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.

Bile Leakage After Hepatic Resection for Hepatocellular Carcinoma: Does It Impact the Short- and Long-term Outcomes?

BACKGROUND: Bile leakage (BL) is one of the commonest morbidities after hepatic resection for hepatocellular carcinoma (HCC). The current study was conducted to evaluate the incidence and different predictive factors for BL after hepatic resection for HCC, and to evaluate of the impact of BL on the long-term survival outcomes. METHODS: We reviewed the patients' data who underwent hepatic resection for HCC during the period between June 2010 and June 2019. RESULTS: A total of 293 patients were included in the study. BL occurred in 17 patients (5.8%). More Child-Pugh class B patients were found in BL group. There were no significant differences between the two groups except for tumor site, macroscopic portal vein invasion, extent of liver resection, Pringle maneuver use, intraoperative blood loss, and transfusions. Longer hospital stay, higher grades of post-hepatectomy liver failure, and abdominal collections were noted in BL group. After median follow-up duration of 17 months (4-110 months), there were no significant differences between BL and non-BL group regarding overall survival (log-rank, p = 0.746) and disease-free survival (log-rank, p = 0.348). In multivariate analysis, Child-Pugh class, macroscopic portal vein invasion, liver resection extent (minor/major), and Pringle's maneuver use were the only significant predictors of BL. CONCLUSION: BL did not significantly impair the long-term outcomes after hepatic resection for HCC. Child-Pugh class, macroscopic portal vein invasion, liver resection extent (minor/major), and Pringle's maneuver use were the main risk factors of BL in the current study.

Outcomes of Hepatic Resection for Hepatocellular Carcinoma Associated with Portal Vein Invasion.

BACKGROUND: To evaluate our experience of liver resection for hepatocellular carcinoma (HCC) patients associated with macroscopic portal vein invasion (PVI). METHODS: Consecutive HCC patients who underwent liver resection for HCC between November 2009 & June 2019 were included. To overcome selection bias between patients with and without macroscopic PVI, we performed 1:1 match using propensity score matching (PSM). RESULTS: Macroscopic PVI was detected in 37 patients (12.8%). We divided our patients into two groups according to the presence of macroscopic PVI. After PSM, 36 patients of PVI group were matched with 36 patients from Non-PVI group. After PSM, both groups were well balanced regarding tumor site, number, liver resection extent and type. Longer operation time and more blood loss were noted in PVI group. Higher incidence of post-operative morbidities occurred in PVI group especially, post-hepatectomy liver dysfunction. The 1-, 2-, and 3-y overall survival rates for Non-PVI group were 85.3%, 64.6%, and 64.6% & 69.8%, 42%, and 0% for PVI group, respectively (P = 0.009). There were no significant differences regarding the recurrence rate, site, and its management. The 1-, 2-, and 3-y disease-free survival (DFS) rates for Non-PVI group were 81.7%, 72.3%, and 21.7% & 67.7%, 42.3%, and 0% for PVI group, respectively (P = 0.172). CONCLUSION: Surgical management of advanced HCCs with macroscopic PVI is feasible, and associated with comparable DFS but poorer overall survival, compared to patients without PVI.

Early and intermediate term outcomes after laparoscopic one-anastomosis gastric bypass for morbidly obese patients: a single center experience.

