Liver resection for hepatocellular carcinoma in elderly patients: does age matter?

BACKGROUND: Evaluation of the influence of the age of the patients upon the outcomes of liver resection (LR) for hepatocellular carcinoma (HCC). METHODS: HCC patients who underwent LR between 2010 and 2020 were analyzed. They were divided into 3 groups depending on the patient's age. Group I (patients less than 60 years), Group II (patients between 60 and 69 years), and Group III (patients equal to or more than 70 years). RESULTS: 364 patients were included. A significantly higher serum bilirubin and alpha feto-protein were noted in Group I and serum creatinine was noted in Group III. The study groups did not show any significant differences regarding HCC site, number, macrovascular invasion, the extent of LR, Pringle maneuver, and perioperative blood transfusions. Longer operation time was found in Groups II and III, while more blood loss was noted in Group (I) Group I patients had longer hospital stays. Higher postoperative morbidities were noted in both Group I and Group (II) Higher incidence of post-hepatectomy liver dysfunction was noted in Group I. More early mortalities were found in Group I, related to liver failure. We did not experience early mortality in Group (III) Late Mortalities occurred in 117 patients (32.1%). HCC recurrence occurred in 165 patients (45.3%). Regarding the overall- and tumor-free survival, we did not experience any significant differences among the 3 groups (Log Rank: p = 0.371 and 0.464 respectively). CONCLUSIONS: Curative LR can be safely performed in selected elderly patients with HCC. An advanced patient's age should not be considered as a contraindication for curative LR.

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.

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.

Color and translucency of repressed lithium disilicate glass ceramic subjected to multiple firings and aging / Cor e translucidez da vitrocerâmica de dissilicato de lítio reprensada submetida a múltiplas queimas e ao envelhecimento

Objetivo: O objetivo deste estudo é avaliar o efeito de múltiplas queimas e envelhecimento na cor e na translucidez da vitrocerâmica de dissilicato de lítio reprensada (IPS e.max press). Material e Métodos: Um total de 42 discos de dissilicato de lítio (15 mm x 1 mm) foram fabricados usando a técnica de prensa térmica seguindo as instruções dos fabricantes. Eles foram divididos em três grupos de acordo com o número de ciclos de prensagem (n=14): Grupo P1 (pressionado uma vez), Grupo P2 (pressionado duas vezes) e Grupo P3 (pressionado três vezes). Cada grupo foi subdividido em dois subgrupos de acordo com o número de ciclos de queima (n=7): Subgrupo (F2): 2 ciclos de queima, Subgrupo (F4): 4 ciclos de queima. Em seguida, todos os corpos de prova foram submetidos à termociclagem. Os parâmetros de cor e translucidez (TP) foram avaliados por espectrofotômetro; após a prensagem, queima (ΔE1: diferença de cor entre prensagem e queima) e envelhecimento (ΔE2: diferença de cor entre prensagem e envelhecimento). Resultados:ΔE1 para o subgrupo F2 (3,38) apresentou menor valor estatisticamente significante do que ΔE1 para o subgrupo F4 (3,94). Após o envelhecimento, o grupo P3 apresentou o maior ΔE2 estatisticamente significante (6,41). Um ΔE2 estatisticamente inferior foi encontrado no grupo P2 (5,55). O grupo P1 apresentou o menor ΔE2 estatisticamente significante (4,28). O TP para o subgrupo F2 (18,27) apresentou valor superior ao subgrupo F4 (17,78). Houve uma diminuição estatisticamente significante no TP após o envelhecimento para todos os grupos testados. Conclusão: O aumento do número de ciclos de queima e de envelhecimento afetaram a cor e a translucidez do dissilicato de lítio reprensado. (AU)

