The usefulness of laparoscopic hernia repair in the management of incisional hernia following liver transplantation.

INTRODUCTION: The reported incidence of incisional hernia following orthotopic liver transplantation (OLT) varies from 4% to 23%. Postoperative wound complications are less frequent after laparoscopic repair while maintaining low recurrence rates. We present our experience in managing this complication. MATERIALS AND METHODS: Retrospectively, collected data of all patients who underwent liver transplant and developed incisional hernias were analyzed. Patients' demographic data, anthropometric data, transplantation-related data, and repair-related operative and postoperative data were collected. Risk factors for post-transplant incisional hernia were appraised in our patients. Patients were divided into two groups: Group A included patients who had their incisional hernia repaired through the laparoscopic approach, and Group B included patients who had their incisional hernia repaired through open conventional approach. RESULTS: A total of 488 liver transplantations were performed at our institution between May 2001 and end of December 2012. Thirty-three patients developed incisional hernias after primary direct closure of the abdominal wall with an overall incidence of 6.9%. Hernia repair was done in 25 patients. Follow-up ranged from 6.4 to 106.1 months with a mean of 48.3 ± 28.3 months. All patients were living at the end of the follow up except four patients (16%). Group A included 13 patients, and Group B included 12 patients. The size of defects and operative time did not differ significantly between both the groups. On the other hand, hospital stay was significantly shorter in laparoscopic group. Complication rate following laparoscopic repair was insignificantly different for open repair. CONCLUSION: In experienced hands, laparoscopic incisional hernia repair in post-liver transplant setting proved to be a safe and feasible alternative to open approach and showed superior outcome expressed in shorter hospital stay, with low recurrence and complication rate.

Revising the upper limit of normal for levels of serum alanine aminotransferase in a Middle Eastern population with normal liver histology.

BACKGROUND: Recently, the upper limits of normal (ULN) for alanine-aminotransferase (ALT) has been recommended to be lowered to ≤ 30 U/l in men and ≤ 19 U/l in women. AIM: To evaluate the ALT concentrations in a healthy Middle Eastern population with biopsy-proven normal liver tissue. METHODS: ALT values were calculated from 175 consecutive Saudi potential living liver donors who underwent a liver biopsy as part of a stepwise pretransplant workup. RESULTS: The mean age of the 110 potential donors with normal liver histology was 27 ± 6.2 years for men and 38.6 ± 7.1 years for women. The mean body mass index (BMI) levels were 23.0 ± 3.5 kg/m(2) for men and 24.7 ± 3.25 kg/m(2) for women, and the ALT levels were higher in male patients (22.6 ± 9 vs. 16.4 U/l ± 8, p value = 0.003). Multivariate linear regression showed that BMI and sex were independent variables that were positively associated with the levels of ALT (p < 0.0001). Moreover, when we analyzed donors according to the Prati criteria, 63 (36.0 %) of the individuals were classified into this subgroup. The mean ALT concentration was 12.9 U/l ± 4.5 in women and 19.7 U/l ± 6.9 in men, and these values were significantly lower than those obtained from subjects who did not fit the Prati criteria (19.4 U/l ± 1.8, p = 0.04 for women and 29.0 U/l ± 12.1, p = <0.0001 for men). Thus, we calculated healthy ALT values of 33 IU/l for men and 22 IU/l for women. CONCLUSIONS: The ULN for ALT levels in Middle Eastern populations should be lowered, including separate values for males and females. Furthermore, metabolic parameters were shown to have a significant effect on ALT levels.

Specialist early and immediate repair of post-laparoscopic cholecystectomy bile duct injuries is associated with an improved long-term outcome.