Objectives: To evaluate our outcomes of laparoscopic one-anastomosis gastric bypass (LOAGB) as a primary weight loss procedure. We evaluated the impact of biliary reflux by combination of upper endoscopy (UGIE), ambulatory pH metry, and ambulatory biliary reflux monitoring. Material and Methods: We reviewed the data of patients who underwent LOAGB during the period between July 2015 till August 2018. Results: Forty consecutive patients were included in the study. Thirty-seven patients (92.5%) had obesity related comorbidities. The median follow-up duration was 18 months (6-36 months). The 1-, 2-, and 3-years excess weight loss percentages were 53.1%, 60.4%, and 62.3%. At three years follow-up, complete remission of diabetes mellitus occurred in 7/7 patients (100%) and of hypertension in 4/7 patients (57.1%). Eighteen patients (45%) accepted to undergo UGIE with routine biopsies and evaluation of acidic and biliary reflux. All examined patients had negative acid reflux results according to ambulatory PH metry with median DeMeester score of 2 (0.3-8.7). According to ambulatory biliary reflux monitoring, 17/18 patients (94.1%) had posi- tive result. Only 6/18 patients (33.3%) had symptoms of biliary reflux and had positive symptom index on bilimetric study. Regarding UGIE, all patients had just gastritis and reflux esophagitis with no evidence of gross mucosal changes. Pathological examination of all routine biopsies did not show any sign of faveolar hyperplasia, atypia or malignancy. Conclusion: LOAGB is a safe and efficient bariatric procedure with acceptable morbidity rate. LOAGB is not associated with significant biliary reflux or pathological changes in the esophagogastric mucosa.

Post-hepatectomy liver failure after hepatic resection for hepatocellular carcinoma: a single center experience.

PURPOSE: Post-hepatectomy liver failure (PHLF) is one of the most feared morbidities after liver resection (LR) for hepatocellular carcinoma (HCC). We aimed to investigate the incidence and predictors of PHLF after LR for HCC and its impact on survival outcomes. METHODS: We reviewed the patients who underwent LR for HCC during the period between January 2010 and 2019. RESULTS: Two hundred sixty-eight patients were included. Patients were divided into two groups according to the occurrence of PHLF, defined according to ISGLS. The non-PHLF group included 138 patients (51.5%), while the PHLF group included 130 patients (48.5%). Two hundred forty-six patients (91.8%) had hepatitis C virus. Major liver resections were more performed in the PHLF group (40 patients (30.8%) vs. 18 patients (13%), p = 0.001). Longer operation time (3 vs. 2.5 h, p = 0.001), more blood loss (1000 vs. 500 cc, p = 0.001), and transfusions (81 patients (62.3%) vs. 52 patients (37.7%), p = 0.001) occurred in PHLF group. The 1-, 3-, and 5-year Kaplan-Meier overall survival rates for the non-PHLF group were 93.9%, 79.5%, and 53.9% and 73.2%, 58.7%, and 52.4% for the PHLF group, respectively (log rank, p = 0.003). The 1-, 3-, and 5-year Kaplan-Meier disease-free survival rates for the non-PHLF group were 77.7%, 42.5%, and 29.4%, and 73.3%, 42.9%, and 25.3% for the PHLF group, respectively (log rank, p = 0.925). Preoperative albumin, bilirubin, INR, and liver cirrhosis were significant predictors of PHLF in the logistic regression analysis. CONCLUSION: Egyptian patients with HCC experienced higher PHLF incidence after LR for HCC. PHLF significantly affected the long-term survival of those patients.

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.

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.

Predictors of hepatitis C virus recurrence after living donor liver transplantation: Mansoura experience.