Objective: The aim of this study is to evaluate the effect of multiple firings and aging on color and translucency of repressed lithium disilicate glass ceramic (IPS e.max press). Material and Methods: A total of 42 lithium disilicate discs (15 mm x 1 mm) were fabricated using heat press technique following the manufacturers' instructions. They were divided into three groups according to the number of pressing cycles (n=14): Group P1 (pressed once), Group P2 (pressed twice) and Group P3 (pressed thrice). Each group was subdivided into two subgroups according to the number of firing cycles (n=7): Subgroup (F2): 2 firing cycles, Subgroup (F4): 4 firing cycles. Then all specimens were subjected to thermocycling. Color and translucency parameter (TP) were evaluated by spectrophotometer; after pressing, firing (ΔE1: color difference between pressing and firing) and aging (ΔE2: color difference between pressing and aging). Results:ΔE1 for subgroup F2 (3.38) showed statistically significant lower value than ΔE1 for subgroup F4 (3.94). After aging, group P3 showed the statistically significant highest ΔE2 (6.41). A statistically significant lower ΔE2 was found with group P2 (5.55). Group P1 showed the statistically significant lowest ΔE2 (4.28). TP for subgroup F2 (18.27) showed higher value than subgroup F4 (17.78). There was a statistically significant decrease in TP after aging for all tested groups. Conclusion: Increasing the number of firing cycles and aging affected color and translucency of repressed lithium disilicate. (AU)

Predictive Factors of De Novo Malignancies After Living-Donor Liver Transplantation: A Single-Center Experience.

BACKGROUND: De novo malignancies are a major reason of long-term mortalities after liver transplantation. However, they usually receive minimal attention from most health care specialists. The current study aims to evaluate our experience of de novo malignancies after living-donor liver transplantation (LDLT). METHODS: We reviewed the data of patients who underwent LDLT at our center during the period between May 2004 and December 2018. RESULTS: During the study period, 640 patients underwent LDLT. After a mean follow-up period of 41.2 ± 25.8 months, 15 patients (2.3%) with de novo malignancies were diagnosed. The most common de novo malignancies were cutaneous cancers (40%), post-transplantation lymphoproliferative disorders (13.3%), colon cancers (13.3%), and breast cancers (13.3%). Acute cellular rejection (ACR) episodes occurred in 10 patients (66.7%). Mild ACR occurred in 8 patients (53.3%), and moderate ACR occurred in 2 patients (13.3%). All patients were managed with aggressive cancer treatment. The mean survival after therapy was 40.8 ± 26.4 months. The mean overall survival after LDLT was 83.9 ± 52.9 months. Twelve patients (80%) were still alive, and 3 mortalities (20%) occurred. The 1-, 5-, and 10-year overall survival rates after LDLT were 91.7%, 91.7%, and 61.1%, respectively. On multivariate regression analysis, smoking history, operation time, and development of ACR episodes were significant predictors of de novo malignancy development. CONCLUSIONS: Liver transplant recipients are at high risk for the development of de novo malignancies. Early detection and aggressive management strategies are essential to improving the recipients' survival.

The role of neoadjuvant FLOT chemotherapy with and without omega 3 in locally advanced gastric carcinoma.

PURPOSE: Gastric is the third leading cause of cancer-related deaths worldwide with two third of the cases presented in advanced stage with resultant increased morbidity and mortality. The purpose of the study was to investigate the nutritional intervention with and without omega 3 fatty acids. METHODS: Forty two cases were randomized into two groups: group; A: FLOT neoadjuvant chemotherapy with omega 3 and group B: FLOT chemotherapy alone in the period from July 2018 to July 2019. We evaluated the radicality of surgical interference, overall response, nutritional status, treatment delivery and toxicity. RESULTS: The radicality, overall response the SGA score and the bioelectrical impedance parameters were higher in those who received omega 3 with chemotherapy and toxicity was less which was statistically significant. CONCLUSIONS: Omega 3 administrations during chemotherapy in gastric cancer increased the chemotherapy tolerability and decreased the treatment gap between cycles and hence improved gastric cancer resection.

