Use of the Right Lobe Graft With Double Hepatic Arteries in Living-Donor Liver Transplant.

OBJECTIVES: We aimed to examine management of double hepatic artery reconstruction in patients under going living-donor liver transplant. MATERIALS AND METHODS: Between January 2002 and June 2014, one thousand thirty-six living-donor liver transplants were performed at the Liver Transplant Institute of Malatya Inonu University. Living liver grafts with a single hepatic artery were used in 983 living-donor liver transplants, while grafts with double hepatic artery branches were used in 53 living-donor liver transplants. All of the liver grafts with double hepatic artery branches were right lobe grafts. Hepatic artery anastomosis technique and the other medical data of recipients who used grafts with double hepatic arteries were analyzed retrospectively. RESULTS: A double hepatic artery anastomosis was created in 43 recipients, while a single anastomosis was created in the remaining 10 because of ligation of the nondominant hepatic artery branch. In 40 recipients, double hepatic artery branches in the graft were anastomosed with the recipient's right and left hepatic artery. In the remaining 3 recipients, double hepatic artery branches in the graft were anastomosed with the recipient's right hepatic artery and large segment 4 hepatic arteries. Postoperative complications related with hepatic artery anas-tomoses developed in 3 recipients: hepatic artery thrombosis (n = 1), hepatic artery aneurysm (n = 1), and hepatic artery stenosis (n = 1). A recipient with hepatic artery aneurysm immediately underwent a retransplant. A recipient with a hepatic artery thrombosis relapsed and required retransplant, which was treated with thrombectomy on postoperative day 10. A recipient with hepatic artery stenosis was followed conservatively. In our series, the incidence of complications related with double hepatic artery anastomosis was found to be 6.9%. CONCLUSIONS: According to our experiences, a double hepatic artery anastomosis does not increase the risk of hepatic artery thrombosis and can be performed safely by surgeons who are experienced with hepatic vascular reconstructions in a living-donor liver transplant recipient.

Evaluation of liver transplant recipients underwent incidental appendectomies.

OBJECTIVE: To assess the clinicopathological features of liver transplant recipients underwent incidental appendectomies. METHODS: Between September 2002 and July 2019, 2500 patients underwent liver transplantation at our Liver Transplant Institute, including 38 (24 males, 14 females) who also underwent incidental appendectomies. Incidental appendectomies were performed on 24 patients during recipient hepatectomies and on 14 during relaparotomies due to various surgical conditions. The following patient parameters were retrospectively evaluated: age, sex, underlying liver disease, liver transplant type, appendectomy indication, appendix length (mm) and diameter (mm), presence of appendicitis, and histopathological findings. RESULTS: The 38 patients who underwent incidental appendectomies had a mean age of 18.3±21.7 (range: 1-66) years and median appendix lengths and diameters of 55 (range: 19-90) mm and 6 (range: 4-20) mm, respectively. Histopathologically, the appendectomy specimens were classified as follows: vermiform appendix (n=16), lymphoid hyperplasia (n=13), acute appendicitis (n=3), fibrous obliteration (n=3), perforated appendicitis (n=1), mucinous cystadenoma (n=1), and appendiceal serosa invasion by sigmoid adenocarcinoma (n=1). There were no postoperative complications, including wound infections, abscesses, or leakage from the appendiceal stumps, related to the incidental appendectomies. CONCLUSION: This study demonstrated that incidental appendectomies can be successfully performed in immunosuppressed patients. However, additional studies are required to confirm these results.

Management of Recurrent HCC After Liver Transplantation.

BACKGROUND: Liver transplantation is the best treatment option for hepatocellular carcinoma (HCC). Although centers use strict selection criteria, there is a risk of recurrence, reaching up to 20% which are mostly observed within two years following the procedure. The survival after the recurrence is poor and it has been reported to be between 7-16 months. This poor prognosis is due to the systemic course of the recurrence even its presentation is local initially. RESULTS: The clinical management and treatment algorithm of recurrence is challenging and there is no guideline regarding the situation. Staging of the disease and multi-disciplinary approach are important. The decision for choice of treatment is given depending on the localization and spread of the recurrence. Adjusting and switching the immunosuppressive therapy should be the first attempt. When the recurrence is limited or confined to resectable regions, surgery should be the choice of treatment. Multiple recurrence sites such as adrenal glands, lung, lymph nodes are not contraindication for curative surgery. Resection of the graft for intrahepatic recurrence is the most beneficial procedure for survival. If resection is not possible due to advanced hepatic disease, loco-regional therapies such as TACE, RF, microwave ablation should be considered. SBRT may be an alternative both for hepatic and extra-hepatic recurrence. In case of systemic disease, sorafenib should be the drug choice.