INTRODUCTION: A majority of bile duct injuries (BDI) sustained during laparoscopic cholecystectomy require formal surgical reconstruction, and traditionally this repair is performed late. We aimed to assess long-term outcomes after repair, focusing on our preferred early approach. METHODS: A total of 200 BDI patients [age 54(20-83); 64 male], followed up for median 60 (5-212) months were assessed for morbidity. Factors contributing to this were analyzed with a univariate and multivariate analysis. RESULTS: A total of 112 (56%) patients were repaired by specialist hepatobiliary surgeons [timing of repair: immediate, n = 28; early (<21 days), n = 43; and late (>21 days) n = 41], whereas 45 (22%) underwent repair by nonspecialist surgeons before specialist referral [immediate, n = 16; early, n = 26 and late, n = 03]. Outcomes after immediate and early repairs were comparable to late repairs when performed by specialists [recurrent cholangitis:11%, 12%, and 10%; P = 0.96, NS; re-stricture:18%,5%, and 29%; P = 0.01; nonsurgical intervention: 14%, 5%, and 24%; P<0.03; redo surgery: 4%, 2%, and 5%; P = 0.81, NS; overall morbidity: 21%, 14%, and 39%; P<0.02]. On multivariate analysis, immediate and early repairs done by nonspecialist surgeons were independent risk factors (P < 0.05) for recurrent cholangitis [50% and 27%], re-stricturing (75% and 61%), redo reconstructions (31% and 61%), and overall morbidity (75% and 84%). CONCLUSION: Immediate and early repair after BDI results in comparable, if not better long-term outcomes compared to late repair when performed by specialists.

Surgical management of biliary complications following living donor liver transplantation.

BACKGROUND: Biliary complications (BC) account for much of the morbidities seen after living donor liver transplantation (LDLT). Surgical reconstruction might be necessary after the failure of endoscopic or percutaneous procedures. METHODS: Between November 2002 and December 2009, a total of 76 LDLTs were performed. Six patients were excluded from statistical analysis because of early graft or patient loss. RESULTS: Of 70, 26 (37.1%) developed BC; 12 (46.2%) were successfully managed by non-surgical procedures, three (11.5%) died from BC-related sepsis, one (3.8%) died from BC-unrelated causes, and 10 (38.5%) underwent surgical reconstruction. Of those 10, four patients had single duct reconstruction, five patients had double ducts reconstruction, and reconstruction was abandoned in one patient because of hepatic artery thrombosis. After a median follow-up period of 4.5 yr (0.1-6), seven (70%) remained well with no recurrent biliary problems, and three (30%) had recurrent BCs that were managed either conservatively or by retransplantation. Patients who underwent surgical reconstruction had significantly fewer hospital admissions, less need for invasive procedures, and shorter cumulative hospital stay (p < 0.05). CONCLUSIONS: In our experience, BCs after LDLT were frequently resistant to non-surgical procedures. Surgical reconstruction is associated with fewer hospital admissions and less need for invasive procedures leading to reduced resources utilization.

The management of an accessory or replaced right hepatic artery during multiorgan retrieval: results of an angiographic study.

In the presence of anatomical variants such as an accessory or replaced (A/R) right hepatic artery (RHA), a conflict of interest can arise during organ retrieval between liver and pancreatic teams. This angiographic study examines the anatomy of the inferior pancreaticoduodenal artery (IPDA), its relation to the A/R RHA, and the implications for the use of livers and pancreases from multiorgan donors. Gastrointestinal angiograms performed in our institution for unrelated indications were reviewed, and the relevant arteries, their diameters, the distances between origins, the time at which variants were found, and the blood supply to relevant solid organs were recorded. A review of 122 angiograms identified 100 patients in whom both the superior mesenteric artery (SMA) and the celiac axis were cannulated synchronously; these patients composed our study cohort. The IPDA was identified in 95% of the cases. There were 8 patients with a replaced RHA and 4 with an accessory RHA. In all 12, the IPDA had an SMA origin; 3 of these shared a common origin with the A/R RHA on the SMA. In the rest, the mean distance between them was 29 mm (range = 17.8-48.3 mm). All anomalous arteries found were segmental vessels. In conclusion, the A/R RHA incidence in our series was 12%, and no case had an IPDA originating from the A/R RHA. Separate accessory RHA and IPDA origins potentially allow an uncompromised accessory RHA (with its Carrel patch) without risk of prejudice to the pancreatic graft if retrieval is accurately performed. Rarely (3%), there is a common origin between the A/R RHA and the IPDA, and back-bench reconstruction would be required to allow the use of both the liver and pancreas.