Effect of Surface Treatment of Two Ceramic Materials by Er, Cr:YSGG Laser Irradiation on The Shear Bond Strength to Resin Cement: "a Comparative in-Vitro Study" / Efeito do tratamento de superfície de dois materiais cerâmicos por Irradiação de laser Er, Cr:YSGG na resistência ao cisalhamento a cimento Resinoso: "um estudo comparativo in-Vitro"

Objective: The aim of this study is to assess the effect of Er,Cr:YSGG laser on the shear bond strength (SBS) and surface topography of two CAD/CAM ceramic materials bonded with self adhesive resin cement. Material and methods: sixty ceramic CAD/CAM discs were obtained, 30 lithium disilicate (IPS Emax) (Group LD), and 30 hybrid resin ceramic (Vita Enamic) (Group RC). The Slices were allocated into six groups (n=10) according to ceramic material and surface treatment; Group (LD-C): IPS Emax treated with 9% hydrofluoric acid (HF), Groups (LD-L1) and (LD-L2): IPS Emax treated with Er,Cr:YSGG, Group (RC-C): Vita Enamic treated with 9% hydrofluoric acid (HF), Groups (RC-L1) and (RC-L2): Vita Enamic treated with Er,Cr:YSGG laser. The laser parameters and irradiation protocol was 1.5 W (L1) and 2.5 W (L2). All samples were cemented with self-adhesive resin cement and thermocycled for 5000 cycles. The SBS was measured using a universal testing machine and the mean values (MPa) were analyzed using Two-way (ANOVA) (P ≤ 0.05) and Bonferroni's post-hoc test. Results: RC-C (16.55) showed highest SBS followed by LD-C (13.79), which revealed no statistically significant difference with RCP1 (12.33) and RC-P2 (11.2). The lowest SBS values were found with LD-P1 (2.7) and LDP2 (2.1). SEM analysis revealed Vita Enamic to have the highest surface roughness. Fracture pattern analysis showed adhesive failure with IPS Emax groups and mixed failure with Vita Enamic groups. Conclusion: Er,Cr:YSGG laser irradiation with the parameters used did not increase SBS of IPS Emax and Vita Enamic with composite resin compared to HF acid etching (AU)

Objetivo: O objetivo deste estudo é avaliar o efeito do laser Er,Cr:YSGG na resistência ao cisalhamento (SBS) e na topografia superficial de dois materiais cerâmicos CAD/CAM cimentados com cimento resinoso autoadesivo. Material e métodos: foram obtidos sessenta discos cerâmicos CAD/CAM, 30 de dissilicato de lítio (IPS Emax) (Grupo LD) e 30 de resina híbrida (Vita Enamic)(Grupo RC). Os discos foram alocados em seis grupos (n = 10), de acordo como material cerâmico e o tratamento de superfície; Grupo (LD-C): IPS Emaxtratado com ácido fluorídrico (HF) a 9%, Grupos (LD-L1) e (LD-L2): IPS Emaxtratado com Er,Cr:YSGG, Grupo (RC-C): Vita Enamic tratada com ácido fluorídrico (HF) a 9%, Grupos (RC-L1) e (RC-L2): Vita Enamic tratada com laser Er,Cr:YSGG. Os parâmetros do laser e o protocolo de irradiação foram de 1,5 W (L1) e 2,5 W (L2). Todas as amostras foram cimentadas com cimento resinoso autoadesivo e termocicladas por 5000 ciclos. A SBS foi medida usando uma máquina de ensaios universais e os valores médios (MPa) foram analisados usando (ANOVA) a dois fatores (P ≤ 0,05) e teste post-hoc de Bonferroni. Resultados: RC-C (16,55) apresentou maior SBS seguido por LD-C (13,79), que não revelou diferença estatisticamente significante com RCP1(12,33) e RC-P2 (11,2). Os menores valores de SBS foram encontrados comLD-P1 (2,7) e LD-P2 (2,1). A análise por MEV revelou que a Vita Enamic possui maior rugosidade de superfície. A análise do padrão de fratura mostrou falha adesiva nos grupos IPS Emax e falha mista nos grupos Vita Enamic. Conclusão: A irradiação com laser Er,Cr:YSGG com os parâmetros utilizados não aumentou a SBS de IPS Emax e Vita Enamic ao cimento resinoso em comparação com o condicionamento ácido com HF.(AU)

Clamp-Crush Technique Versus Harmonic Scalpel for Hepatic Parenchymal Transection in Living Donor Hepatectomy: a Randomized Controlled Trial.