Author Correction: Liver Transplantation for Hepatocellular Carcinoma: Malatya Experience and Proposals for Expanded Criteria.

The original version of this article unfortunately contained a mistake in the author group section.

Liver Transplantation for Hepatocellular Carcinoma: Malatya Experience and Proposals for Expanded Criteria.

Survival was examined from a Turkish liver transplant center of patients with HCC, to identify prognostic factors. Data from 215 patients who underwent predominantly live donor liver transplant for HCC at our institute over 12 years were included in the study and prospectively recorded. They were 152 patients within and 63 patients beyond Milan criteria. Patients beyond Milan criteria were divided into two groups according to presence or absence of tumor recurrence. Recurrence-associated factors were analyzed. These factors were then applied to the total cohort for survival analysis. We identified four factors, using multivariate analysis, that were significantly associated with tumor recurrence. These were maximum tumor diameter, degree of tumor differentiation, and serum AFP and GGT levels. A model that included all four of these factors was constructed, the 'Malatya criteria.' Using these Malatya criteria, we estimated DFS and cumulative survival, for patients within and beyond these criteria, and found statistically significant differences with improved survival in patients within Malatya criteria of 1, 5, and 10-year overall survival rates of 90.1%, 79.7%, and 72.8% respectively, which compared favorably with other extra-Milan extended criteria. Survival of our patients within the newly defined Malatya criteria compared favorably with other extra-Milan extended criteria and highlight the usefulness of serum AFP and GGT levels in decision-making.

Artificial vascular graft migration into hollow viscus organs in patients who underwent right lobe living donor liver transplantation.

BACKGROUND: To share our experience with hollow viscus migration of artificial vascular grafts (AVG) used for venous reconstruction of the right anterior sector in living donor liver transplantations (LDLT). METHODS: Clinical, radiological, and endoscopic data of 13 right lobe LDLT patients (range: 26-67 years) with a diagnosis of postoperative AVG migration into adjacent hollow viscus were analyzed. RESULTS: Biliary complications were detected in 12 patients. A median of four times endoscopic retrograde cholangiopancreatography (ERCP) procedures were performed in 11 patients prior to AVG migration diagnosis. A median of 2.5 times various percutaneous radiological interventional procedures were performed in eight patients prior to AVG migration diagnosis. The site of migration was the duodenum in eight patients, gastric antrum in four, and Roux limb in the remaining one patient. The migrated AVS were made of polytetrafluoroethylene (PTFE) in 10 patients and polyethylene terephthalate (Dacron) in three. The migrated AVGs were endoscopically removed in seven patients and surgically removed in six. Only one patient died due to sepsis unrelated to AVG migration. CONCLUSION: AVG migration into the adjacent hollow viscus following right lobe LDLT is a rare and serious complication. Repetitive ERCP, interventional radiological procedures, infection related to biliary leakage, and thrombosis of AVGs are among the possible risk factors.

Comparison of the demographic and clinical features of pregnant and non-pregnant patients undergoing appendectomy.

BACKGROUND: This retrospective study aims to compare the demographic and clinicopathological characteristics of the pregnant and non-pregnant patients who underwent appendectomy with a presumed diagnosis of acute appendicitis. METHODS: Between June 2009 and January 2019, 431 reproductive-aged of female patients underwent appendectomy with a presumed diagnosis of acute appendicitis. Patients were divided into two groups considering their pregnancy status: pregnant group (n=48) and non-pregnant group (n=383). Both groups were compared with respect to demographic, clinical and histopathological features. RESULTS: No statistically significant difference was found between pregnant and non-pregnant groups except total bilirubin level (p=0.019) and ultrasonographic findings (p=0.016). In the non-pregnant group, negative appendectomy and perforation rates were 26% and 10.5%, where these rates for the pregnant group were 20.8% and 4.2%. Sensitivity, specificity and accuracy rates of ultrasonography for the pregnant group were 50%, 100% and 58.5%, where these rates for the non-pregnant group were 67.3%, 57.9% and 65%. The pregnancy date was the first trimester in 52.1%, the second trimester in 29.2% and the third trimester in 16.7% of the pregnants. None of the term births (87.5%) resulted in neither a fetal nor a maternal complication. However, 12.5% of the preterm births resulted in neonatal mortality. CONCLUSION: Although not statistically significant, this study points out relatively lower rates of negative appendectomy and perforated acute appendicitis among pregnant patients, which is related to the overly attentive evaluation of pregnants admitted due to acute abdomen.

