Techniques of hepatic arterial reconstruction in liver transplantation.

BACKGROUND: Hepatic artery reconstruction is an essential part of liver transplantation. This difficult stage of the operation is even more demanding in living donor liver transplantation than in deceased donor liver transplantation. One of the most important advances in hepatic artery reconstruction for living liver grafts was the introduction of microsurgical techniques involving an operative microscope or surgical loupe. Many surgical reconstruction techniques have been used in this field. PURPOSE: In this article, first, we will talk about the hepatic artery reconstruction techniques that are frequently used in deceased donor liver transplantation, and afterward, we will talk about the hepatic artery reconstruction techniques used in living donor liver transplantation, which include the hepatic artery reconstruction technique we use and call "one stay corner suture technique". CONCLUSIONS: We think high-volume transplant centers should tend to develop a standardized technique for doing hepatic artery reconstruction with their teams. We think the "one stay corner suture technique" can be easily applied in centers that perform LDLT.

Living Donor Versus Deceased Donor Liver Transplantation for HCC.

INTRODUCTION: Liver transplantation is the definitive treatment modality of the patients having an end-stage liver disease with hepatocellular carcinoma. DISCUSSION: The number of living donor liver transplantations has been increased because of the deceased donor organ shortage, especially in Asian countries. CONCLUSION: Reports of different clinics about the postoperative course and tumor recurrence rates comparing living donor versus deceased donor liver transplantations, besides patient selection criteria, are reviewed along with our clinic's experiences.

Is peritoneal dialysis prior to kidney transplantation a risk factor for ureteral stenosis after adult to adult live kidney transplantation.

OBJECTIVES: Major urinary complications such as urinary leaks, stenosis or urinary tract infections after kidney transplantation can lead to graft or patient loss. The effect of peritoneal dialysis on post-kidney transplantation complications have been discussed but its effect on ureteral stenosis is unknown. In this study, it was aimed to analyze factors effecting major ureteral complications after living donor kidney transplantation and impact of peritoneal dialysis and double J-stents (JJ stents). MATERIAL AND METHODS: This study included 116 adult to adult living donor kidney transplant patients. Factors effecting major urologic complications after living donor kidney transplantation were analyzed. The donors were primary relatives of the recipients. RESULTS: Major urologic complications after living donor kidney transplantation was 8/116 (6.9%). Urinary leak was present in 2 (1.7%) patients. Ureteral stenosis was encountered in 6 (5.2%) patients. Double J stents were used in 84 (72.4%) of the cases. The effect of JJ ureteral stent was not statistically significant for urinary leak, ureteral stenosis (p= 0.074, p= 0.470, respectively). A total of 29 (25%) patients had peritoneal dialysis before kidney transplantation. Preoperative peritoneal dialyses and bacteriuria after kidney transplantation were independent risk factors for ureteral stenosis in multivariate analysis (p= 0.013, and p= 0.010 respectively). CONCLUSION: In the guidance of the results of the present study, peritoneal dialysis prior to kidney transplantation and bacteriuria are independent risk factors for ureteral stenosis after living donor kidney transplantation. JJ stents have no effect on urologic complications after living donor kidney transplantation.

Author Correction: Liver Transplantation for Hepatocellular Carcinoma: Malatya Experience and Proposals for Expanded Criteria.

The original version of this article unfortunately contained a mistake in the author group section.

Liver Transplantation for Hepatocellular Carcinoma: Malatya Experience and Proposals for Expanded Criteria.

Survival was examined from a Turkish liver transplant center of patients with HCC, to identify prognostic factors. Data from 215 patients who underwent predominantly live donor liver transplant for HCC at our institute over 12 years were included in the study and prospectively recorded. They were 152 patients within and 63 patients beyond Milan criteria. Patients beyond Milan criteria were divided into two groups according to presence or absence of tumor recurrence. Recurrence-associated factors were analyzed. These factors were then applied to the total cohort for survival analysis. We identified four factors, using multivariate analysis, that were significantly associated with tumor recurrence. These were maximum tumor diameter, degree of tumor differentiation, and serum AFP and GGT levels. A model that included all four of these factors was constructed, the 'Malatya criteria.' Using these Malatya criteria, we estimated DFS and cumulative survival, for patients within and beyond these criteria, and found statistically significant differences with improved survival in patients within Malatya criteria of 1, 5, and 10-year overall survival rates of 90.1%, 79.7%, and 72.8% respectively, which compared favorably with other extra-Milan extended criteria. Survival of our patients within the newly defined Malatya criteria compared favorably with other extra-Milan extended criteria and highlight the usefulness of serum AFP and GGT levels in decision-making.