BACKGROUND: Hepatic parenchymal transection is the most invasive step in donor operation. During this step, blood loss and unintended injuries to the intrahepatic structures and hepatic remnant may occur. There is no evidence to prove the ideal techniques for hepatic parenchymal transection. The aim of this study is to compare the safety, efficacy, and outcome of clamp-crush technique versus harmonic scalpel as a method of parenchymal transection in living-donor hepatectomy. METHODS: Consecutive living liver donors, undergoing right hemi-hepatectomy, during the period between May 2015 and April 2016, were included in this prospective randomized study. Cases were randomized into two groups; group (A) harmonic scalpel group and group (B) Clamp-crush group. RESULTS: During the study period, 72 cases underwent right hemi-hepatectomy for adult living donor liver transplantation and were randomized into two groups. There were no statistically significant differences between the two groups regarding preoperative demographic and radiological data. Longer operation time and hepatectomy duration were found in group B. There were no significant differences between the two groups regarding blood loss, blood loss during hepatectomy, and blood transfusion. More unexpected bleeding events occurred in group A. Higher necrosis at the cut margin of the liver parenchyma was noted in group A. There were no statistically significant differences between the two groups regarding postoperative ICU stay, hospital stay, postoperative morbidities, and readmission rates. CONCLUSION: Clamp-crush technique is advocated as a simple, easy, safe, and cheaper method for hepatic parenchymal transection in living donors.

Adrenalectomy for solitary recurrent hepatocellular carcinoma five years after living donor liver transplantation: A case report.

INTRODUCTION: The adrenal gland is a rare site for hepatocellular carcinoma (HCC) recurrence after living-donor liver transplantation (LDLT). Solitary adrenal recurrence can be managed by surgical excision, with expected better survival outcomes. We describe a rare case of successful left adrenalectomy of solitary recurrent HCC in the left adrenal gland 5 years after LDLT. PRESENTATION: 59 years male patient with HCC complicating chronic HCV infection received a right hemi-liver graft from his son. The actual graft weight was 1208 g and GRWR was 1.5. The patient started oral direct acting antiviral drugs for recurrent HCV 2 years after LDLT. A left adrenal mass was detected on follow up radiology. No other metastatic lesions were detected on metastatic workup. Left adrenalectomy was done by an anterior approach. The postoperative course was uneventful and was discharged a week after operation. Postoperative pathological and immune-histochemical examinations confirmed the metastatic HCC nature of the mass. The patient is under regular follow up with no recurrences 6 month after resection. DISCUSSION: There is no consensus regarding the management of HCC recurrence after LDLT. Most patients had multi-organ recurrences and usually offered palliative or supportive care. Solitary HCC recurrence offers a better chance for more aggressive therapy, offering better prognosis. CONCLUSION: Solitary adrenal recurrence of HCC after LDLT is extremely rare. Strict follow up protocol is necessary to allow early detection of tumor recurrence. Curative surgical resection is a safe option associated with low morbidity and expected to have a good long-term survival.

Effect of different root dentin pretreatment protocols on the bond strength of fiber posts cemented with core buildup material / Efeito de diferentes protocolos de pré tratamento de dentinas radiculares na força de adesão de pinos de fibra cimentados com material de núcleo de preenchimento

Objective: The purpose of the study was to evaluate the push out bond strength of fiber posts -after cementaion with core build up material and dentin pretreatment using different adhesive protocolsin different root regions. Material and Methods: 28 endodonticaly treated human premolars were divided into 4 groups. The post spaces were treated with 1 of 4 different dentin bonding protocols: total etch light cured adhesive, solobond m; total etch dual cured adhesive, Excite f DSC; self-etching light cured adhesive, single bond universal; or selfetching dual cured adhesive, futura bond dc. Fiber posts, were luted with dual cured core material. The roots were cut into 2-mm-thick sections, in cervical, middle, and apical regions. Push-out tests were performed with a universal testing machine, and bond strength values (MPa) were calculated. Data were analyzed with 1- and 2-way analysis of variance and Tukey multiple comparison tests (a=.05). Failure modes were examined under stereo microscope. Results: The highest mean bond strength values were obtained for self-etch dual cured adhesive, (9.69 MPa). The Total etch light cured adhesive (2.81 MPa) showed the lowest bond strength. Self-etch light-polymerized and total etch dual-polymerized adhesives provided similar bond strengths (5.37, 5.72 respectively). The regional bond strength values were reduced significantly in apical post space (P<0.01). The most predominant failure type was mixed failure followed by adhesive failure. Conclusion: Dentin pretreatment using self-etch dual cured adhesives prior to fiber posts cementation offers a high bond strength. While using total-etch light cured adhesives is not recommended due to the low bonding quality.(AU)