Corrigendum: Analysis of donor motivations in living donor liver transplantation.

[This corrects the article DOI: 10.3389/fsurg.2014.00025.].

The impact of metabolic syndrome and prevalent liver disease on living donor liver transplantation: a pressing need to expand the pool.

BACKGROUND AND AIMS: Organ shortage has been the ongoing obstacle to expanding liver transplantation worldwide. Living donor liver transplantation (LDLT) is hoped to improve this shortage. The aim of the present study is to analyze the impact of metabolic syndrome and prevalent liver disease on living donations. METHODS: From July 2007 to May 2012, 1065 potential living donors were evaluated according to a stepwise evaluation protocol. The age of the worked-up donors ranged from 18 to 45 years. RESULTS: Only 190 (18%) were accepted for donation, and 875 (82%) were rejected. In total, 265 (24.9%) potential donors were excluded because of either diabetes or a body mass index >28. Some potential donors were excluded at initial screening because of incompatible blood groups (115; 10.8%), social reasons (40; 3.8%), or elevated liver enzymes (9; 1%). Eighty-five (8%) donors were excluded because of positive hepatitis serology. Steatosis resulted in the exclusion of 84 (8%) donors. In addition, 80 (7.5%) potential donors were rejected because of variations in biliary anatomy, and 20 (2%) were rejected because of aberrant vascular anatomy. Rejection due to biliary-related aberrancy decreased significantly in the second half of our program (11 vs. 4%, p = 0.001). In total, 110 (10.3%) potential donors were rejected because of insufficient remnant volume (<30%) as determined by CT volumetry, whereas 24 (2.2%) were rejected because of a graft-to-recipient body weight ratio less than 0.8%. CONCLUSION: Metabolic syndrome and viral hepatitis negatively impacted our living donor pool. Expanding the donor pool requires the implementation of new strategies.

Salvaging of severely ruptured living-related renal allograft secondary to acute antibody mediated rejection.

INTRODUCTION: Spontaneous renal allograft rupture (RAR) is a serious and potentially life-threatening complication of kidney transplantation. Debate on the management of RAR has focused on graft nephrectomy versus salvaging in cases where: the allograft rupture site is surgically manageable; the bleeding can be controlled; and/or leaving the renal allograft in situ does not compromise patient survival. PRESENTATION OF CASE: A 45-year-old, living-related, female, kidney allograft recipient experienced RAR on the fourth day post transplantation. Surgical exploration showed 12cm laceration along the convex border of the graft. Histologically the graft demonstrated mild acute kidney injury and linear deposition of C4d along the cortical peritubular capillaries; morphological features for violent humoral or cellular rejection were not identified. The graft was surgically salvaged with excellent clinical and biochemical improvement. DISCUSSION: Observations arising from this case are: (1) RAR caused by rejection is still encountered in clinical practice despite effective immunosuppressive management; (2) the severity of the histopathological features of rejection does not necessarily correlate with the extent of graft rupture; and (3) salvaging the graft should be attempted whenever possible as current immunosuppression and advances in surgical techniques may have an impact on long-term graft function and survival, differing from those previously published. CONCLUSION: With modern immunosuppression therapy and proven surgical procedures, the efficacy of salvaged renal grafts and graft survival rates may improve substantially.

Analysis of donor motivations in living donor liver transplantation.

