Impact of tumor size on the outcomes of hepatic resection for hepatocellular carcinoma: a retrospective study.

BACKGROUND: To evaluate the impact of tumor size on the perioperative and long-term outcomes of liver resection for hepatocellular carcinoma (HCC). METHODS: We reviewed the patients' data who underwent liver resection for HCC between November 2009 and 2019. Patients were divided into 3 groups according to the tumor size. Group I: HCC < 5 cm, Group II: HCC between 5 to 10 cm, and Group III: HCC ≥ 10 cm in size. RESULTS: Three hundred fifteen patients were included in the current study. Lower platelets count was noted Groups I and II. Higher serum alpha-feto protein was noted in Group III. Higher incidence of multiple tumors, macroscopic portal vein invasion, nearby organ invasion and presence of porta-hepatis lymph nodes were found in Group III. More major liver resections were performed in Group III. Longer operation time, more blood loss and more transfusion requirements were found in Group III. Longer hospital stay and more postoperative morbidities were noted in Group III, especially posthepatectomy liver failure, and respiratory complications. The median follow-up duration was 17 months (7-110 months). Mortality occurred in 100 patients (31.7%) and recurrence occurred in 147 patients (46.7%). There were no significant differences between the groups regarding recurrence free survival (Log Rank, p = 0.089) but not for overall survival (Log Rank, p = 0.001). CONCLUSION: HCC size is not a contraindication for liver resection. With proper selection, safe techniques and standardized care, adequate outcomes could be achieved.

A comparative analysis of the passivity of fit of complete arch implant-supported frameworks fabricated using different acquisition techniques.

STATEMENT OF PROBLEM: The accuracy of intraoral scanners (IOSs) in recording edentulous jaws has improved recently. However, improvement in accuracy does not necessarily imply the clinical validity of the scans, and limited information is available regarding the manufacture of passively fitting prostheses. PURPOSE: The purpose of this in vitro study was to analyze the passivity of complete arch screw-retained frameworks fabricated using different acquisition techniques. MATERIAL AND METHODS: A 3-dimensional maxillary edentulous model to receive all-on-4 screw-retained frameworks was prototyped. Eighteen polymethylmethacrylate (PMMA) frameworks were fabricated with a 5-axis milling machine and divided into 3 groups according to the acquisition technique (n=6): scanned by using an IOS (CEREC Primescan; Dentsply Sirona), scanned with the aid of an auxiliary device by using the same IOS, and by using a conventional impression and then scanning the stone cast with an extraoral scanner (EOS). The passivity of fit of the frameworks was tested with the 1-screw test, the terminal screw of the framework assembly was tightened on the multiunit abutment (MUA), and the vertical marginal gap (µm) was measured at the other 3 framework-to-abutment interfaces by using a digital microscope at ×40 magnification. A modification to the 1-screw test was analyzed by tightening all screws and then unscrewing all except 1 of the anterior abutments. Data were explored for normality by using the theoretical quantile-quantile (Q-Q) plots and the Shapiro-Wilk test of normality. The Friedman test compared data between the different acquisition techniques; the tightening methods and locations (buccal and palatal) were used as the block variable. The post hoc Dunn test was used when the Friedman test was significant. The Kruksal-Wallis test compared the data from the 2 groups of the tightening methods and the 2 location groups. The aligned rank transformation (ART) ANOVA test was used for the interaction effects among the 3 variables. A multiway ANOVA was applied to the ranked data. (α=.05 for all tests). RESULTS: Significant differences were found among all groups (P<.001). Regarding the passivity of fit, the mean vertical marginal gap was 50 µm for frameworks fabricated from an intraoral scan with the aid of an auxiliary device, 62 µm for frameworks fabricated by using an IOS, and 140 µm for frameworks fabricated by using an EOS. No significant difference was found among all groups regarding the tightening method (P=.355) or location measured (P=.175). CONCLUSIONS: Digital scanning with the aid of an auxiliary device resulted in the best fit; however, digital approaches with or without the auxiliary device resulted in a more accurate fit with a smaller marginal gap than with the conventional impression.

The effect of speed sintering on the optical properties and microstructure of multi-layered cubic zirconia.