Should percutaneous cholecystostomy be used in all cases difficult to manage?

BACKGROUND: Cholecystectomy is the well-accepted management method for acute cholecystitis in patients suitable for surgery. Percutaneous cholecystostomy is planned and used in patients at high surgical risk due to acute symptomatic cholecystitis and/or acute or chronic comorbidity. Percutaneous cholecystostomy can provide permanent treatment, or it may act as a bridge for elective cholecystectomy. METHODS: We presented the outcomes of 50 patients who initially underwent ultrasound-guided transhepatic percutaneous cholecystostomy and 4-6 weeks later, an interval cholecystectomy. All patients had either impaired gallbladder wall integrity on contrast-enhanced abdominal computed tomography performed during admission or had grade II acute cholecystitis according to the Tokyo Guidelines 13 diagnostic criteria and severity grading of acute cholecystitis or exhibited clinical signs of acute cholecystitis on the fifth day of non-operative treatment. RESULTS: Our results suggest that although percutaneous cholecystostomy is a useful method for alleviation of the emergency clinical condition in acute cholecystitis, it makes the interval cholecystectomy more difficult to perform due to the dense fibrosis developing during the healing process, eventually complicating laparoscopic cholecystectomy. CONCLUSION: Cholecystostomy may cause fibrosis during the healing process, eventually complicating laparoscopic cholecystectomy. Thus, there is a need for better evaluation during the identification of indications for cholecystostomy.

Analysis of risk factors of mortality in abdominal trauma.

BACKGROUND: The present study aims to analyze blunt and penetrating abdominal traumas that were evaluated in our emergency department, the treatment approaches and risk factors of mortality. METHODS: Six hundred and sixty-four patients were admitted to our emergency department for surgical evaluation for trauma between January 2009 and April 2019. After the exclusion of dead on arrival, patients with missing data and patients without abdominal trauma were excluded from this study. Hundred and thirteen patients with abdominal trauma admitted to our department were evaluated in this study. Demographic, clinical, prognostic and mortality related factors were retrospectively analyzed. RESULTS: The mean age of the patients was 36.08±16.1 years. There were 90 male patients. Eighty patients (70.8%) had blunt abdominal trauma (BAT). Twenty-eight patients (24.7%) had isolated liver and two patients (1.7%) had isolated spleen injury. Combined liver and spleen injury was found in two patients (1.7%). Twenty-two (19.4%) patients had mortality. Causes of mortality were an irreversible hemorrhagic shock (40.9%) and central nervous system (13.6%) injuries. BAT was the main mechanism of injury in patients with mortality (86.4% versus 67%; p<0.001). The frequency of retroperitoneal injury was significantly higher in patients with mortality (50% versus 16.5%, p<0.001). The frequency of extra-abdominal injury in patients with mortality was higher (68.1% versus 49.4%; p=0.047). Mean arterial pressure at admission was found to be significantly lower in patients with mortality (67±26.8 mmHg versus 84.3±17 mmHg; p=0.02). The number of packed erythrocytes transfused in patients with mortality was higher (8.8±8.6 versus 3.3±5.9 units; p=0.047). Mean international normalized ratio (INR) was significantly higher in patients with mortality (4.3±7.1 versus 2.7±4; p=0.016). Mean lactate dehydrogenase level was higher in patients with mortality (1685.7±333.8 versus 675.8±565.3 IU/mL; p<0.001). Mean alanine aminotransferase (ALT) was significantly higher in patients with mortality (430±619 versus 244±448 IU/mL; p<0.001). Mean alkaline phosphatase (ALP) level in patients with mortality was higher (76.9±72.8 versus 67.3±27.8 IU/mL; p=0.003). The presence of retroperitoneal injury and ALT >516 IU/mL were independent risk factors o mortality. CONCLUSION: We have found certain laboratory variables to increase in patients with mortality. These are related to the severity of trauma. Retroperitoneal injury and increased ALT levels being risk factors of mortality is the most important finding of this study. Our results can guide other centers in the evaluation of trauma patients, and high-risk groups can be identified.

Usability of Inferior Vena Cava Interposition Graft During Living Donor Liver Transplantation: Is This Approach Always Necessary?