Objetivo: O objetivo do estudo foi avaliar a força de adesão dos pinos de fibra após o cimentação com material de núcleo e o pré-tratamento da dentina utilizando diferentes protocolos adesivos em diferentes regiões radiculares. Material e Métodos: 28 pré-molares humanos tratados endodonticamente foram divididos em 4 grupos. Os condutos foram tratados com 1 de 4 diferentes protocolos de união à dentina: adesivo fotopolimerizável total, solobond m; adesivo de polimerização dual de condicionamento total, Excite f DSC; adesivo fotopolimerizável autocondicionante, Single Bond universal; ou adesivo de dupla curado autocondicionante, futura bond dc. Núcleos de fibra, foram cimentados com material resinoso e polimerizados. As raízes foram cortadas em seções de 2 mm de espessura, nas regiões cervical, média e apical. Testes de push-out foram realizados com uma máquina de testes universal, e os valores de resistência de união (MPa) foram calculados. Os dados foram analisados com análise de variância de 1 e 2 fatores e testes de comparação múltipla de Tukey (a = 0,05). Modos de falha foram examinados sob estéreo-microscópio. Resultados: Os valores médios mais elevados de resistência adesiva foram obtidos para o adesivo dual autocondicionante (9,69 MPa). O adesivo fotopolimerizável Total etch (2,81 MPa) apresentou a menor resistência de união. Os adesivos autocondicionantes fotopolimerizáveis e os de condicionamento tal duais, proporcionaram forças de adesão semelhantes (5,37, 5,72, respectivamente). Os valores de força de união regional foram significativamente reduzidos na região apical (P<0,01). O tipo de falha mais predominante foi falha mista seguida de falha adesiva. Conclusão: O pré-tratamento com dentina utilizando adesivos duais autocondicionantes antes da cimentação dos pinos de fibra oferece uma alta resistência de união. Enquanto que os adesivos de condicionamento total fotopolimerizáveis não sforam recomendados devido à baixa qualidade da adesão proporcionada. (AU)

Biaxial flexural strength of different types of monolithic zirconia / Resistência Flexural Biaxial de diferentes tipos de zircônia monolítica

Objective: This study was designed to evaluate the biaxial flexural strength (BFS) of different types of unshaded and shaded monolithic zirconia. Material and Methods: 120 monolithic zirconia ceramic discs were fabricated. They were divided into twelve groups (n=10), Group 1; Bruxzir unshaded, Group 2; Bruxzir shaded A2, Group 3; Bruxzir anterior white, Group 4; Bruxzir anterior shade A2, Group 5; Prettau unshaded, Group 6; Prettau shaded with A2 coloring liquid, Group 7; Prettau anterior white, Group 8; Prettau anterior shaded with A2 coloring liquid, Group 9; Katana HT white, Group 10; Katana HT shade A2, Group 11; Katana ST white, Group 12; Katana ST shade A2. All discs were milled using a dental milling machine, and had final dimensions after sintering of 15 mm diameter and 1 mm thickness. BFS was tested using piston on three ball technique. Results: One-way ANOVA revealed significant differences among the 12 groups. Tukey post-hoc tests revealed no significant differences between the groups 3, 4, ,7 ,8 11, and 12. However, they all had BFS values that are significantly lower than all other groups. Group 2 showed statistically significant higher BFS values when compared to group 3,4, 7, 8, 11, and 12 while it showed statistically significant lower values when compared to groups 1, 5, 6, 9, and 10. Conclusion: Increase in the yttria content in zirconia led to a decrease in its BFS. Shading of zirconia did not have a significant effect on the final strength of zirconia. (AU)

