Delayed complete gastric outlet obstruction due to a dinner fork: report of a case.

Ingestion of foreign bodies can be a common problem especially among children, alcoholics, psychiatric patients, and senile patients, but ingestion of a metallic dinner fork is uncommon. Foreign bodies with smooth edges usually do not pose significant problems, but a sharp foreign object that is not retrieved at the earliest may penetrate the wall and cause complications. Ingested foreign bodies usually pass the intestinal tract without problems, and perforation occurs in less than 1%. In this paper, a case of rare gastric outlet obstruction due to a dinner fork, which was ingested 25 days before, is reported.

Recurrence of Hepatitis D Virus in Liver Transplant Recipients With Hepatitis B and D Virus-Related Chronic Liver Disease.

PURPOSE: Data on recurrence of hepatitis D virus (HDV) and its long-term impact on liver transplant (LT) are limited. In this study, we investigated the incidence of hepatitis B virus (HBV) and the long-term effect of postoperative HDV recurrence HDV coinfection in our liver transplant patients. PATIENTS AND METHODS: Between 2004 and 2018, all patients with LT because of HBV (n = 361; 37.3%) were reviewed, and those with HBV and HDV coinfection (n = 104; 30% of all HBV patients) were enrolled in our study. All patients received post-transplant combination therapy with nucleos(t)ide analogue and antihepatitis B immunoglobulins. Breakthrough infection was defined as reemergence of HBV DNA or hepatitis B surface antigen during postoperative treatment. In case of recurrence, another oral nucleos(t)ide analogue was added and antihepatitis B immunoglobulins were stopped. RESULTS: During the study period, the frequency of HDV (+) was decreased (41% to 14%). Median follow-up time was 82 months (range, 1-274 months). Post LT survival and HBV recurrence were 97% (n = 15) and 13.4%, respectively. Only 15 patients (14%) developed breakthrough infection. There was no predictive factor for recurrent HDV infection, including demographics data and concomitant hepatocellular carcinoma (P = .73). Mortality was similar between patients with and without recurrence (2.2% vs 7.1%, P = .35) CONCLUSIONS: Patients who received transplants for hepatitis B and D virus cirrhosis had favorable prognosis and good long-term results despite recurrent infection. Close follow-up of patients and effective postoperative viral suppression with appropriate medications seems to be favorable for both prevention and management of recurrence and provides comparable outcome with patients without recurrence.

Experience in Liver Transplantation Due to Primary Sclerosing Cholangitis: A Single Center Experience.

PURPOSE: Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease of unknown origin. Although the course of PSC is variable, it frequently is progressive, leading to cirrhosis and requiring a liver transplantation (LT) in more than half of the patients. PSC is the fifth most common indication for LT in the United States and one of the leading indications in Scandinavian countries, whereas PSC affects fewer than 5% of patients undergoing LT in Turkey. In this study, we analyzed our results in the patients with LT owing to PSC. MATERIALS AND METHODS: Between March 2013 and August 2017, all adult patients (>18 years) with LT owing to PSC were analyzed, and clinical data were obtained via retrospective review of patient charts. Demographic features, presence of any concomitant inflammatory bowel disease (IBD), time to LT, and outcome data were recorded. RESULTS: There were 15 patients (8 men and 7 women) with a mean age of 46 ± 13 (age at diagnosis = 36 y). Median time to transplantation was 3 years (range: .5-14 yrs.). All patients had a pretransplant history of IBD. Concomitant cholangiocarcinoma was diagnosed in 1 patient (6.5%). Postoperative complications were observed in 4 patients (26%), and in 2 patients (13%) PSC recurred at a mean of 52 months postorthotopic LT. Disease-free survival and overall survival were 37.3 and 38 ± 21 months, respectively. One of the patients with recurrence and 1 with graft failure owing to rejection died in the follow-up period. CONCLUSIONS: In one single-center study of adults with PSC, we found that all patients with PSC had IBD at diagnosis. The recurrence rate (13%) was comparable to the literature (20% [5.7-59%]). Despite the low frequency of PSC in our clinic, LT in these patients resulted in favorable outcomes regarding postoperative morbidity and mortality compared with other etiologies.

A Changing Etiologic Scenario in Liver Transplantation: A Single-Center Cohort Study From Turkey.