BACKGROUND AND STUDY AIMS: Hepatitis C virus (HCV)-related cirrhosis is the leading cause of liver transplantation (LT). All patients who undergo LT with detectable serum HCV-RNA experience graft reinfection, which is the most frequent cause of graft loss and death in these patients. We estimated the rate of HCV recurrence and evaluated the current therapeutic regimens. PATIENTS AND METHODS: The records of consecutive 325 living donor LT (LDLT) surgeries performed between May 2004 and August 2014 were retrospectively analysed; 207 of them were followed-up throughout the study. Clinical, laboratory, radiological and histopathological examinations were performed thoroughly. Patients received treatment in the form of either pegylated interferon (PEG-IFN) or sofosbuvir, both in combination with ribavirin. RESULTS: In total, 90.3% of recipients who were transplanted because of HCV-related end-stage liver disease experienced recurrence due to the virus. The donor age was older in the HCV recurrent group versus the non-recurrence group (28.7±7.1 versus 22.6±2.6years: p≤0.001), warm ischaemia time was prolonged (46.1±18.1 versus 28.6±4.1min: p≤0.001), median cold ischaemia time was 40.0 (10-175) versus 22.5 (15-38) min (p≤0.001) and basal PCR was 414000 (546-116000000) versus 10766 (1230-40000) (p≤0.001). Sustained virological response was achieved in 95.4% of patients treated with a combination of a fixed daily dose of 400mg sofosbuvir with ribavirin and in 65.1% of those who were treated with PEG-IFN with ribavirin. CONCLUSIONS: Older donor age and prolonged warm ischaemia time are independent predictors of HCV recurrence after LDLT, and early treatment with the direct-acting sofosbuvir is helpful in resolving the problem of post-LT HCV recurrence.

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

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

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.

Hepatic venous outflow obstruction after living donor liver transplantation managed with ectopic placement of a foley catheter: A case report.

INTRODUCTION: The early hepatic venous outflow obstruction (HVOO) is a rare but serious complication after liver transplantation, which may result in graft loss. We report a case of early HVOO after living donor liver transplantation, which was managed by ectopic placement of foley catheter. PRESENTATION: A 51 years old male patient with end stage liver disease received a right hemi-liver graft. On the first postoperative day the patient developed impairment of the liver functions. Doppler ultrasound (US) showed absence of blood flow in the right hepatic vein without thrombosis. The decision was to re-explore the patient, which showed torsion of the graft upward and to the right side causing HVOO. This was managed by ectopic placement of a foley catheter between the graft and the diaphragm and the chest wall. Gradual deflation of the catheter was gradually done guided by Doppler US and the patient was discharged without complications. DISCUSSION: Mechanical HVOO results from kinking or twisting of the venous anastomosis due to anatomical mismatch between the graft and the recipient abdomen. It should be managed surgically by repositioning of the graft or redo of venous anastomosis. Several ideas had been suggested for repositioning and fixation of the graft by the use of Sengstaken-Blakemore tubes, tissue expanders, and surgical glove expander. CONCLUSION: We report the use of foley catheter to temporary fix the graft and correct the HVOO. It is a simple and safe way, and could be easily monitored and removed under Doppler US without any complications.

Comparative study between duct to mucosa and invagination pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized study.

BACKGROUND: The ideal technical pancreatic reconstruction following pancreaticoduodenectomy (PD) is still debated. The aim of the study was to assess the surgical outcomes of duct to mucosa pancreaticojejunostomy (PJ) (G1) and invagination PJ (G2) after PD. METHODS: Consecutive patients treated by PD at our center were randomized into either group. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF); secondary outcomes included; operative time, day to resume oral feeding, postoperative morbidity and mortality, exocrine and endocrine pancreatic functions. RESULTS: One hundred and seven patients treated by PD were randomized. The median operative time for reconstruction was significantly longer in G1 (34 vs. 30 min, P=0.002). POPF developed in 11/53 patients in G1 and 8/54 patients in G 2, P=0.46 (6 vs. 2 patients had a POPF type B or C, P=0.4). Steatorrhea after one year was 21/50 in G1 and 11/50 in G2, respectively (P=0.04). Serum albumin level after one year was 3.4 gm% in G1 and 3.6 gm in G2 (P=0.03). There was no statistically significant difference regarding the incidence of DM preoperatively and one year postoperatively. CONCLUSION: Invagination PJ is easier to perform than duct to mucosa especially in small pancreatic duct. The soft friable pancreatic tissue can be problematic for invagination PJ due to parenchymal laceration. Invagination PJ was not associated with a lower rate of POPF, but it was associated with decreased severity of POPF and incidence of postoperative steatorrhea. CLINICAL TRIALS. GOV ID: NCT02142517.

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

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