Histopathological features of incidental appendectomy specimens obtained from living liver donors.

BACKGROUND/AIMS: To determine the histopathological features of incidental appendectomy specimens obtained from living liver donors (LLDs) Materials and Methods: Between September 2005 and November 2018, 1910 LLDs underwent living donor hepatectomy at our institute. Incidental appendectomy together with living donor hepatectomy (LDH) was performed in 170 LLDs. The decision for incidental appendectomy was made by experienced gastrointestinal surgeons. Histopathological features of the appendectomy specimens were analyzed by two pathologists, and the following parameters were retrospectively evaluated: age, sex, appendix length (mm), appendix width (mm), presence of appendicitis, and unusual histopathological findings. RESULTS: Histopathological findings from 97 male and 73 female LLDs aged between 18 and 64 (median: 30) years were retrospectively examined. The length of the appendix vermiformis ranged from 25 to 120 (median: 70) mm, whereas its width ranged from 4 to 13 (median: 6) mm. The following histopathological findings were observed: normal appendix vermiformis (n=137), fibrous obliteration (n=13), acute appendicitis (n=5), enterobius vermicularis (n=4), lymphoid hyperplasia (n=4), low-grade appendiceal mucinous neoplasm (n=2), mucinous cystadenoma (n=1), grade 1 neuroendocrine tumor (n=1), hyperplastic polyp (n=1), enterobius vermicularis with fibrous obliteration (n=1), and acute appendicitis with eosinophilic infiltration (n=1). CONCLUSION: This study showed that a careful inspection of the abdominal cavity was useful, and appendectomy should be performed when required. In addition, even if the macroscopic appearance of the appendectomy specimens is normal, histopathological evaluations facilitate an early diagnosis of numerous unusual appendiceal diseases.

Unusual infectious agents detected in appendectomy specimens: A retrospective analysis of 42 cases.

OBJECTIVES: The aim of this study was to evaluate the clinical and histopathological features of 42 patients with unusual infectious agents detected in their appendectomy specimens. MATERIAL AND METHODS: Between January 1999 and November 2018, 2.754 patients underwent emergency or incidental appendectomy in our clinic, and their pathology reports were retrospectively reviewed. Unusual infectious agents or eosinophilic infiltration of the appendix were reported in the initial pathological examinations of 57 patients. The pathological slides of these patients were re-examined by histopathologists. The examinations revealed that 15 of these patients had no microscopic findings suggestive of parasitic infections. The remaining 42 patients with unusual appendiceal infectious agents were included into the study. RESULTS: A total of 42 patients (25 females and 17 males) aged 18 to 75 years were included into this study. While 32 of these patients (76%) underwent emergency appendectomy with a presumed diagnosis of acute appendicitis (AAp), the remaining 10 patients underwent incidental appendectomy for various reasons. Twenty-two patients (52.4%) had histopathological changes consistent with AAp while 20 patients had no evidence of AAp. Histopathological examination revealed infection with Enterobius vermicularis in 38 of the patients, Taenia species in 2, and Ascaris lumbricoides and Actinomyces species in 1 patient each. A total of 24 patients were treated for infections with mebendazole (n = 20), albendazole (n =1), niclosamide (n = 2), and amoxicillin (n = 1). CONCLUSION: Unusual infectious agents should be considered as factors potentially triggering AAp, especially in patients living in endemic areas. The appendiceal stump should be inspected for parasite residues.

Liver transplant for large hepatocellular carcinoma in Malatya: The role of gamma glutamyl transferase and alpha-fetoprotein, a retrospective cohort study.

