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.

Gastrointestinal stromal tumors of the small intestine: the challenge of diagnosis and the outcome of management.

PURPOSES: Gastrointestinal stromal tumor (GIST) is a rare small intestinal tumor. Most patients usually report long-period complaints due to difficult diagnoses. A high grade of suspicion is required for early diagnosis and initiation of the proper management. METHODS: A retrospective study of all patients with small intestinal GIST who were operated in the period between January 2008 and May 2021 at Mansoura University Gastrointestinal Surgical Center (GIST). RESULTS: Thirty-four patients were included in the study with a mean age of 58.15 years (± 12.65) with a male to female ratio of 1.3:1. The mean duration between onset of symptoms and diagnosis was 4.62 years (± 2.34). Diagnosis of a small intestinal lesion was accomplished through abdominal computed tomography (CT) in 19 patients (55.9%). The mean size of the tumor was 8.76 cm (± 7.76) ranging from 1.5 to 35 cm. The lesion was of ileal origin in 20 cases (58.8%) and jejunal in 14 cases (41.2%). During the scheduled follow-up period, tumor recurrence occurred in one patient (2.9%). No mortality was encountered. CONCLUSION: Diagnosis of a small bowel GISTs requires a high grade of suspicion. Implementing new diagnostic techniques like angiography, capsule endoscopy, and enteroscopy should be encouraged when suspecting these lesions. Surgical resection is always associated with an excellent postoperative recovery profile and very low recurrence rates.

Impact of donor-recipient genetic relationship on outcome of living donor liver transplantation.

Living donor liver transplantation (LDLT) is a valuable option for expanding the donor pool, especially in localities where deceased organ harvesting is not allowed. In addition, rejection rates were found to be lower in LDLT, which is attributed to the fact that LDLT is usually performed between relatives. However, the impact of genetic relation on the outcome of LDLT has not been studied. In this study, we examined the difference in rejection rates between LDLT from genetically related (GR) donors and genetically unrelated (GUR) donors. All cases that underwent LDLT during the period from May 2004 until May 2014 were included in the study. The study group was divided into 2 groups: LDLT from GR donors and LDLT from GUR donors. A total of 308 patients were included in the study: 212 from GR donors and 96 from GUR donors. Human leukocyte antigen (HLA) typing was not included in the workup for matching donors and recipients. GUR donors were wives (36; 11.7%), sons-in-law (7; 2.3%), brothers-in-law (12; 3.9%), sisters-in-law (1; 0.3%), and unrelated (38; 12.3%). The incidence of acute rejection in the GR group was 17.4% and 26.3% in the GUR group (P value = 0.07). However, there was a significant difference in the incidence of chronic rejection (CR) between the 2 groups: 7% in GR group and 14.7% in the GUR group (P value = 0.03). In terms of overall survival, there was no significant difference between both groups. LDLT from the GUR donors is not associated with a higher incidence of acute cellular rejection. However, CR was significantly lower when grafts were procured from GR donors. HLA matching may be recommended before LDLT from GUR donors. Liver Transplantation 23:43-49 2017 AASLD.

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.

Caudate lobe resection with major hepatectomy for central cholangiocarcinoma: is it of value?

BACKGROUND/AIMS: The aim of this study was to evaluate the importance of concomitant caudate lobe resection in the course of major hepatectomy for hilar cholangiocarcinoma. METHODOLOGY: During the period between January 1995 and December 2010, 159 patients were subjected to major hepatectomy with or without total caudate lobe resection at the Gastroenterology Centre, Mansoura University. These patients were divided in two groups: 1) a caudate lobe preservation (CLP) group (79 patients) and 2) a caudate lobe resection (CLR) group (80 patients). All patient data were retrospectively reviewed. RESULTS: This study included 94 men and 65 women with a mean age of 53.5±0 years without operative mortality. No differences were observed between groups regarding operative time, blood loss or the development of any individual postoperative complication. There were 23 (28.8%) margin-positive resections in the CLR group and 49 (62%) margin-positive resections in the CLP group (p≤0.001). Recurrence was confirmed in 53 (67.1%) and in 41(51.3%) patients in the CLP and CLR groups, respectively (p=0.031). The median survival of the CLR group was 36 months with a 5-year survival rate of 28%, while the median survival of the CLP group was 22 months with a 5-year survival rate of 5% (p≤0.001). CONCLUSIONS: Caudate lobe resection in combination with major hepatectomy did not affect operative or postoperative morbidity and mortality. However, it led to higher rates of margin-negative resections and significantly improved survival.

Contamination and health risk assessment of heavy metals in beach sediments of Red Sea and Gulf of Aqaba, Egypt.