PURPOSE: Speed sintering was introduced to fabricate time-efficient chairside restorations, however, its influence on the microstructure and optical properties of zirconia is still unclear. This study investigated the influence of speed sintering on the microstructure and optical properties of ultra-translucent multi-layered cubic zirconia. MATERIALS AND METHODS: Ultra-translucent cubic zirconia (Katana™ UTML; Kuraray Noritake Dental Inc., Aichi, Japan) was cut into a total of 80 specimens, twenty within each layer of the blank. The specimens were divided into 2 groups: speed and conventional sintering. The translucency parameter, opalescence, chromaticity, and color difference were recorded using a spectrophotometer. Scanning electron microscope images were used for crystallographic analysis. One-way ANOVA and Tukey's post-hoc test (p < 0.05) were used for data analysis. RESULTS: Speed sintering significantly reduced the translucency and opalescence compared to conventional sintering excluding the opalescence of the dentin layer. Chromaticity significantly decreased with speed sintering in less chromatic layers and significantly increased in more chromatic layers. Mean color change ranged between 0.65 and 1.25 across different layers. Mean crystal size decreased with speed sintering. CONCLUSIONS: With speed sintering, translucency, and opalescence decrease while chromaticity increases in the more chromatic layers. Additionally, no clinically perceptible color change was found compared to conventional sintering.

Feasibility and outcomes of living-donor liver transplantation utilizing the right hemi-liver graft with portal vein anatomical variations.

PURPOSE: Portal vein (PV) reconstruction is a key factor for successful living-donor liver transplantation (LDLT). Anatomical variations of right PV (RPV) are encountered among potential donors. METHODS: To evaluate a single center experience of reconstruction techniques for the right hemi-liver grafts with PV variations during the period between May 2004 and 2022. RESULTS: A total of 915 recipients underwent LDLT, among them 52 (5.8%) had RPV anatomical variations. Type II PV was found in 7 cases (13.5%), which were reconstructed by direct venoplasty. Type III PV was found in 27 cases (51.9%). They were reconstructed by direct venoplasty in 2 cases (3.8%), Y graft interposition in 2 cases (3.8%), and in situ double PV anastomoses in 23 cases (44.2%). Type IV PV was found in 18 cases (34.6%) and was reconstructed by Y graft interposition in 9 cases (17.3%), and in situ double PV anastomoses in 9 cases (17.3%). Early right posterior PV stenosis occurred in 2 recipients (3.8%). Early PV thrombosis occurred in 3 recipients (5.8%). The median follow-up duration was 54.5 months (4 - 185). The 1-, 3-, and 5-years survival rates were 91.9%, 86%, and 81.2%, respectively. Late PV stenosis occurred in 2 recipients (3.8%) and was managed conservatively. CONCLUSION: Utilization of potential living donors with RPV anatomic variations may help to expand the donor pool. We found that direct venoplasty and in situ dual PV anastomoses techniques were safe, feasible, and associated with successful outcomes.

Effect of different preparation designs of minimally invasive occlusal onlays on the accuracy of different intraoral scanners: An in vitro study.