PURPOSE: Nonalcoholic steatohepatitis (NASH) is an increasing cause of liver transplantation (LT) worldwide, especially in Europe and North America. In this study, we aimed to investigate the changing pattern of etiologic causes of LT in our center for the past 15 years. MATERIALS AND METHODS: A cohort of 967 consecutive adult patients with history of LT between 2004 and 2018 in our center was reviewed regarding etiologies for LT. All patients who had a transplant during this time frame were divided into 3 time periods as follows: 2004 to 2009, 2010 to 2013, and 2014 to 2018. All explanted liver samples were sent to pathology for establishment of a definitive etiologic cause. RESULTS: Chronic hepatitis B virus (HBV) infection was the leading cause of LT in the overall cohort (37%), followed by hepatitis C virus (HCV) infection (11%), and alcoholic liver disease (9.5%). NASH accounted for 7.5% of the cases. While HBV decreased from 44% in 2004 to 2009 to 36% in 2014 to 2018, NASH increased from 1.1% to 9.4% in overall transplants during the same period, accounting for one-third of the etiologies for LT following HBV and HCV. CONCLUSIONS: There might be a global changing figure regarding etiology for LT in Turkey, especially NASH, which is the fastest growing cause of LT. However, this topic needs to be evaluated in large cohort series from collaborative multicenter studies from Turkey.

Effectiveness of Noninvasive Fibrosis Markers for the Prediction of Hepatocellular Carcinoma in Chronic Hepatitis B and Chronic Hepatitis B+D Induced Cirrhosis.

PURPOSE: Despite advances in prevention techniques, screening, and new technologies in both diagnosis and treatment, the incidence and mortality of hepatocellular carcinoma (HCC) continue to rise. To obtain the best treatment result for HCC, early diagnosis is the key. In this study, we investigated the accuracy of noninvasive fibrosis markers, which have been typically used to predict liver fibrosis in recent years, in the prediction of HCC development in patients with chronic hepatitis B and chronic hepatitis B + D-induced cirrhosis. METHODS: Between 2004 and 2018, 1216 patients with chronic liver disease were retrospectively reviewed, and 331 patients (27%) with hepatitis B and hepatitis B+D virus-related cirrhosis were enrolled in our study. Patients were divided into 2 groups based on HCC diagnosis (HCC and non-HCC group). Eleven noninvasive fibrosis markers were evaluated in the groups. These markers included 3 alpha-fetoprotein (AFP)-based models (PAPAS index, Fibro-alpha, and BRC score) and 8 non-AFP based models (Lok index, FIB-4, Fibro-O index, APRI, King's score, Forns index, Bonacini score, and HUI model) for each Child-Pugh score in the prediction of HCC. RESULTS: AFP-based models were higher in HCC group patients, and statistically significant outcomes were detected with these methods in each Child-Pugh score group for HCC prediction (P < .05). Non-AFP based-methods showed different and inconsistent results in each Child-Pugh score group. CONCLUSION: These easily applied fibrosis markers, particularly AFP-based models, may provide an effective, simple, and low-cost way to predict HCC development in patients with hepatitis B and hepatitis B + D cirrhosis.

Analysis of the Liver Transplant Waiting List in Our Center.

BACKGROUND: Liver transplantation (LT) is an important treatment for acute liver failure and end-stage liver disease. Due to the limited supply of livers, there are still thousands of candidates waiting for transplantation in Turkey. We aimed to analyze LT waiting list access by demographics and etiology, particularly the diagnosis of hepatocellular carcinoma (HCC), which has been prioritized for LT in recent years. MATERIALS AND METHODS: Between 2011 and 2018, all patients listed for LT in our center were retrospectively reviewed. Demographic features, etiology of liver disease, waiting time, Model for End-Stage Liver Disease (MELD) score, and survival data were recorded. Differences between the LT group and deceased patients on the waiting list were evaluated. RESULTS: During this period, 266 patients were included in the LT waiting list. Only 119 patients (44.7%) underwent LT (men, 94; women, 25; mean age, 53 years), whereas 103 (38%) died (men, 60; women, 43; mean age, 53 years) in the waiting period. Seventeen patients were status 1A or 1B and of these, 7 patients died from fulminant hepatic failure. MELD score was significantly higher in deceased group (28 ± 7 vs 25 ± 6; P = .014). The frequency of HCC was significantly higher in LT group (29% vs 11%; P = .002). Overall survival of the patients in the waiting list with and without liver transplantation were 63% and 41%, respectively. CONCLUSIONS: HCC is one of the leading etiologies that is considered for cadaveric LT from the waiting list in our center. These patients had slightly lower MELD scores compared to deceased patients with shorter waiting times. We recommend early referral and close monitoring of the patients who are LT candidates.

Role of Preoperative Viral Load and Presence of Hepatocellular Carcinoma in the Biliary Complications After Liver Transplantation Due to Hepatitis C Virus.