The Egyptian beaches on the Red Sea and the Gulf of Aqaba in Sinai are a destination for international tourism throughout the year. Therefore, assessing the concentration levels of heavy metal pollutants and identifying the extent of their impact on human health is important. Single and integrated pollutants indices have been used to assess the risks of these elements. The results of single indices proved that the study area contain Fe and Zn came mostly from natural source while Cu, Pb, Cd and Hg originated from anthropogenic sources. However, the integrated pollutants indices revealed that this area is not polluted with heavy metals. On the other hand, the hazard index, and the carcinogenic risk over the lifetime coefficients proved that the beach sand of the study area is completely safe and does not have additional health risks to children or adults, where LCR < 10-6.

Caudate lobe resection for hepatocellular carcinoma.

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC) originating in the caudate lobe is rare, and the treatment for this type of carcinoma is a complex surgical procedure. We aimed to evaluate the surgical outcomes after isolated caudate lobe resection for HCC. METHODOLOGY: We retrospectively analyzed 30 consecutive patients with HCC originating in the caudate lobe who underwent isolated caudate lobe resection. RESULTS: Thirty patients underwent caudate lobe resection for HCC. The main sites of the tumors were located in the Spiegel lobe, the paracaval portion and caudate process. The surgical margin was tumor negative in all of the patients. The median tumor size was 4.3cm. The mean operative time was 230 ± 50min and the intraoperative blood loss was 1200 ± 200mL. The hospital morbidity rate was 33%. There was no postoperative mortality. The mean survival rate was 25.3+11.7 months. The overall survival rates were 62%, 34% and 11% at 1, 3 and 5 years, respectively. The disease free survival rate after isolated caudate lobectomy was 31% at 3 years. Recurrence was noted in 12 patients (40%). Eleven patients were identified as having intrahepatic recurrences and 1 patient as having peritoneal dissemination. CONCLUSIONS: Isolated caudate lobe resection is a feasible procedure and can be undertaken with low morbidity and nil mortality. Careful technique and detailed anatomic knowledge of the caudate lobe are essential for this procedure.

Post-cholecystectomy biliary injuries: one center experience.

BACKGROUND/AIMS: Post-cholecystectomy bile duct injuries (BDIs) represent a challenge in diagnosis and management. METHODOLOGY: From March 1995 to August 2009, 274 patients with post-cholecystectomy BDIs were managed at our center. All patients were subjected to laboratory tests, sonography, ERCP and MRCP. The management varied according to the type of injury. RESULTS: Seventy-one (25.9%) LC and 203 (74.1%) OC were performed; 8(2.9%) were detected intraoperatively; 270 patients were referred from other hospitals. From those discovered intraoperatively, 7 had hepatico-jejunostomy and one died from severe peritonitis; 11 (4%) presented with generalized and 112 (40.9%) with localized peritonitis. The leak site was the cystic duct (57 cases), accessory duct in the liver bed (5 cases), right hepatic duct (4 cases) and lateral tear in the CBD (12 cases). Endoscopic stenting was performed for all of them. The remaining 34 patients had a completely ligated distal duct and therefore had hepatico-jejunostomy Roux loop; 143 patients (52.2%) presented with early (79 cases) and late (64 cases) jaundice; 126 cases had hepatico-jejunostomy. The remaining 17 patients were treated by balloon dilatation. CONCLUSIONS: Endoscopic stenting can manage cases with cystic or accessory duct leak while, hepatico-jejunostomy Roux loop represents the golden procedure for management of transected or ligated CBD.

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.

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.

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.

Dexmedetomidine in a surgically inserted catheter for transversus abdominis plane block in donor hepatectomy: A prospective randomized controlled study.

BACKGROUND: Transversus abdominis plane (TAP) block is a promising technique for analgesia after abdominal surgery. This prospective, randomized controlled trial assessed the effect of adding dexmedetomidine to bupivacaine in TAP block for donor hepatectomy. We hypothesized that this would improve postoperative morphine consumption and reduce analgesia related complication and inflammation. METHODS: A total of 50 donor hepatectomy were enrolled in this study. Patients divided into two equal groups according to drugs used for TAP block. Group (B) received 20 ml of bupivacaine hydrochloride 0.25%, Group (BD) received 20 ml of bupivacaine hydrochloride 0.25% and 0.3 µg/kg dexmedetomidine, on both sides at the end of surgery and every 8 h for 48 h at right side only through inserted catheter. Primary outcome objective was morphine consumption at first 72 h. Secondary outcome objectives were morphine requirement, numbers of intake, time to first intake, pain score numerical analog scale (NAS), postoperative analgesia related complications, recovery of intestinal motility, and inflammatory markers. RESULTS: Data were analyzed, rescue morphine analgesia was significantly lower in (BD) group compared with (B) groups as considering total morphine consumption (B 4 ± 1.9, BD 1.5 ± 0.5, P = 0.03), numbers of morphine intake (P = 0.04), morphine requirement (P = 0.03), and first time of analgesia intake (P = 0.04). NAS was significantly lower in group (BD) compared with group (B) group in the first 12 h (NAS 0 - P = 0.001, NAS 1 - P = 0.03). Adding dexmedetomidine improved gut motility, first oral intake without detectable anti-inflammatory effect. CONCLUSION: Adding dexmedetomidine to bupivacine in a surgically inserted catheter for TAP block in donor hepatectomy reduced morphine consumption without detectable anti-inflammatory effect.