PURPOSE: To share the outcome of caval reconstruction technique in patients who underwent living donor liver transplantation (LDLT) with inferior vena cava (IVC) interposition grafting. METHODS: Between January 2009 and December 2018, an artificial or homologous interposition vascular graft was used for the continuity of resected native (IVC) due to various reasons in 29 of 1740 patients who underwent LDLT at our institute. Demographic, clinical, and radiological data were prospectively collected and retrospectively analyzed. RESULTS: Sixteen female and 13 male patients ranging 6-67 years of age were included. Right, left, and left lobe lateral segments were used in 22, 5, and 2 patients, respectively. The three leading LDLT indications were primary or idiopathic Budd-Chiari syndrome (BCS) (n = 12), alveolar echinococcosis (n = 7), and secondary BCS (n = 5). The three leading indications for IVC interposition grafting were thrombosis, dense fibrosis, and IVC invasion caused by tumor or echinococcosis. Homologous IVC graft was used in 17, homologous aortic graft in 7, and Dacron graft in 5 patients. Throughout the follow-up period, ascites ± pleural effusion and elevated liver enzymes were detected in 12 and 4 patients, respectively. Stenosis and/or thrombosis requiring one or more procedures such as 1-6 sessions balloon angioplasty, stent, and thrombus aspiration were observed in half of the patients. CONCLUSION: Retrohepatic IVC damages are not a contraindication for LDLT. The presence or absence of venous collateral circulation is an important indicator of the need for IVC interposition graft use.

Liver transplant for large hepatocellular carcinoma in Malatya: The role of gamma glutamyl transferase and alpha-fetoprotein, a retrospective cohort study.

BACKGROUND: There is increasing interest in transplanting patients with hepatocellular carcinoma (HCC) with tumors greater than 5 cm (Milan criteria). AIM: To investigate possible prognostically-useful factors for liver transplantation in HCC patients with large tumors. METHODS: In this clinical study, 50 patients with HCC who were transplanted at our Liver Transplant Center between April 2006 and August 2019 and had tumors greater than 6 cm maximum diameter were retrospectively analyzed. Their survival and full clinical characteristics were examined, with respect to serum alpha-fetoprotein (AFP) and gamma glutamyl transpeptidase (GGT) levels. Kaplan-Meier survival estimates were used to determine overall survival and disease-free survival in these patients. The inclusion criterion was evidence of HCC. Exclusion criteria were the presence of macroscopic portal vein thrombosis or metastasis and a follow-up period of less than 90 d. RESULTS: Using receiver operating characteristic curve (ROC) analysis, cutoff values of AFP 200 ng/mL and GGT 104 IU/L were identified and used in this study. Significantly longer overall survival (OS) and disease-free-survival (DFS) were found in patients who had lower values of either parameter, compared with higher values.  Even greater differences in survival were found when the 2 parameters were combined. Two tumor size bands were identified, in searching for the limits of this approach with larger tumors, namely 6-10 cm and > 10 cm. Combination parameters in the 6-10 cm band reflected 5-year OS of 76.2% in patients with low AFP plus low GGT vs 0% for all other groups. Patients with tumors greater than 10 cm, did not have low AFP plus low GGT. The most consistent clinical correlates for longer survival were degree of tumor differentiation and absence of microscopic portal venous invasion. CONCLUSION: Serum levels of AFP and GGT, both alone and combined, represent a simple prognostic identifier in patients with large HCCs undergoing liver transplant-ation.

Does Preoperative Transarterial Chemoembolization for Hepatocellular Carcinoma Increase the Incidence of Hepatic Artery Thrombosis After Living-Donor Liver Transplant?

