Ahmed Shehta

Introduction: Direct-acting antiviral drugs have been recently introduced for management of chronic hepatitis C virus (HCV) patients. Those medications have achieved a dramatic improvement of sustained virologic response (SVR) reaching almost 90%. However, reports regarding the increased risk of occurrence or recurrence of hepatocellular carcinoma (HCC) in chronic HCV patients who achieved SVR after direct-acting antiviral drugs are controversial.Methods: We report two cases of giant HCCs complicating chronic HCV infection after direct-acting antiviral drugs-based therapies and were managed by major hepatic resection.Results: Two male patients with chronic HCV infection received several regimens oral direct acting antiviral drugs with a SVR for 3 and 6 months, respectively. They complained of progressive right hypochondrial pain and abdominal enlargement. Two large HCCs were diagnosed (16.2 cm * 17.6 cm * 16.9 cm, and 18 cm * 13 cm * 16.5 cm in dimensions) with markedly elevated ser...

The adrenal gland is a rare site for hepatocellular carcinoma (HCC) recurrence after living-donor liver transplantation (LDLT). Solitary adrenal recurrence can be managed by surgical excision, with expected better survival outcomes. We describe a rare case of successful left adrenalectomy of solitary recurrent HCC in the left adrenal gland 5 years after LDLT. 59 years male patient with HCC complicating chronic HCV infection received a right hemi-liver graft from his son. The actual graft weight was 1208 g and GRWR was 1.5. The patient started oral direct acting antiviral drugs for recurrent HCV 2 years after LDLT. A left adrenal mass was detected on follow up radiology. No other metastatic lesions were detected on metastatic workup. Left adrenalectomy was done by an anterior approach. The postoperative course was uneventful and was discharged a week after operation. Postoperative pathological and immune-histochemical examinations confirmed the metastatic HCC nature of the mass. The patient is under regular follow up with no recurrences 6 month after resection. There is no consensus regarding the management of HCC recurrence after LDLT. Most patients had multi-organ recurrences and usually offered palliative or supportive care. Solitary HCC recurrence offers a better chance for more aggressive therapy, offering better prognosis. Solitary adrenal recurrence of HCC after LDLT is extremely rare. Strict follow up protocol is necessary to allow early detection of tumor recurrence. Curative surgical resection is a safe option associated with low morbidity and expected to have a good long-term survival.

Background. There is paucity of data about the impact of using magnification on rate of pancreatic leak after pancreaticoduodenectomy (PD). The aim of this study was to show the impact of using magnifying surgical loupes 4.0× EF (electro-focus) on technical performance and surgical outcomes of PD. Patients and Method. This is a propensity score–matched study. Thirty patients underwent PD using surgical loupes at 4.0× magnification (Group A), and 60 patients underwent PD using the conventional method (Group B). The primary outcome was postoperative pancreatic fistula. Secondary outcomes included operative time, intraoperative blood loss, postoperative complications, mortality, and hospital stay. Results. The total operative time was significantly longer in the loupe group ( P = .0001). The operative time for pancreatic reconstruction was significantly longer in the loupe group ( P = .0001). There were no significant differences between both groups regarding hospital stay, time to ora...

The efficacy of octreotide to prevent postoperative pancreatic fistula (POPF) of pancreaticoduodenectomy (PD) is still controversial. This study aimed to evaluate the effect of postoperative use of octreotide on the outcomes after PD. This is a prospective randomized controlled trial for postoperative use of octreotide in patients undergoing PD. Patients with soft pancreas and pancreatic duct < 3 mm were randomized to 2 groups. Group I did not receive postoperative octreotide. Group II received postoperative octreotide. The primary end of the study is to compare the rate of POPF. A total of 104 patients were included in the study and were divided into two randomized groups. There were no significant difference in overall complications and its severity. POPF occurred in 11 patients (21.2%) in group I and 10 (19.2%) in group II, without statistical significance (P = 0.807). Also, there was no significant differences between both groups regarding the incidence of biliary leakage (P ...

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. 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 t...

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). 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 pat...

Hepatic hemangioma (HH) is the most common benign solid tumor of the liver. The aim of this study is to review our experiences of surgical treatment for giant HH and to show the impact of HH size and type of surgical resection on surgical outcomes. This is a retrospective study of the cases who underwent surgery for giant HH during the period from January 2000 to April 2017. Elective surgery was performed for 144 patients who had giant HH. The median diameter of resected HH was 10 cm (5-31 cm). Enucleation was performed for 92 (63.9%) patients and anatomical resection was required in 52 (36.1%) patients. No statistical difference between enucleation and resection as regards intraoperative and postoperative findings. The amount of intraoperative blood loss is significantly more in HH > 10 cm (300 vs. 575 ml, P = 0.007), the need of blood transfusion was significantly more in HH > 10 cm (P = 0.000), and the operation time was significantly longer in HH > 10 cm (120 vs. 180 mi...

To evaluate the evolution, trends in surgical approaches and reconstruction techniques, and important lessons learned from performing 1000 consecutive pancreaticoduodenectomies (PDs) for periampullary tumors. 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). 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 p...