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.

Ischemia modified albumin (IMA) in acute coronary syndrome (ACS) and left bundle branch block (LBBB). Does it make the difference?

BACKGROUND: Management of patients with a suspected ACS and LBBB is a challenge to the clinician. AIM: To detect the ability of IMA to exclude myocardial ischemia in suspected patients with ACS and LBBB. MATERIAL AND METHODS: A total of 68 patients with suspected ACS and LBBB (group I) and another twenty patients age and sex matched known to have LBBB with normal coronary angiography (group II) were included in this study and subjected to: routine laboratory tests, 12 lead ECG, echocardiography, and measurement of serum troponin I (TnI) and IMA (measured by ELISA). Diagnostic coronary angiography was performed on all patients and scored by severity and modified Gensini scores. RESULTS: IMA and TnI levels are significantly increased in group I compared to group II (P value <0.001). IMA with a cutoff value >95 could predict significant CAD (lesions >50%) with AUC of 0.923, sensitivity of 88%, specificity of 83.33%, PPV of 93.6%, NPV of 71.4% and accuracy 86.76%. Moreover, by using both simple and multiple logistic regression analyses IMA could also independently detect significant CAD. The combined use of IMA and TnI significantly improved the sensitivity and the negative predictive value to 98% and 90.9% respectively. CONCLUSION: There was a distinct advantage of measuring IMA in patients presenting to the emergency department with acute chest pain and LBBB to rule out a final diagnosis of ACS.

Microalbuminuria is a late event in patients with hypertension: Do we need a lower threshold?

BACKGROUND: Microalbuminuria (MA) is a marker of vascular damage. However, many studies have observed an increased risk at lower levels of albuminuria than are currently used to define MA. AIM: To verify early cardiovascular changes occurring before MA in hypertensive patients. MATERIALS AND METHODS: One hundred and fifty hypertensive patients and 60 normotensive individuals were divided into normotensive individuals with normal left ventricular (LV) geometry (Group I), hypertensive patients with normal LV geometry (Group II), and hypertensive patients with abnormal LV geometry (Group III). The LV mass index, ambulatory arterial stiffness index, flow-mediated dilatation of the brachial artery, and intima-media thickness (IMT) of the common carotid were assessed. Urinary albumin/creatinine ratio was determined using a morning spot-urine sample. RESULTS: Compared with Group I, ambulatory arterial stiffness index and IMT were significantly increased and flow-mediated dilatation was significantly decreased in Group II; however, MA did not differ between both groups. These changes were augmented when Group III was compared with Group II. MA significantly increased in Group III compared with Group II. Receiver operating characteristic analysis revealed that MA, with a cut-off value of 19.25 mg/g, predicted increased IMT, and abnormal LV geometry in a statistically significant manner. CONCLUSION: Many vascular changes, in the form of increased IMT, reduced vasodilator capacity, and increased arterial stiffness, preceded MA and any change in LV geometry. The results presented here strengthen the usefulness of adopting a lower cut-off to define MA.

Clinicopathological features and surgical outcome of patients with fibrolamellar hepatocellular carcinoma (experience with 22 patients over a 15-year period).

AIM: To evaluate the clinicopathological features and the surgical outcomes of patients with fibrolamellar hepatocellular carcinoma (FL-HCC) over a 15-year period. METHODS: This is a retrospective study including 22 patients with a pathologic diagnosis of FL-HCC who underwent hepatectomy over a 15-year period. Tumor characteristics, survival and recurrence were evaluated. RESULTS: There were 11 male and 11 female with a median age of 29 years (range from 21 to 58 years). Two (9%) patients had hepatitis C viral infection and only 2 (9%) patients had alpha-fetoprotein level > 200 ng/mL. The median size of the tumors was 12 cm (range from 5-20 cm). Vascular invasion was detected in 5 (23%) patients. Four (18%) patients had lymph node metastases. The median follow up period was 42 mo and the 5-year survival was 65%. Five (23%) patients had a recurrent disease, 4 of them had a second surgery with 36 mo median time interval. Vascular invasion is the only significant negative prognostic factor. CONCLUSION: FL-HCC has a favorable prognosis than common HCC and should be suspected in young patients with non cirrhotic liver. Aggressive surgical resection should be done for all patients. Repeated hepatectomy should be considered for these patients as it has a relatively indolent course.

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.

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%.