OBJECTIVES: The introduction of the living donor liver transplantation (LDLT) in Egypt as in elsewhere, has raised important psychological conflicts and ethical questions. The objective of this study was to get better understanding of the potential donors' motives toward LDLT. METHODS: This study was conducted on consecutive 193 living-liver donors who underwent partial hepatectomy as donors for LDLT during the period between April 2003 and January 2013, at the National Liver Institute Menoufeyia University, Egypt. Potential donors were thoroughly evaluated preoperatively through a screening questionnaire and interviews as regard their demographic data, relationship to the potential recipient, and motives toward proceeding to surgery. They were assured that the information shared between them and the transplant center is confidential. RESULTS: The donors' mean age was 25.53 ± 6.39 years with a range of 18-45 years. Males represented 64.7% and females were 35.3%. The most common donors (32.1%, n = 62) were sons and daughters to their parents (sons: n = 43, daughters: n = 19) while parents to their offsprings represent 15% (mothers: n = 21, fathers: n = 8). Brothers and sisters represent 16.5% (brothers: n = 22, sisters: n = 10). Nephews and nieces giving their uncles or aunts were 14%. The number of wives donating to their husbands was 11 (5.7%). Interestingly, there was no single husband who donated his wife. Among the remaining donors, there were 11 cousins and 1 uncle. Unrelated donors were 20 (10.4%). Several factors seemed to contribute to motivation for donation: the seriousness of the potential recipient condition, the relationship and personal history of the donor to the potential recipient, the religious beliefs, the trust in the health care system, and family dynamics and obligations. CONCLUSION: Absolute absence of coercion on the living-liver donor's motives may not be realistic because of the serious condition of the potential recipient. It is mandatory that the donor is truly willing to donate.

Liver transplantation at KFSHRC: achievement and challenges.

The liver transplantation program at KFSHRC has been active since 2001. More than 450 liver transplants have been performed so far. The program evolved from adult cadaveric transplant to living donor and recently to pediatric and split techniques. The 1-year survival of patients for both pediatric and adult exceeded 90% and the 5-year survival of patients is more than 80%. Associated with this success are challenges that include: organ shortage, quality of organ harvested, inability to meet the growing national need, increased demand of resource to meet the need of the program, and lack of a collaborative national strategy in organ donation and transplantation.

Day-of-surgery rejection of donors in living donor liver transplantation.

AIM: To study diagnostic laparoscopy as a tool for excluding donors on the day of surgery in living donor liver transplantation (LDLT). METHODS: This study analyzed prospectively collected data from all potential donors for LDLT. All of the donors were subjected to a three-step donor evaluation protocol at our institution. Step one consisted of a clinical and social evaluation, including a liver profile, hepatitis markers, a renal profile, a complete blood count, and an abdominal ultrasound with Doppler. Step two involved tests to exclude liver diseases and to evaluate the donor's serological status. This step also included a radiological evaluation of the biliary anatomy and liver vascular anatomy using magnetic resonance cholangiopancreatography and a computed tomography (CT) angiogram, respectively. A CT volumetric study was used to calculate the volume of the liver parenchyma. Step three included an ultrasound-guided liver biopsy. Between November 2002 and May 2009, sixty-nine potential living donors were assessed by open exploration prior to harvesting the planned part of the liver. Between the end of May 2009 and October 2010, 30 potential living donors were assessed laparoscopically to determine whether to proceed with the abdominal incision to harvest part of the liver for donation. RESULTS: Ninety-nine living donor liver transplants were attempted at our center between November 2002 and October 2010. Twelve of these procedures were aborted on the day of surgery (12.1%) due to donor findings, and eighty-seven were completed (87.9%). These 87 liver transplants were divided into the following groups: Group A, which included 65 transplants that were performed between November 2002 and May 2009, and Group B, which included 22 transplants that were performed between the end of May 2009 and October 2010. The demographic data for the two groups of donors were found to match; moreover, no significant difference was observed between the two groups of donors with respect to hospital stay, narcotic and non-narcotic analgesia requirements or the incidence of complications. Regarding the recipients, our study clearly revealed that there was no significant difference in either the incidence of different complications or the incidence of retransplantation between the two groups. Day-of-surgery donor assessment for LDLT procedures at our center has passed through two eras, open and laparoscopic. In the first era, sixty-nine LDLT procedures were attempted between November 2002 and May 2009. Upon open exploration of the donors on the day of surgery, sixty-five donors were found to have livers with a grossly normal appearance. Four donors out of 69 (5.7%) were rejected on the day of surgery because their livers were grossly fatty and pale. In the laparoscopic era, thirty LDLT procedures were attempted between the end of May 2009 and October 2010. After the laparoscopic assessment on the day of surgery, twenty-two transplantation procedures were completed (73.4%), and eight were aborted (26.6%). Our data showed that the levels of steatosis in the rejected donors were in the acceptable range. Moreover, the results of the liver biopsies of rejected donors were comparable between the group A and group B donors. The laparoscopic assessment of donors presents many advantages relative to the assessment of donors through open exploration; in particular, the laparoscopic assessment causes less pain, requires a shorter hospital stay and leads to far superior cosmetic results. CONCLUSION: The laparoscopic assessment of donors in LDLT is a safe and acceptable procedure that avoids unnecessary large abdominal incisions and increases the chance of achieving donor safety.