PURPOSE: The aim of this in vitro study was to assess and compare three different preparation designs of minimally invasive occlusal onlays on the trueness and precision of three different intraoral scanners under two different scanning conditions. MATERIALS AND METHODS: Three maxillary premolars were prepared in three different designs and divided accordingly into three groups, Group 1: Anatomical (n = 60), Group 2: Flat (n = 60), and Group 3: Ferrule (n = 60). The samples were then further divided into subgroups according to scanners as subgroup A: Medit i500 (n = 20), subgroup B: 3Shape TRIOS 4 (n = 20), and subgroup C: Cerec Primescan (n = 20). Last, the samples were further divided according to scanning conditions: Division i: As prepared (n = 10) and Division ii: Sprayed - scan spray (n = 10). An industrial 3D scanner was used to obtain the reference STL files. Accuracy was assessed in terms of trueness and precision and recorded in terms of root mean square in micrometers. Numerical data were explored for normality using Shapiro-Wilk test and were analyzed using 3-way ANOVA followed by Tukey's post hoc test. RESULTS: Regarding trueness, 3-way ANOVA showed that all tested variables had a significant effect on trueness. Significant interactions were found between the different variables (p < 0.001). For preparation design the highest value was found in ferrule preparation (27.88 ± 7.11), followed by flat preparation (22.99 ± 7.56), while the lowest value was found in anatomical preparation (18.83 ± 5.71) (p < 0.001). For scanner type, the highest value was found in Primescan (25.36 ± 10.66), followed by TRIOS 4 (22.75 ± 5.98), while the lowest value was found in Medit i500 (21.59 ± 5.03) (p < 0.001). As for the scanning condition, sprayed samples (26.54 ± 8.24) had a significantly higher value than non-sprayed samples (19.93 ± 5.53) (p < 0.001). Regarding precision, both preparation design and scanner type had a significant effect on precision. Scanning conditions had no significant effect. There was a significant interaction between the three tested variables (p = 0.012). CONCLUSIONS: Anatomical preparation of minimally invasive occlusal onlays produced the most accurate scans. Within the tested preparation designs, Medit i500 and 3Shape TRIOS 4 have better trueness than Cerec Primescan. Cerec Primescan is more precise than 3Shape TRIOS 4 and Medit i500 Scan spray application causes a higher deviation in the trueness of the tested intraoral scanners while it does not affect their precision.

Effect of Different Preparation Depths for an Inlay-Retained Fixed Partial Denture on the Accuracy of Different Intraoral Scanners: An In Vitro Study.

PURPOSE: The aim was to evaluate the effect of different preparation depths for inlay-retained fixed partial dentures on the accuracy of intraoral scanners. MATERIALS AND METHODS: Tooth preparations for two inlay-retained fixed partial dentures were done and divided according to depth of the preparation. Group A: 2 mm pulpal floor depth, 3 mm gingival floor depth and Group B: 3 mm pulpal floor depth, 4mm gingival floor depth. The CEREC Omnicam 4.4.4, Omnicam 4.6.2. Trios3 and Medit i500 intraoral scanners were used in this study. Tooth preparations were scanned by each scanner 10 times. The STL files obtained from the intraoral scanners were compared to the reference models (trueness) and within each test group (precision) using a 3D comparison software. Data were then statistically analyzed. RESULTS: Regarding trueness, two-way ANOVA revealed significant differences between the different types of scanners (p < 0.001) (Omnicam 4.4.4: 65.09 ± 2.87 Omnicam 4.6.1: 52.73 ± 3.31 Medit i500: 58.45 ± 2.63 Trios 3: 41.79 ± 4.42). Preparation depth had no significant influence on the trueness (p = 0.083). For precision two-way ANOVA revealed significant differences between the different types of scanners (p < 0.001). Preparation depth had no significant influence on the precision (p = 0.111). Statistically significant interactions were found between the different variables. CONCLUSIONS: The depth of preparation did not have an influence on the accuracy of different scanners. However, the type of scanner influenced the accuracy of digital impressions with Trios3 showing the highest accuracy.

The Effect of Different Wax Pattern Fabrication Techniques on the Marginal Fit of Customized Lithium Disilicate Implant Abutments.

PURPOSE: To evaluate the effect of different wax pattern fabrication techniques on the fit of customized pressed lithium disilicate implant abutments on titanium inserts before and after pressing. The marginal fit results of pressed lithium disilicate implant abutments were then compared with those of milled lithium disilicate abutments. MATERIALS AND METHODS: After scanning the titanium inserts and designing an implant abutment, wax patterns were fabricated with three techniques (n = 15 each): computer-aided design/computer-aided manufacturing (CAD/CAM) milling, 3D printing and conventional layering. The marginal fit (µm) was measured using a stereomicroscope for all the wax patterns before pressing them into the lithium disilicate abutments. The pressed implant abutments were measured again for marginal fit, and the results were compared to those of the milled lithium disilicate abutments. One-way analysis of variance (ANOVA) was used to assess different wax pattern fabrication techniques in each stage before and after pressing. One-way ANOVA was also used to compare the groups of pressed and milled lithium disilicate abutments. Multiple pairwise comparisons were performed using the Tukey post hoc test in each stage. RESULTS: There were statistically significant differences between the marginal fit of the three wax patterns groups (p < 0.001; f = 123.33), wherein the mean marginal fit was the highest for conventionally layered wax patterns (30 ± 13.09) µm. Furthermore, after pressing, there were statistically significant differences between the marginal fit of the three pressed abutments groups (p < 0.001; f = 518.62), wherein the mean marginal fit was the highest for pressed e.max abutments fabricated from conventionally layered wax patterns (25.26 ± 3.9) µm. There was no statistically significant difference between the mean marginal fit of the pressed abutments fabricated from conventional layered wax patterns and that of the milled CAD/CAM abutments. However, the mean marginal fit of the milled CAD/CAM abutments was higher than that of the pressed abutments fabricated from both CAD/CAM wax and 3D printed wax. CONCLUSION: All the tested fabrication methods provided degrees of accuracy that lie well within accepted limits. The use of pressed lithium disilicate abutments fabricated from conventional layering wax pattern technique should provide a more consistent better marginal fit between the titanium insert and the abutment and may therefore be the preferable fabrication method.