Objetivo: Este estudo foi desenhado para avaliar a resistência à flexão biaxial (RFB) de diferentes tipos de zircônia monolítica maquiada e não-maquiadas. Material e Métodos: 120 discos cerâmicos de zircônia monolítica foram fabricados. Eles foram divididos em doze grupos (n = 10), Grupo 1; Bruxzir Não-maquiado, Grupo 2; Bruxzir maquiado A2, Grupo 3; Branco anterior de Bruxzir, Grupo 4; Maquiagem anterior de Bruxzir A2, Grupo 5; Prettau não maquiado, Grupo 6; Prettau maquiado com corante A2, Grupo 7; Prettau anterior branco, Grupo 8; Prettau anterior maquiado com corante A2, Grupo 9; Katana HT branco, Grupo 10; Katana HT maquiagem A2, Grupo 11; Katana ST White, Grupo 12; Katana ST maquiagem A2. Todos os discos foram fresados em uma fresadora dentária e tiveram suas dimensões finais após sinterização de 15 mm de diâmetro e 1 mm de espessura. A RFB foi testado usando pistão na técnica de três bolas. Resultados: One-way ANOVA revelou diferenças significativas entre os 12 grupos. Os testes post-hoc de Tukey não revelaram diferenças significativas entre os grupos 3, 4, 7, 8 11 e 12. No entanto, todos eles exibiram valores de RFB significativamente menores do que todos os outros grupos. O Grupo 2 apresentou valores estatisticamente significantes de ICS mais elevados quando comparado aos grupos 3,4, 7, 8, 11 e 12, enquanto apresentou valores estatisticamente significantes menores quando comparados aos grupos 1, 5, 6, 9 e 10. Conclusão: o aumento do conteúdo de ítria na zircônia levou a uma diminuição em sua RFB. A maquiagem da zircônia não teve um efeito significativo sobre a resistência final da zircônia. (AU)

Internal hernia of the small intestine around biliary catheter after living-donor liver transplantation: A case report.

INTRODUCTION: Biliary reconstruction is a cornerstone of living-donor liver transplantation (LDLT). The routine uses of trans-anastomotic biliary catheters in biliary reconstruction had been a controversial issue. We describe a rare complication related to the use of trans-anastomotic biliary catheter after LDLT. In this case, intestinal obstruction occurred early after LDLT due to internal herniation of the small bowel around trans-anastomotic biliary catheter. PRESENTATION: A 42 years male patient with end stage liver disease underwent LDLT utilizing a right hemi-liver graft. Biliary reconstruction was done by single duct-to-duct anastomosis over trans-anastomotic biliary catheter. The patient was doing well apart from early postoperative ascites that was managed medically. Three weeks after surgery, the patient developed severe agonizing central abdominal pain not responding to anti-spasmodics and analgesics. The decision was to proceed for surgical exploration. Exploration revealed internal herniation of the small bowel loops around the trans-anastomotic biliary catheter without strangulation. Reduction of the internal hernia was done by releasing the fixation of the biliary catheter from the anterior abdominal wall. Small bowel resection was not required. The patient had smooth postoperative course and was discharged 10 days after surgery. DISCUSSION: Awareness regarding this rare complication plus early surgical intervention can prevent the development of postoperative morbidity and mortality. To the best of our knowledge this is the first report to describe such are complication after LDLT. CONCLUSION: We report the first case of internal herniation of small bowel around biliary catheter early after LDLT.

Outcomes of Living Donor Liver Transplantation for Patients with Preoperative Portal Vein Problems.

BACKGROUND: Portal vein thrombosis (PVT) is a common complication for patients with end-stage liver disease. The presence of PVT used to be a contraindication to living donor liver transplantation (LDLT). The aim of this study is to evaluate the influence of preoperative PVT on perioperative and long-term outcomes of the recipients after LDLT. METHODS: We reviewed the data of patients who underwent LDLT during the period between 2004 till 2017. RESULTS: During the study period, 500 cases underwent LDLT. Patients were divided into three groups. Group I included non-PVT, 446 patients (89.2%); group II included attenuated PV, 26 patients (5.2%); and group III included PVT, 28 patients (5.6%). Higher incidence of hematemesis and encephalopathy was detected in PVT (p = 0.001). Longer anhepatic phase was found in PVT (p = 0.013). There were no significant differences between regarding operation time, blood loss, transfusion requirements, ICU, and hospital stay. The 1-, 3-, and 5-year overall survival (OS) rates of non-PVT were 80.5%, 77.7%, and 75%, and for attenuated PV were 84.6%, 79.6%, and 73.5%, and for PVT were 88.3%, 64.4%, and 64.4%, respectively. There was no significant difference between the groups regarding OS rates (logrank 0.793). CONCLUSION: Preoperative PVT increases the complexity of LDLT operation, but it does not reduce the OS rates of such patients.