De novo malignancies after liver transplantation: a single-center experience.

BACKGROUND AND OBJECTIVES: The recipients of liver transplantation (LT) are subjected to lifelong immunosuppression with its many drawbacks. De novo and recurrent malignancy in transplant recipients are attributed to attenuation of immunosurveillance. In the present study, we present our experience with de novo malignancies encountered after both deceased and living donor liver transplantations. DESIGN AND SETTING: Retrospective study of patients referred to LT center between April 2001 and January 2010. PATIENTS AND METHODS: Various data were collected including type of malignancy and histopathologic features, immunosuppression regimen, and patient survival. RESULTS: Of 248 LT procedures performed in 238 patients (10 retransplants), 8 patients (3.4%) developed de novo post-LT malignancies. De novo malignancies included post-LT lymphoproliferative disorders (PTLD) in 5 patients who were all Epstein-Barr virus (EBV) positive, and who were treated successfully with anti-CD20 monoclonal antibody therapy, reduction of immunosuppression, and control of EBV activity; urinary bladder cancer in 1 patient who was treated with radical surgical resection and chemotherapy but died of bone and lung metastasis within 1 year of diagnosis; endometrial carcinoma in 1 patient who was treated with radical surgical resection; and Kaposi sarcoma in 1 patient who was successfully treated with surgical excision and reduction of immunosuppression. CONCLUSION: EBV-associated PTLD is the most frequently encountered de novo malignancy after LT and is easily treatable by chemotherapy and reduction of immunosuppression.

Biliary dilatation and strictures after composite liver-small bowel transplantation in children: defining a newly recognized complication.

BACKGROUND: Biliary dilatation and strictures (BDS) are well recognized after liver transplantation but not reported after composite liver-small bowel transplantation (CLSBT). We aimed to describe and propose a classification of BDS in children undergoing CLSBT and analyze the potential risk factors. METHODS: Biliary complications of 47 consecutive children undergoing CLSBT were reviewed and classified according to presentation, location, and intervention required. The following variables were studied: small recipient (weight, <10 kg), donor-recipient weight ratio, liver/bowel graft reduction/not, partial/full pancreas, liver/bowel rejection, and median cold ischemia time (>454 min). RESULTS: Twenty-one (45%) children developed BDS at median 190 days (22 [7-138] months follow-up). Five distinct biliary lesions were identified. Most of the BDS (14/21; 67%) consisted of sphincter dysfunction-related bile duct dilatation (type I), whereas others (7/21; 33%) comprised extrahepatic bile duct (type II; n=3), hilar (type III; n=1), segmental (type IV; n=1), and diffuse (type V; n=2) intrahepatic strictures. None of the graft reduction strategies or other variables studied demonstrated a significant association with BDS. Therapeutic intervention was required in 1 of 14 type I and four of seven type II to V BDS in the form of percutaneous biliary dilatation with or without drainage. CONCLUSION: This article identifies BDS after CLSBT as a frequent late complication after CLSBT, which has a benign outcome in most cases. The natural history of children with extrahepatic and intrahepatic strictures is not yet clear and will need multicenter prospective studies.