Assessment of marginal adaptation and fracture resistance of endocrown restorations utilizing different machinable blocks subjected to thermomechanical aging.

OBJECTIVE: This in vitro study was conducted to assess the marginal adaptation and fracture resistance of computer aided design/computer aided manufacturer (CAD-CAM) fabricated endocrowns restoring endodontically treated molars using different machinable blocks with thermomechanical loading protocols. MATERIALS AND METHODS: Devitalized mandibular molars were prepared in a standardized way and divided into 4 groups (n = 10) to receive CAD/CAM fabricated endocrowns using four materials (Lithium disilicate ceramics, polymer infiltrated ceramics, zirconia-reinforced lithium silicate ceramics and resin nanoceramics. Marginal gaps (µm) were measured using stereomicroscope before cementation and after cementation. After thermomechanical aging, marginal gap measurements were repeated, and then fracture resistance test was performed. Two-way analysis of variance (ANOVA) and Tukey HSD multiple comparisons were used to assess the effect of material on the marginal gap before, after cementation, and after thermomechanical aging. One Way ANOVA was used to assess the effect of material on the fracture resistance. RESULTS: The difference between marginal gaps values of the tested materials was statistically insignificant but with significant increase after cementation and after thermomechanical aging. Cerasmart endocrowns showed the highest mean fracture load value (1508.5 ± 421.7N) with statistically significant difference than Vita Enamic endocrowns and Celtra Duo. CONCLUSION: The tested materials showed marginal vertical gap readings within the limits of clinically acceptable standards. Resin nanoceramics and lithium disilicate showed the highest values of fracture resistance followed by polymer infiltrated ceramics favoring their use for endocrown restorations. CLINICAL SIGNIFICANCE: The mechanical behavior of ceramic materials varies with the variation of their structure and mechanical properties. Accordingly, further investigation is always needed to explore the biomechanical behavior of recent materials when used as endocrowns before clinical trials.

Impact of donor-recipient genetic relationship on outcome of living donor liver transplantation.

Living donor liver transplantation (LDLT) is a valuable option for expanding the donor pool, especially in localities where deceased organ harvesting is not allowed. In addition, rejection rates were found to be lower in LDLT, which is attributed to the fact that LDLT is usually performed between relatives. However, the impact of genetic relation on the outcome of LDLT has not been studied. In this study, we examined the difference in rejection rates between LDLT from genetically related (GR) donors and genetically unrelated (GUR) donors. All cases that underwent LDLT during the period from May 2004 until May 2014 were included in the study. The study group was divided into 2 groups: LDLT from GR donors and LDLT from GUR donors. A total of 308 patients were included in the study: 212 from GR donors and 96 from GUR donors. Human leukocyte antigen (HLA) typing was not included in the workup for matching donors and recipients. GUR donors were wives (36; 11.7%), sons-in-law (7; 2.3%), brothers-in-law (12; 3.9%), sisters-in-law (1; 0.3%), and unrelated (38; 12.3%). The incidence of acute rejection in the GR group was 17.4% and 26.3% in the GUR group (P value = 0.07). However, there was a significant difference in the incidence of chronic rejection (CR) between the 2 groups: 7% in GR group and 14.7% in the GUR group (P value = 0.03). In terms of overall survival, there was no significant difference between both groups. LDLT from the GUR donors is not associated with a higher incidence of acute cellular rejection. However, CR was significantly lower when grafts were procured from GR donors. HLA matching may be recommended before LDLT from GUR donors. Liver Transplantation 23:43-49 2017 AASLD.