OBJECTIVES: Transarterial chemoembolization is a potential risk factor for hepatic artery damage, which may lead to severe consequences. We aimed to investigate this controversial issue in our population of liver transplant patients with hepatocellular carcinoma. MATERIALS AND METHODS: Between March 2006 and December 2016, a total of 262 patients with hepatocellular carcinoma underwent liver transplant at our institution. Of these, 22 (8.4%) had preoperative transarterial chemoembolization. We retrospectively reviewed the data of all patients, comparing those who did and did not undergo transarterial chemoembolization. RESULTS: The groups were similar in terms of patient sex, mean age, mean alpha-fetoprotein levels, and Milan criteria. The nontransarterial chemoembolization group had a significantly higher mean Model for End-Stage Liver Disease score. Hepatic artery thrombosis after liver transplantation was diagnosed in 6 of 22 patients (27%) in the transarterial chemoembolization group and in 12 of 240 patients (5%) in the nontransarterial chemoembolization group (P = .002). Retransplant was performed in 5 of the 6 patients with hepatic artery thrombosis in the transarterial chemoembolization group and 3 of the 12 patients in the nontransarterial chemoembolization group (P = .04). CONCLUSIONS: In patients who undergo transarterial chemoembolization before liver transplantation, the incidence of hepatic artery thrombosis and retransplantation is significantly higher than in those who do not undergo this intervention. The tissues should be carefully handled at the time of transplantation to prevent trauma that may cause intimal dissection in the fragile vessels.

Laparoscopic right-sided colonic resection with transluminal colonoscopic specimen extraction.

AIM: To study the transcolonic extraction of the proximally resected colonic specimens by colonoscopic assistance at laparoscopic colonic surgery. METHODS: The diagnoses of our patients were Crohn's disease, carcinoid of appendix and adenocarcinoma of cecum. We preferred laparoscopic total mesocolic resections. Colon and terminal ileum were divided with endoscopic staplers. A colonoscope was placed per anal and moved proximally in the colon till to reach the colonic closed end under the laparoscopic guidance. The stump of the colon was opened with laparoscopic scissors. A snare of colonoscope was released and the intraperitoneal complete free colonic specimen was grasped. Specimen was moved in to the colon with the help of the laparoscopic graspers and pulled gently through the large bowel and extracted through the anus. The open end of the colon was closed again and the ileal limb and the colon were anastomosed intracorporeally with a 60-mm laparoscopic stapler. The common enterotomy orifice was closed in two layers with a running intracorporeal suture. RESULTS: There were three patients with laparoscopic right-sided colonic resections and their specimens were intended to remove through the remnant colon by colonoscopy but the procedure failed in one patient (adenocarcinoma) due to a bulky mass and the specimen extraction was converted to transvaginal route. All the patients had prior abdominal surgeries and had related adhesions. The operating times were 210, 300 and 500 min. The lengths of the specimens were 13, 17 and 27 cm. In our cases, there were no superficial or deep surgical site infections or any other complications. The patients were discharged uneventfully within 4-5 d and they were asymptomatic after a mean 7.6 mo follow-up (ranged 4-12). As far as we know, there were only 12 cases reported yet on transcolonic extraction of the proximal colonic specimens by colonoscopic assistance after laparoscopic resections. With our cases, success rate of the overall experience in the literature was 80% (12/15) in selected cases. CONCLUSION: Transcolonic specimen extraction for right-sided colonic resection is feasible in selected patients. Both natural orifice surgery and intracorporeal anastomosis avoids mini-laparotomy for specimen extraction or anastomosis.

Donor Postoperative Biliary Complications After Living-Donor Liver Transplant.

OBJECTIVES: Although the main factors responsible for donor deaths after living-donor liver transplant are liver failure and sepsis, the most common donor complications are associated with the biliary tract. MATERIALS AND METHODS: Between April 2006 and May 2012, five hundred ninety-three donors underwent living-donor hepatectomy procedures for living-donor liver transplants. The mean age of donors was 31.0 ± 9.9 years and the ratio of men to women was 341:252. Of all donors, 533 (89.9%) underwent a right lobe hepatectomy, 45 (7.6%) underwent a left lateral segmentectomy, and 15 (2.5%) underwent a left hepatectomy. RESULTS: Biliary complications were observed in 51 liver donors (8.6%). Based on the Clavien-Dindo classification, grade I and grade II complications were 3.2% and 0%, while grade IIIa and grade IIIb complications were observed in 3.5% and 1.85% of cases. Right lobe donor biliary complications occurred at the rate of 8.2% in 44 donors. Grade IV and grade V complications were not observed. Grade IIIa complications necessitating radiologic and endoscopic procedures were observed in 21 liver donors (3.5%). Bile leakage unresponsive to medical therapy was detected in 19 donors (3.2%). Nasobiliary catheters were placed in 3 of 19 donors and internal stents were placed in 1. Two sessions of balloon dilatation were performed in the 2 grade IIIb donors (0.33%). Biliary strictures observed in 2 right lobe donors and 1 left lobe donor was treated by hepaticojejunostomy an average of 14 months after surgery. CONCLUSIONS: Avoidance of intraoperative issues and early recognition of bile leakage are fundamental in preventing complications in living-donor liver transplant donors.