BACKGROUND: Chronic hepatitis C virus (HCV) infection is a global health problem, and the need for liver transplants is ever-growing. For optimal surgical success, risk factors must be identified and HCV viral load must be reduced to a minimum to avoid complications. In this study, we aimed to investigate the role of HCV viral load on the post-transplant biliary complications. METHOD: Between 2004 and 2018, the cases of 114 liver transplant recipients with HCV infection were retrospectively reviewed. Data collection included demographic variables, preoperative and postoperative amount of serum HCV RNA copies, preoperative diagnosis of hepatocellular carcinoma (HCC), and postoperative biliary complications in the early and late period. After missing values were excluded, the remaining 97 patients were divided into 2 groups according to preoperative HCV RNA status (Group A: HCV RNA [+] and Group B: HCV RNA [-]). RESULTS: Demographic parameters were similar among both groups. There were 67 patients in Group A and 30 patients in Group B. The overall rate of biliary complications was higher in Group A without statistical significance (20% [n = 14] vs 13% [n = 4], respectively, P = .573). Biliary stricture occurrence in the late period was also higher in Group A. In HCC (+) patients (n = 26), biliary complications were significantly higher compared to HCC (-) patients (34% vs 12%, P = .018). However, in patients with biliary complications, the rate of multiple duct anastomoses was higher with no statistical significance (45% vs 26%, respectively, P = .14). CONCLUSION: The biliary complications on patient survival has been previously established, and this is mostly evident in those patients with viral etiology and hepatocellular carcinoma. As was also suggested in our study, hepatocellular carcinoma and positive viral status should be considered as predisposing factors for postoperative biliary complications after liver transplantation. However, the rate of multiple duct anastomoses should also be taken into consideration. New standards of antiviral medications and bridge therapy for HCC may improve transplant outcomes.

Does Multiple Bile Duct Anastomosis in Living Donor Liver Transplantation Affect the Postoperative Biliary Complications?

PURPOSE: The variation of multiple bile ducts in a living donor graft is not infrequent; however, the literature on the impact of the number of bile ducts on postoperative biliary complications is scarce. We investigated whether the number of biliary duct anastomoses affects the rate of postoperative biliary complications in patients undergoing living donor liver transplantation (LDLT). MATERIALS AND METHODS: Between January 2016 and January 2018, all patients who underwent LDLT were reviewed. The patients were divided into 2 groups according to the number bile duct anastomoses (single duct [group A, n = 78] or multiple ducts [group B, n = 94]). Data collection included demographic features, Child Pugh Score (CPS), graft-recipient weight ratio (GRWR), surgical data including technique of biliary anastomosis (duct-to-duct, duct-to-sheath, double duct-to-duct, and hepaticojejunostomy), and postoperative morbidity and mortality. RESULTS: The duct-to-duct anastomosis was the mostly commonly performed technique in group A, whereas double duct-to-duct and duct-to-sheath were significantly higher in group B. Operating time was quite high in group B compared to group A (438 ± 72 minutes vs 420 ± 61 minutes, respectively; P = .05). Regarding biliary complications (n = 40, 23.2%), the rates of biliary leakage (n = 17, 9.9%) and strictures (n = 25, 14.5%) were similar in both groups (P = .164 and .773, respectively). CPS was positively correlated (for Child B and C, odds ratio [OR]: 10.669 and 17.866, respectively), whereas GRWR was negatively correlated (OR: 9.530) with biliary stricture. Increased risk for bile leakage was observed in younger donors (OR: .929). Although overall mortality rate was 9.8% (n = 17), only 5 of the patients (29%) died of biliary complications. CONCLUSION: The number of biliary ducts and anastomoses did not affect the rate of complications. However, CPS, GRWR, and young donor age were found to be predisposing factors for postoperative biliary complications. Mortality was mostly based on the causes other than biliary complications.

The Utility of Noninvasive Scoring Systems for Prediction of Hepatic Steatosis in Liver Transplantation Donor Candidates.

BACKGROUND: The degree of liver steatosis is an important factor for donor selection in living donor liver transplantation. Multidetector computed tomography (MDCT) has long been used in many transplantation centers to determine donor liver steatosis. Noninvasive scoring methods based on laboratory tests have been investigated as potential methods for altering liver biopsy and imaging techniques in evaluating the liver steatosis. In this study, we assess the utility of several noninvasive methods for the evaluation of donor hepatosteatosis. In comparison, MDCT was used for the evaluation of liver steatosis. METHODS: A total of 205 donor candidates with significant hepatosteatosis were included in the study and divided into 4 groups according to the degrees of steatosis as measured by MDCT (mild, mid- to moderate, moderate to severe, and severe). In comparison, the aspartate aminotransferase-platelet ratio index (APRI), nonalcoholic fatty liver disease fibrosis score, BARD score, and FIB-4 scores were calculated. RESULTS: The diagnostic performance of APRI in prediction of all degrees of hepatosteatosis on MDCT was significantly higher (P < .01). The BARD score showed the second best performance (P = .018), whereas FIB-4 and nonalcoholic fatty liver disease fibrosis score were not correlated with degree of liver steatosis on MDCT. CONCLUSION: Some noninvasive scoring methods including APRI and BARD score seem to be more beneficial for the detection of hepatic steatosis in donor candidates and may reduce the need for other invasive and expensive diagnostic techniques.