Short-term effects of extracorporeal graft rinse versus circulatory graft rinse in living donor liver transplantation. A prospective randomized controlled trial.

Living donor liver transplantation has shorter cold ischemia time, less preservative volume, and lower metabolic load compared to transplantation from deceased donors. We investigated the impact of rinsing the graft contents into the systemic circulation on operative course and postoperative outcomes. Donors had right hepatectomy, and grafts were preserved with cold histidine-tryptophan-ketoglutarate solution. On ending portal vein anastomosis, grafts were flushed by patient's portal blood either through incompletely anastomosed hepatic vein (extracorporeal rinse group, EcRg, n = 40) or into systemic circulation (circulatory rinse group, CRg, n = 40). The primary outcome objective was the lowest mean arterial blood pressure within 5 min after portal unclamping as a marker for postreperfusion syndrome (PRS). Secondary objectives included hemodynamics and early graft's and patient's outcomes. Within 5 min postreperfusion, mean arterial blood pressure was significantly lower in the CRg compared to the EcRg, yet this was clinically insignificant. Postoperative graft functions, early biliary and vascular complications, and three-month survival were comparable in both groups. Rinsing the graft into the circulation increased the incidence of PRS without significant impact on early graft or patient outcome in relatively healthy recipients.

Biliary complications in living donor right hepatectomy are affected by the method of bile duct division.

The bile duct division is a crucial step in the donor hepatectomy. Multiple small ducts will make the biliary reconstruction more difficult and may influence the outcome of the recipient. Biliary leakage, bilomas and biliary strictures are well recognized donor complications that may be directly linked to bile duct division. Biliary division still needs more standardization. This work aims to analyze our experience with two different methods of bile duct division in relation to the development of intraoperative and postoperative biliary complications. Between April 2004 and March 2013, 216 liver donors underwent right hepatectomy, in Gastro-Enterology Surgical Center, Mansoura University, Egypt. According to the method of bile duct division, the study population was divided into 2 groups; 1- extrahepatic dissection group (EDG) and 2- fluoroscopy guided transection group (FGG), each comprised 108 patients. Data were collected from a prospectively registered database, with special emphasis on the occurrence of biliary complications. Complications were classified according to the latest version of Clavien classification. Intraoperative biliary complications did not differ between both groups, p = 0.313. The commonest postoperative complication was biliary leak/biloma accounting for 32.5% of all donor complications, followed by non-biliary fluid collections. 24 (11.1%) donors developed 27 biliary complications. The FGG showed significantly less biliary complications (5.6%, 6 donors), when compared to EDG (15.7%, 18 donors), p = 0.015. Grade 3 complications were significantly higher in EDG, p = 0.024. On multivariate analysis, the only significant factor predicting the occurrence of biliary complications was the use of fluoroscopy guided bile duct division, p = 0.009. In conclusion, we believe that the proposed method of biliary division is safe, simple and reproducible.

Isolated Roux loop pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a prospective randomized study.

OBJECTIVES: The optimal strategy for the reconstruction of the pancreas following pancreaticoduodenectomy (PD) is still debated. The aim of this study was to compare the outcomes of isolated Roux loop pancreaticojejunostomy (IRPJ) with those of pancreaticogastrostomy (PG) after PD. METHODS: Consecutive patients submitted to PD were randomized to either method of reconstruction. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF). Secondary outcomes included operative time, day to resumption of oral feeding, postoperative morbidity and mortality, and exocrine and endocrine pancreatic functions. RESULTS: Ninety patients treated by PD were included in the study. The median total operative time was significantly longer in the IRPJ group (320 min versus 300 min; P = 0.047). Postoperative pancreatic fistula developed in nine of 45 patients in the IRPJ group and 10 of 45 patients in the PG group (P = 0.796). Seven IRPJ patients and four PG patients had POPF of type B or C (P = 0.710). Time to resumption of oral feeding was shorter in the IRPJ group (P = 0.03). Steatorrhea at 1 year was reported in nine of 42 IRPJ patients and 18 of 41 PG patients (P = 0.029). Albumin levels at 1 year were 3.6 g/dl in the IRPJ group and 3.3 g/dl in the PG group (P = 0.001). CONCLUSIONS: Isolated Roux loop PJ was not associated with a lower rate of POPF, but was associated with a decrease in the incidence of postoperative steatorrhea. The technique allowed for early oral feeding and the maintenance of oral feeding even if POPF developed.

Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience).

BACKGROUND: Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains a challenge even at high-volume centers. METHODS: This study was designed to analyze perioperative risk factors for POPF after PD and evaluate the factors that predict the extent and severity of leak. Demographic data, preoperative, intraoperative, and postoperative variables were collected. RESULTS: A total of 471 consecutive patients underwent PD in our center. Fifty-seven patients (12.1 %) developed a POPF of any type; 21 patients (4.5 %) had a fistula type A, 22 patients (4.7 %) had a fistula type B, and the remaining 14 patients (3 %) had a POPF type C. Cirrhotic liver (P = 0.05), BMI > 25 kg/m(2) (P = 0.0001), soft pancreas (P = 0.04), pancreatic duct diameter <3 mm (0.0001), pancreatic duct located <3 mm from the posterior border (P = 0.02) were significantly associated with POPF. With the multivariate analysis, both BMI and pancreatic duct diameter were demonstrated to be independent factors. The hospital mortality in this series was 11 patients (2.3 %), and the development of POPF type C was associated with a significantly increased mortality (7/14 patients). The following factors were predictors of clinically evident POPF: a postoperative day (POD) 1 and 5 drain amylase level >4,000 IU/L, WBC, pancreatic duct diameter <3 mm, and pancreatic texture. CONCLUSIONS: Cirrhotic liver, BMI, soft pancreas, pancreatic duct diameter <3 mm, pancreatic duct near the posterior border are risk factors for development of POPF. In addition a drain amylase level >4,000 IU/L on POD 1 and 5, WBC, pancreatic duct diameter, pancreatic texture may be predictors of POPF B, C.

Factors affecting recurrence and survival after living donor liver transplantation for hepatocellular carcinoma.

BACKGROUND/AIMS: HCC is a leading cause of cancer-related deaths worldwide. The main etiological factor in Egypt is HCV infection. Lack of cadaveric transplantation in Egypt makes LDLT the only available option for liver transplantation for HCC patients with advanced cirrhosis and/or non-resectable tumors. METHODOLOGY: Between January 2004 and April 2012, 170 patients underwent LDLT at the Liver Transplantation Unit, Mansoura University, and 52 (30.6%) were shown to have HCC by pathological examination. Patient demographics, preoperative interventions and pathological findings were evaluated for their influence on recurrence and survival. Patients were followed-up with abdominal sonography and AFP every 3 months and CT scans every 6 months. Median follow-up was 22.9 months. RESULTS: The main cause of underlying cirrhosis was HCV (96.2%). One or more different pre-transplant treatments of HCC were performed in 14 (27.4%) patients. The median total size was 4cm (0.8-15.5). Microvascular invasion was detected in 16 (31.4%) patients; 16 patients proved to have tumors beyond the Milan criteria. Pre-transplantation AFP more than 200ng/mL, total tumor size more than 8cm and microvascular invasion influenced recurrence rate on univariate analysis. Multivariate analysis identified AFP (p = 0.016) as independent factor for recurrence. Survival was significantly affected by AFP (p = 0.003) and microvascular invasion (p = 0.003). CONCLUSIONS: LDLT is a feasible option for patients with HCC on top of cirrhosis with good survival and recurrence-free survival rates.

Predictive factors of postendoscopic retrograde cholangiopancreatography pancreatitis for biliary complications in living-donor liver transplantation recipients.

