUND Living-donor liver transplantation with inferior vena cava resection and reconstruction is rarely indicated for Budd-Chiari syndrome. The aim of this case presentation was to present and discuss the inferior vena cava reconstruction with the use of cadaveric aortic allograft after resection of the suprahepatic inferior vena cava in a patient with Budd-Chiari syndrome who was treated with living-donor liver transplantation. CASE REPORT A 29-year-old male patient with end-stage liver disease and suprahepatic inferior vena cava obstruction was referred to our center. He was scheduled for living-donor liver transplantation. The suprahepatic inferior vena cava was resected and reconstruction was achieved by means of interposition of the cadaveric aortic allograft between the right atrium and inferior vena cava. Postoperative course was uneventful. DISCUSSION Liver transplantation and vena cava reconstruction is indicated in some patients with end-stage liver disease and Budd-Chiari syndrome. Limitations in cadaveric organ donation may be compensated for with the use of living-donor liver. In this condition, various aspects of inferior vena cava reconstruction may be discussed. CONCLUSIONS Budd-Chiari syndrome due to suprahepatic inferior vena cava obstruction close to the right atrium may be treated with vascular reconstruction with the use of a cadaveric aortic allograft.