Spontaneous migration of thrombosed synthetic vascular graft to the duodenum after living-donor liver transplantation: A case-report.

INTRODUCTION: Spontaneous migration of synthetic grafts had been described after abdominal vascular procedures into the duodenum and small bowel. In the setting of liver transplantation, synthetic grafts are commonly used for overcoming shortened or poor-quality vasculatures. We describe a case of spontaneous migration of thrombosed synthetic vascular graft after living-donor liver transplantation (LDLT). PRESENTATION: A 59 years male patient with end stage liver disease underwent LDLT utilizing a right hemi-liver graft. Drainage of segment V vein was done to inferior vena cava using a vascular graft. Graft patency was confirmed by regular follow up doppler ultrasound. Graft thrombosis was detected on the 4th postoperative month. The patient developed anastomotic biliary stricture 3 months after LDLT, which required repeated endoscopic retrograde cholangio-pancreatography (ERCP). During an ERCP set two and half years after LDLT, the thrombosed graft was seen eroding into the first part of the duodenum. The patient was generally stable and the decision was to follow up the condition. Follow up computed tomography showed disappearance of the graft from the abdomen, and endoscopy revealed a small ulcer at the site of the migrated graft. DISCUSSION: Reports regarding spontaneous migration of synthetic grafts in this setting of LDLT are extremely rare. We report a rare case of spontaneous migration of thrombosed synthetic vascular graft into the duodenum after LDLT. CONCLUSION: We report a rare case of spontaneous migration of thrombosed synthetic vascular graft into the duodenum after LDLT.

Trends and outcomes of pancreaticoduodenectomy for periampullary tumors: A 25-year single-center study of 1000 consecutive cases.

AIM: To evaluate the evolution, trends in surgical approaches and reconstruction techniques, and important lessons learned from performing 1000 consecutive pancreaticoduodenectomies (PDs) for periampullary tumors. METHODS: This is a retrospective review of the data of all patients who underwent PD for periampullary tumor during the period from January 1993 to April 2017. The data were categorized into three periods, including early period (1993-2002), middle period (2003-2012), and late period (2013-2017). RESULTS: The frequency showed PD was increasingly performed after the year 2000. With time, elderly, cirrhotic and obese patients, as well as patients with uncinate process carcinoma and borderline tumor were increasingly selected for PD. The median operative time and postoperative hospital stay decreased significantly over the periods. Hospital mortality declined significantly, from 6.6% to 3.1%. Postoperative complications significantly decreased, from 40% to 27.9%. There was significant decrease in postoperative pancreatic fistula in the second 10 years, from 15% to 12.7%. There was a significant improvement in median survival and overall survival among the periods. CONCLUSION: Surgical results of PD significantly improved, with mortality rate nearly reaching 3%. Pancreatic reconstruction following PD is still debatable. The survival rate was also improved but the rate of recurrence is still high, at 36.9%.

Ligation of huge spontaneous porto-systemic collaterals to avoid portal inflow steal in adult living donor liver transplantation: A case-report.