OBJECTIVES: Endoscopic retrograde cholangiopancreatography (ERCP) has shown great safety and efficacy in the management of post-living-donor liver transplantation (LDLT) biliary complications. Pancreatitis is the most commonest and the most feared complication after ERCP. METHODS: We reviewed the data of liver transplant recipients who underwent ERCP for biliary complications after LDLT between 2011 and 2022. RESULTS: In total 63 patients underwent ERCP after LDLT. They were targeted to 134 set of ERCP. Pancreatitis occurred in 52 sets (38.8%). We subclassified the patients into two groups, without pancreatitis: 31 patients (49.2%) and with pancreatitis 32 patients (50.8%). A higher incidence of pancreatitis was noticed with the first ERCP set (P = 0.04). Biliary strictures were more noted in the pancreatitis group (P = 0.025). Difficult cannulation requiring precut was more observed in the pancreatitis group (P = 0.007). Also, more frequent sphincterotomy was observed in the pancreatitis group (P = 0.003). Longer hospital stay, more fever, abdominal pain and vomiting were noted in the pancreatitis group (P = 0.001). Higher post-ERCP serum amylase (P = 0.001) and creatinine (P = 0.021), while lower serum calcium (P = 0.21) were noticed in the pancreatitis group. On multivariate analysis, preoperative diabetes, number of biliary anastomoses (single/multiple) and difficult cannulation requiring precut were significant predictors of post-ERCP pancreatitis. CONCLUSION: Patient-related risk factors and bedside procedure-related risk factors play an essential role in the development of pancreatitis after ERCP for LDLT recipients. Endoscopists should be mindful by those high-risk patients during ERCP to apply appropriate techniques to prevent the development of this serious complication.

The impact of portopulmonary hypertension on intraoperative right ventricular function of living donor liver transplant recipients.

BACKGROUND: Portopulmonary hypertension (PPH) burdens a right ventricle (RV) already exposed to physiologic stress during liver transplantation. The magnitude of the impact of PPH on RV function, especially early reperfusion, has not been evaluated adequately by prospective controlled trials. In this study, we prospectively quantified the impact of PPH on the RV function in living donor liver transplant recipients. METHODS: Twenty patients undergoing living donor liver transplant were stratified based on mean pulmonary artery pressure (mPAP) into a control group (mPAP <25 mm Hg) and a PPH group (mPAP ≥25 mm Hg). Standard anesthetic technique and monitoring were used. Fiberoptic pulmonary artery catheters enabled to measure RV ejection fraction (RVEF) were used. Hemodynamics were recorded after induction of anesthesia, the end of hepatectomy, before portal unclamping, 5 and 30 minutes after reperfusion, and at skin closure. RESULTS: The PPH group had significantly lower RVEF, stroke volume, and higher central venous pressure and RV end-diastolic volume index after portal unclamping versus the controls. Pulmonary vascular resistance index and mPAP were significantly higher throughout the operation in the PPH group, but RV stroke work index did not differ significantly between groups. RVEF was significantly reduced in the PPH group after reperfusion compared with baseline, but the control group did not experience such a reduction. CONCLUSIONS: Mild to moderate PPH was associated with reduced RVEF during liver transplantation, especially after reperfusion, likely because of a reduced RV contractile reserve in PPH patients. This reduction in RVEF was clinically well tolerated by patients with mild to moderate PPH.

Laparoscopic Heller myotomy for achalasia: analysis of successes and failures.

BACKGROUND/AIMS: The outcome of laparoscopic myotomy for achalasia is dictated by many factors. METHODOLOGY: A retrospective study was conducted between 1997-2007, 58 patients who fulfilled all criteria for the diagnosis of achalasia underwent laparoscopic Heller myotomy and 45 (77.6%) were included. Mean follow-up period was 36±15 months; 56 patients had Dor fundoplication; 17 patients had been previously treated by pneumatic dilatation. All steps of the procedure, esophageal manometric findings and radiological records were analyzed to determine factors contributing to the clinical success or failure of the operation. The main outcome measure was swallowing status. RESULTS: Median hospital stay was 3±1 days and mean operative time was 75±20min. There were 7 intra-operative mucosal injuries; all sutured laparoscopically (5 had previous pneumatic dilatation). Good or excellent relief of dysphagia was obtained in 41 patients and was persistent among 2 patients (both had pneumatic dilatation preoperatively). The remaining 2 patients developed gastroesophageal reflux symptoms. These 41 patients had a preoperative smaller diameter of the esophagus (stage I, II and III), while those with guarding results (4) had stages III and IV. There was a decrease in LES pressure from 45±7mmHg to 10±2mmHg without evidence of restoration of esophageal peristalsis in any patient. CONCLUSIONS: Laparoscopic Heller myotomy with Dor fundoplication significantly relieves the symptoms of achalasia without causing the symptoms of gastroesophageal reflux disease. A good postoperative result is expected when the length of myotomy is adequate, LES pressure declines substantially, preoperative esophageal dilation is not excessive and distortion of the distal esophagus is absent.