Pseudoangiomatous Stromal Hyperplasia of The Breast Presenting As A Giant Breast Tumor: A Case Report.

Pseudoangiomatous stromal hyperplasia (PASH) of the breast is a benign proliferative lesion of mammary stroma. It is identified as stromal cleavage surrounded by spindle-shaped stromal cells histomorphologicaly. Generally, it is determined in premenopausal women incidentally during breast biopsy. Clinically, it is rarely emerges as a palpable mass. PASH may be confused with low-grade angiosarcoma, hamartomas and phyllodes tumors in histopathological examination. Here, we report a giant left breast lesion that caused breast asymmetry and pain, and treated by total excision of the mass. The patient was a 39 years old women. Histopathologic examination of the specimen was evaluated as PASH. No additional medical treatment and clinical follow-up was recommended to patient. Within four months of the patient fallow-up, no problem occured.

Thyroid pathologies accompanying primary hyperparathyroidism: a high rate of papillary thyroid microcarcinoma.

OBJECTIVE: Thyroid pathologies and non-medullary thyroid cancer often accompany primary hyperparathyroidism (PHPT). The purpose of this study was to examine the association between thyroid diseases, especially micropapillary thyroid cancer, with PHPT. MATERIAL AND METHODS: Data regarding 46 patients who were operated on with a diagnosis of PHPT at Inonu University Faculty of Medicine, General Surgery Clinic between June 2009 and March 2013 were retrospectively analyzed. Age, gender, levels of preoperative calcium, parathyroid hormone and phosphorus, and the histopathological results of the removed parathyroid and thyroid tissues were evaluated. All of the patients had a preoperative diagnosis of PHPT and there was no history of radiation to the head and neck region in any of the patients. RESULTS: Out of the 46 patients who were operated on for PHPT, 39 were female and 7 were male. The mean age was 52.8 years (25-76). Simultaneous thyroidectomy was performed in 35 patients (76.1%) due to an accompanying thyroid disorder. Papillary microcarcinoma was detected in 5 of these 35 (10.9%) patients who underwent thyroidectomy, two of which (40%) were multifocal tumors. The benign thyroid pathologies detected in the remaining 30 (65.2%) cases included lymphocytic thyroiditis in 3, Hashimoto thyroiditis in 1, follicular adenoma in 3 (two of which was Hurtle cell), and nodular colloidal goiter in 23 patients. The preoperative serum phosphate level was significantly higher in the group with papillary thyroid microcarcinoma (p=0.013). CONCLUSION: In regions where goiter is endemic, thyroid diseases and thyroid papillary microcarcinoma occur in association with PHPT at a higher rate compared to the normal population. Therefore, we believe that patients who are planned for surgery due to PHPT should be thoroughly investigated for the presence of any concomitant malignant thyroid pathologies in the preoperative period. It should also be kept in mind that patients with high blood serum phosphate values may have an increased risk of papillary thyroid microcarcinoma.

En masse resection of pancreas, spleen, celiac axis, stomach, kidney, adrenal, and colon for invasive pancreatic corpus and tail tumor.

Providing a more comfortable life and a longer survival for pancreatic corpus/tail tumors without metastasis depends on the complete resection. Recently, distal pancreatectomy with celiac axis resection was reported as a feasible and favorable method in selected pancreatic corpus/tail tumors which had invaded the celiac axis. Additional organ resections to the celiac axis were rarely required, and when necessary it was included only a single extra organ resection such as adrenal or intestine. Here, we described a distal pancreatic tumor invading most of the neighboring organs-stomach, celiac axis, left renal vein, left adrenal gland, and splenic flexure were treated by en bloc resection of all these organs. The patient was a 60-year-old man without any severe medical comorbidities. Postoperative course of the patient was uneventful, and he was discharged on postoperative day eight without any complication. Histopathology and stage of the tumor were adenocarcinoma and T4 N1 M0, respectively. Preoperative back pain of the patient was completely relieved in the postoperative period. As a result, celiac axis resection for pancreatic cancer is an extensive surgery, and a combined en masse resection of the invaded neighboring organs is a more extensive surgery than the celiac axis resection alone. This more extensive surgery is safe and feasible for selected patients with pancreatic cancer.