Liver transplantation in patients with hepatocellular carcinoma: a single-center experience.

OBJECTIVES: Liver transplantation has become one of the best treatment options for early hepatocellular carcinoma in cirrhosis. We sought to study the results of liver transplantation in patients with hepatocellular carcinoma and to evaluate the outcome of the patients. MATERIALS AND METHODS: The medical records of 256 recipients who underwent a liver transplantation from April 2001 to January 2010 were reviewed. One hundred seventy-six patients received their livers from deceased donors, and 80 received their livers from living donors. Fifty-two patients underwent liver transplantation for hepatocellular carcinoma. RESULTS: From April 2001 until now, 52 patients (20.3%) underwent liver transplantation for hepatocellular carcinoma. Eighteen patients (34.6%) were performed from living-related donors, and 34 (65.4%) were from deceased donors. The patients were 37 males and 15 females (median, 55 years old; age range, 5 through 68 years). Model for end-stage liver disease score ranged from 6 to 40 with a median of 14. All patients were within the Milan criteria by the preoperative evaluation. Hospital stay ranged from 6 to 338 days with a median 14 days. Operating time ranged from 4 to 15 hours with a median 7.5 hours. Blood transfusion ranged from 0 to 19 units median 5 units. Thirty-four complications occurred in 23 patients (44.2%). Recurrence of hepatocellular carcinoma in 7 patients (13.5%), of which recurrent cholangiocarcinoma was diagnosed in 3 (5.7%), accidentally discovered in the explant. One deceased donor had hepatitis B core antibody positive. One explant showed macrovascular invasion. Sixteen patients died, 7 of 52 (13.5%) from hepatocellular carcinoma recurrence, including the 3 cases of accidental discovery of cholangiocarcinoma (5.7%). CONCLUSIONS: Apart from the common complications that can occur with any transplantation, liver transplantation remains the most-promising solution for patients with hepatocellular carcinoma among the available ones, and represents a cornerstone in managing hepatocellular carcinoma. It is the only acceptable option for complete eradication of both the disease and the predisposing factor.

Detection of pancreatic adenocarcinoma using circulating fragments of fibrinogen.

BACKGROUND: There is an urgent need for biomarkers to detect pancreatic cancer in the early, potentially curable, stages. METHODS: We have used SELDI profiling to analyze serum from 75 patients with pancreatic cancer and 61 patients with nonmalignant pancreaticobiliary diseases. RESULTS: A peak in the SELDI spectra corresponding to a 53 residue fragment of the α-chain of fibrinogen is remarkably elevated in approximately 50% of the cancer patients. In addition, fibrinogen degradation products were measured using the DR-70 assay. The areas under the receiver operating characteristic curves for the SELDI-detected fibrinogen fragment, DR-70 and CA19-9 were 0.65, 0.75 and 0.86, respectively. Class prediction models using combinations of these markers did not increase the area under the receiver operating characteristic curve compared with CA19-9. The novel fibrinogen fragment was not elevated to the same extent in other malignancies but was elevated in some patients with benign pancreatic disease. CONCLUSION: Both the SELDI-detected fragment of fibrinogen and DR-70 are significantly elevated in the serum of pancreatic cancer patients. However, they do not seem to improve pancreatic cancer detection over CA19-9 alone.