Liver Graft Volume Estimation by Manual Volumetry and Software-Aided Interactive Volumetry: Which is Better?

PURPOSE: Estimation of graft volume is critical in living donor liver transplantation (LDLT). In this study, we aimed to evaluate the accuracy of software-aided automated computer tomography (CT) volumetry in the preoperative assessment of graft size for LDLT and to compare this method with manual volumetry. MATERIALS AND METHODS: Forty-one donors (27 men; 14 women) with a mean age in years ± standard deviation (28.4 ± 6.6) underwent contrast-enhanced CT prior to graft removal for LDLT. A liver transplant surgeon determined the weights of liver grafts using automated 3-dimensional volumetry software, and an abdominal radiologist specializing in liver imaging independently and blindly used the commercial interactive volumetry-assisted software on a viewing workstation to determine the liver volume on CT images. Both results were then compared to the weights of actual grafts obtained during surgery. Intraclass correlation coefficients were used to assess the consistency of numerical measurements and Pearson correlation coefficients were calculated to detect a linear relationship between numerical variables. To compare correlation coefficients, z scores were used. RESULTS: Regarding the right and left lobe graft volume estimation by the surgeon, there was a positive correlation between the results and actual graft weight (r = 0.834; P = .001; and r = 0.587; P = .001, respectively). Likewise, graft volume estimation by the radiologist for the right and left lobe was also positively correlated with the actual graft weight (r = 0.819; P = .001 and r = 0.626, P = .001, respectively). There was no significant difference between correlation coefficients (P = .836). CONCLUSION: Volumetric measurement of donor graft using 3-dimensional software provides comparable results to manual CT calculation of liver volume.

The prevalence of Helicobacter pylori infection in patients with gastric and duodenal ulcers - a 10-year, single-centre experience.

INTRODUCTION: Helicobacter pylori (H. pylori) occurs throughout the world and causes gastroduodenal diseases. There is data indicating a change in the prevalence of H. pylori infection worldwide. The prevalence of H. pylori is 80% in Turkey, while it is higher in many developing countries, and the rate of infection varies throughout the world. In many developing countries, the prevalence of infection exceeds 90% by adulthood. AIM: To determine the change in the rate of H. pylori infection in gastric ulcers and duodenal ulcers for a 10-year period in a single centre. MATERIAL AND METHODS: The study population included 550 patients (342 in 2004, 208 in 1994) with gastric and duodenal ulcers. RESULTS: In 2004 there were 125 (36.5%) patients with gastric ulcer and 217 patients with duodenal ulcer (64.5%). CLO test positivity was 39.2% in patients with gastric ulcers and 60% in patients with duodenal ulcers. In 1994 there were 208 patients (159 duodenal ulcers, 49 gastric ulcers). Urease test was positive in 74.2% of patients with duodenal ulcer and in 65.2% of patients with gastric ulcer. The decrease in the rate of urease positivity in patients with gastric ulcer was statistically significant (p = 0.01) during this 10-year period. CONCLUSIONS: In the present study we found that the urease positivity decreased significantly in patients with gastric ulcer between 1994 and 2004.

Changes of Some Hormones Levels in Patients With Hepatitis B Virus-Related Chronic Liver Disease.

BACKGROUND: The purpose of the study was to evaluate some of the hormones in patients with chronic liver disease and cirrhosis. METHODS: The men patients with chronic hepatitis B (Group 1), liver cirrhosis secondary to hepatitis B (Group 2), were included in this study. Additionally, a control group of healthy volunteers (Group 3) was formed. We investigated serum levels of Follicle-stimulating hormone (FSH), Luteinizing hormone (LH), Total testosterone (T. TES), Free-testosterone (F. TES), Estradiol (E2), Androstenedione (ANDR), Dihydroepiandrosterone (DHEA), Progesterone (PPOGES), Prolactin (PRL), Sex hormone binding protein (SHGB) were measured by radioimmunoassay and chemiluminescent immunoassay methods. RESULT: A total of 73 patients with chronic liver disease and cirrhosis were included in the study. Patients were grouped as cirrhosis (n = 28), chronic hepatitis B (n = 41) according to the type of their chronic liver disease. Serum F.TEST level in patient groups (group 1, group 2) was found to be lower than control group (P = 0.045, P = 0.047). Serum LH value was found to be higher in patient group (group 2) than control group (P = 0.048). Serum estradiol was higher in the group 2 compared to the control group (P = 0.046). CONCLUSIONS: The described disturbances of some of the observed hormones (LH, E2, F. TES) are complex, particularly in their relationship by which the clinical picture of the hepatitis B related cirrhotic patients and chronic liver disease can be explained.