Caudate lobe resection with major hepatectomy for central cholangiocarcinoma: is it of value?

BACKGROUND/AIMS: The aim of this study was to evaluate the importance of concomitant caudate lobe resection in the course of major hepatectomy for hilar cholangiocarcinoma. METHODOLOGY: During the period between January 1995 and December 2010, 159 patients were subjected to major hepatectomy with or without total caudate lobe resection at the Gastroenterology Centre, Mansoura University. These patients were divided in two groups: 1) a caudate lobe preservation (CLP) group (79 patients) and 2) a caudate lobe resection (CLR) group (80 patients). All patient data were retrospectively reviewed. RESULTS: This study included 94 men and 65 women with a mean age of 53.5±0 years without operative mortality. No differences were observed between groups regarding operative time, blood loss or the development of any individual postoperative complication. There were 23 (28.8%) margin-positive resections in the CLR group and 49 (62%) margin-positive resections in the CLP group (p≤0.001). Recurrence was confirmed in 53 (67.1%) and in 41(51.3%) patients in the CLP and CLR groups, respectively (p=0.031). The median survival of the CLR group was 36 months with a 5-year survival rate of 28%, while the median survival of the CLP group was 22 months with a 5-year survival rate of 5% (p≤0.001). CONCLUSIONS: Caudate lobe resection in combination with major hepatectomy did not affect operative or postoperative morbidity and mortality. However, it led to higher rates of margin-negative resections and significantly improved survival.

Fracture Resistance of Custom Lithium Disilicate Implant Restorations with Two Fabrication Techniques and Two Designs.

PURPOSE: To compare the fracture resistance of a press-on ceramic custom implant restoration with pressed and cemented restorations. MATERIALS AND METHODS: Thirty-two (32) lithium disilicate (IPS e.max Press) custom hybrid abutment restorations were fabricated. The restorations were divided into two groups (n = 16) according to the construction technique: the commercial control group (C) and the press-on group (P). For the control group, lithium disilicate restorations were pressed and cemented on titanium bases. For the press-on group, lithium disilicate pressable ceramic (IPS e.max Press) was pressed on the titanium bases with injection molding. Each group was further divided according to the restoration design, either screw- or cement-retained, into two subgroups of eight specimens each. Specimens of C group were divided into screw-retained (cemented hybrid abutment crown, CHAC) or cement-retained (cemented hybrid abutment, CHA). Specimens of the P group were also divided into screw-retained (pressed hybrid abutment crown, PHAC) and cement-retained (pressed hybrid abutment, PHA). The specimens were subjected to static loading until failure with a universal testing machine. Two-way analysis of variance (ANOVA) was used to assess the effect of different techniques and designs on the fracture resistance of the samples (P < .05), followed by one-way ANOVA and Tukey honest significant difference (HSD) test (α = .05). RESULTS: C group showed higher mean fracture resistance (812.443 ± 129.14 N) than P group (596.71 ± 108.83 N), and the difference was statistically significant (P < .05). Regarding restoration design, HA groups showed higher mean fracture resistance (742.621 ± 153.82 N) than HAC (666.53 ± 163.07 N) groups with no statistically significant difference. CHA showed the highest mean fracture resistance (817.65 ± 161.76 N), while PHAC showed the lowest mean fracture resistance values (525.83 ± 47.29 N). CONCLUSION: The commercial cemented lithium disilicate restorations showed higher fracture resistance than the press-on restorations, although both showed a maximum load capacity that was greater than physiologic incisal force in the anterior region, and both hybrid abutments and hybrid abutment crowns were equally efficient in withstanding occlusal loading forces.