INTRODUCTION: In adult living donor liver transplantation (LDLT), maintenance of adequate portal inflow is essential for the graft regeneration. Portal inflow steal (PFS) may occur due to presence of huge spontaneous porto-systemic collaterals. A surgical procedure to increase the portal inflow is rarely necessary in adult LDLT. PRESENTATION: A 52 years male patient with end-stage liver disease due to chronic hepatitis C virus infection. Preoperative portography showed marked attenuated portal vein and its two main branches, patent tortuous splenic vein, multiple splenic hilar collaterals, and large lieno-renal collateral. He received a right hemi-liver graft from his nephew. Exploration revealed markedly cirrhotic liver, moderate splenomegaly with multiple collaterals and large lieno-renal collateral. Upon dissection of the hepato-duodenal ligament, a well-developed portal vein could be identified with a small mural thrombus. The recipient portal vein stump was anastomosed, in end to end fashion, to the graft portal vein. Doppler US showed reduced portal vein flow, so ligation of the huge lieno-renal collateral that allows steal of the portal inflow. After ligation of the lieno-renal collateral, improvement of the portal vein flow was observed in Doppler US. DISCUSSION: There is no accepted algorithm for managing spontaneous lieno-renal shunts before, during, or after liver transplantation, and evidence for efficacy of treatments remains limited. We report a case of surgical interruption of spontaneous huge porto-systemic collateral to prevent PFS during adult LDLT. CONCLUSION: Complete interruption of large collateral vessels might be needed as a part of adult LDLT procedure to avoid devastating postoperative PFS.

Spray Diathermy Versus Harmonic Scalpel Technique for Hepatic Parenchymal Transection of Living Donor.

BACKGROUND: Liver parenchymal transection is the most invasive and challenging part in the living donor operation. The study was planned to compare the safety, efficacy, and outcome of harmonic scalpel versus spray diathermy as a method of parenchymal liver transection in donor hepatectomy. PATIENT AND METHOD: Eighty consecutive patients, who were treated by living donor liver transplantation (LDLT), were included in the study. The study population was divided into two groups according to the method of liver transection: group A by harmonic scalpel (HS) and group B by spray diathermy (SD). The primary outcome was the volume of blood loss during transection. Secondary outcomes were time of transection, number of ligatures needed during transection, pathological changes at cut surface, postoperative morbidities, cost, and hospital stay RESULTS: Blood loss during overall liver transection and in each zone was significantly less in the SD than in the HS group (P = 0.015). The number of ligatures was significantly less in the SD than in the HS group (P = 0.0001). The SD group had significantly higher level of serum bilirubin, serum glutamic pyruvic transaminase (SGPT), and international normalized ratio (INR) levels on postoperative day 3 than the HS group. Lateral tissue coagulation and hepatic necrosis are significantly less in HS group. The overall incidence of postoperative morbidities was the same in both groups. The cost was higher in HS group than SD group (US$760 vs. US$40 P = 0.0001). CONCLUSION: Spray diathermy is an effective method of parenchymal transection with significantly lower blood loss and lower cost compared to HS with no increase in morbidity. HS is associated with earlier recovery of liver functions.

Predictors of long term survival after hepatic resection for hilar cholangiocarcinoma: A retrospective study of 5-year survivors.

AIM: To determine predictors of long term survival after resection of hilar cholangiocarcinoma (HC) by comparing patients surviving > 5 years with those who survived < 5 years. METHODS: This is a retrospective study of patients with pathologically proven HC who underwent surgical resection at the Gastroenterology Surgical Center, Mansoura University, Egypt between January 2002 and April 2013. All data of the patients were collected from the medical records. Patients were divided into two groups according to their survival: Patients surviving less than 5 years and those who survived > 5 years. RESULTS: There were 34 (14%) long term survivors (5 year survivors) among the 243 patients. Five-year survivors were younger at diagnosis than those surviving less than 5 years (mean age, 50.47 ± 4.45 vs 54.59 ± 4.98, P = 0.001). Gender, clinical presentation, preoperative drainage, preoperative serum bilirubin, albumin and serum glutamic-pyruvic transaminase were similar between the two groups. The level of CA 19-9 was significantly higher in patients surviving < 5 years (395.71 ± 31.43 vs 254.06 ± 42.19, P = 0.0001). Univariate analysis demonstrated nine variables to be significantly associated with survival > 5 year, including young age (P = 0.001), serum CA19-9 (P = 0.0001), non-cirrhotic liver (P = 0.02), major hepatic resection (P = 0.001), caudate lobe resection (P = 0.006), well differentiated tumour (P = 0.03), lymph node status (0.008), R0 resection margin (P = 0.0001) and early postoperative liver cell failure (P = 0.02). CONCLUSION: Liver status, resection of caudate lobe, lymph node status, R0 resection and CA19-9 were demonstrated to be independent risk factors for long term survival.