BACKGROUND: There is increasing interest in transplanting patients with hepatocellular carcinoma (HCC) with tumors greater than 5 cm (Milan criteria). AIM: To investigate possible prognostically-useful factors for liver transplantation in HCC patients with large tumors. METHODS: In this clinical study, 50 patients with HCC who were transplanted at our Liver Transplant Center between April 2006 and August 2019 and had tumors greater than 6 cm maximum diameter were retrospectively analyzed. Their survival and full clinical characteristics were examined, with respect to serum alpha-fetoprotein (AFP) and gamma glutamyl transpeptidase (GGT) levels. Kaplan-Meier survival estimates were used to determine overall survival and disease-free survival in these patients. The inclusion criterion was evidence of HCC. Exclusion criteria were the presence of macroscopic portal vein thrombosis or metastasis and a follow-up period of less than 90 d. RESULTS: Using receiver operating characteristic curve (ROC) analysis, cutoff values of AFP 200 ng/mL and GGT 104 IU/L were identified and used in this study. Significantly longer overall survival (OS) and disease-free-survival (DFS) were found in patients who had lower values of either parameter, compared with higher values.  Even greater differences in survival were found when the 2 parameters were combined. Two tumor size bands were identified, in searching for the limits of this approach with larger tumors, namely 6-10 cm and > 10 cm. Combination parameters in the 6-10 cm band reflected 5-year OS of 76.2% in patients with low AFP plus low GGT vs 0% for all other groups. Patients with tumors greater than 10 cm, did not have low AFP plus low GGT. The most consistent clinical correlates for longer survival were degree of tumor differentiation and absence of microscopic portal venous invasion. CONCLUSION: Serum levels of AFP and GGT, both alone and combined, represent a simple prognostic identifier in patients with large HCCs undergoing liver transplant-ation.

Appendiceal Carcinoid Tumor within Amyand's Hernia: A Case Report and Review of the Literature.

INTRODUCTION: Amyand's hernia is defined as the herniation of the whole or a part of appendix vermiformis into an inguinal hernia sac. Amyand's hernia is very rare, constituting about 1% of all inguinal hernia patients and 0.1% of all acute appendicitis patients. In one-quarter of Amyand's hernia patients, inflammatory changes are detected in appendix vermiformis. Detecting an appendiceal tumor in an Amyand's hernia sac is extremely rare, with only eight cases having been reported so far in the English literature. CASE PRESENTATION: A 64-year-old man with an appendiceal carcinoid tumor inside an incarcerated Amyand's hernia sac. As the tumor was localized to the radix of the appendix, resection was carried out with the help of a linear-cutter stapler in a way to contain a part of the cecal wall. As the pathology examination revealed a carcinoid tumor infiltrating the periappendicular fatty tissue, right hemicolectomy was performed in a second session, in compliance with the oncological principles. No metastasis was present at the 24th month. Case reports published in the English literature regarding the Amyand's hernia with an appendiceal tumor were also analyzed in this study. CONCLUSION: Amyand's hernia containing an appendiceal tumor is an extremely rare clinical entity. Clinical manifestations mostly mimic the incarcerated hernia and thus accurate diagnosis is made incidentally during hernia surgery. The basic oncological principles apply for the approach to tumors inside a hernia sac.

Advanced alveolar echinococcosis disease associated with Budd-Chiari syndrome.

INTRODUCTION: Alveolar echinococceal disease of the liver is rare. Echinococcus multilocularis is responsible for the development of the related clinical conditions. Advanced disease may result with serious complications such as end stage liver disease and Budd-Chiari syndrome. PRESENTATION OF CASE: In this presentation, a 28 years-old woman who was a case with advanced alveolar echinococcosis complicated with a Budd-Chiari syndrome and was performed successful living donor liver transplantation, has been demonstrated with clinical and radiological images. DISCUSSION: Initially there may be no clinical evidence of the disease in humans for years. Severity and fatality are the significant characteristics of the natural history. Extension to the surrounding tissues and metastasis of the parasitic mass may be observed. Prevention is essential in disease control. Serologic assay may identify the parasite. However, early diagnosis is rare. Staging is based on radiologic imaging. Some patients with advanced disease may require surgery. Hepatic resection and liver transplantation are accepted procedures in selected patients. CONCLUSION: The importance of early diagnosis to prevent advanced complications such as development of Budd-Chiari syndrome and metastasis has been underlined.