Liver resection is the main treatment for hepatocellular carcinoma (HCC) patients with sufficient liver reserve. However, the long-term outcomes are dismal because the recurrence rate is high, especially in cirrhotic patients. The role of platelets as a predictive factor for HCC recurrence is still controversial. The aim of this study was to assess the influence of the preoperative platelet count on HCC recurrence after liver resection in patients with liver cirrhosis. Between 2004 and 2013, 233 HCC patients with pathologically proven liver cirrhosis underwent liver resection and were enrolled in this study. Recurrence occurred in 125 patients (53.6%), predominantly within the remnant liver (100 patients, 42.9%). The 1-, 3-, and 5-year disease-free survival (DFS) rates were 71.4%, 48.1%, and 40.5%, respectively. The predictive factors for DFS were analyzed with Cox's proportional hazard regression model. In the multivariable analysis, the preoperative platelet count (p = 0.021) ...

Although the mortality and morbidity of pancreaticoduodenectomy (PD) have improved significantly over the past years, the concerns for elderly patients undergoing PD are still present. Furthermore, the frequency of PD is increasing because of the increasing proportion of elderly patients and the increasing incidence of periampullary tumors. This study aimed to analyze the outcomes of PD in elderly patients. We studied all patients who had undergone PD in our center between January 1995 and February 2015. The patients were divided into three groups based on age: group I (patients aged <60 years), group II (those aged 60 to 69 years) and group III (those aged ≥70 years). The primary outcome was the rate of total postoperative complications. Secondary endpoint included total operative time, hospital mortality, length of postoperative hospital stay, delayed gastric emptying, re-exploration, and survival rate. A total of 828 patients who had undergone PD for resection of periampullary tumor were included in this study. There were 579 (69.9%) patients in group I, 201 (24.3%) in group II, and 48 (5.8%) in group III. The overall incidence of complications was higher in elderly patients (25.9% in group I, 36.8% in group II, and 37.5% in group III; P=0.006). There were more patients complicated with delayed gastric emptying in group II compared with the other two groups. There was no significant difference in the incidence of postoperative pancreatic fistula, biliary leakage, pancreatitis, pulmonary complications and hospital mortality. PD can be performed safely in selected elderly patients. Advanced age alone should not be a contraindication for PD. The outcome of elderly patients who have undergone PD is similar to that of younger patients, and the increased rate of complications is due to the presence of associated comorbidities.

Introduction Living donor liver transplantation (LDLT) is a valuable option for expanding 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 hasn't been studied. In this study, we examined the difference in rejection rates between LDLT from genetically related (GR) donors and genetically unrelated (GUR) donors. Patients and Methods All cases that underwent LDLT during the period from May 2004 till May 2014 were included in the study. The study group was divided into 2 groups; LDLT from GR donors and LDLT from GUR donors. Results Three-hundred and eight patients were included in the study; 214 from GR donors and 94 from GUR donors. HLA typing wasn't 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 GR group was 17.4%, and in GUR group was 26.3% (p-value= 0.07). However, there was a significant difference in the incidence of chronic rejection between the 2 groups; 7% in GR group and 14.7% in GUR group (p-value= 0.03). In terms of overall survival, there was no significant difference between both groups. Conclusion LDLT from GUR donors is not associated with higher incidence of ACR. However, CR was significantly lower when grafts are procured from GR donors. HLA matching may be recommended before LDLT from GUR donors. This article is protected by copyright. All rights reserved.

The aim of this study was to evaluate the clinical and oncological outcomes after laparoscopic liver resection (LLR) in patients with hepatitis B and C virus-related hepatocellular carcinoma (HCC) with Child B or C cirrhosis. Between January 2004 and December 2013, LLR was performed in 232 patients with HCC. Of these, 141 patients also had pathologically proven cirrhosis. Sixteen patients with hepatitis B and C virus-related HCC with Child B or C cirrhosis were included in the study. Thirteen (81.3%) patients had Child B disease and three (18.8%) patients had Child C disease. The median operation time was 215 min, the median estimated blood loss was 350 mL, and the median hospital stay was eight days. Three patients (18.8%) experienced complications after surgery. There was no postoperative mortality or reoperation. The mean follow-up period was 51.6 months. HCC recurred in eight (50%) patients: seven intrahepatic recurrences and one extrahepatic recurrence. The treatments for recur...

ABSTRACT Liver resection in cirrhotic patients reported to have higher morbidity and mortality rates compared to non-cirrhotic patients. Recently, there is increased acceptance of laparoscopic approach in liver surgery. However, few reports evaluated laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) in cirrhotic patients. The aim of this study is to evaluate our experience of LLR for HCC and to compare perioperative and long-term outcomes between patients with and without liver cirrhosis (LC). A retrospective analysis of 232 patients who underwent LLR for HCC between 2004 and 2013 was carried out. Patients were divided into two groups according to the pathological status of their liver parenchyma, in terms of presence or absence of LC. LC group had 141 patients, and non-LC group had 91 patients. There were no statistically significant differences between both groups regarding operation time, blood loss, transfusion requirements, intraoperative complications, hospital stay, and postoperative complications. Long-term oncologic outcomes were comparable between both groups regarding the recurrence rates (p = 0.067), overall survival (OS) rates (p = 0.908), and disease-free survival (DFS) rates (p = 0.197). The 1-, 3-, 5-, and 7-year OS were 91.7, 85.5, 79.4, and 70.1 % in LC group, and 93.9, 86, 79.5, and 72.3 % in non-LC group. The 1-, 3-,5-, and 7-year DFS were 75.3, 52.4, 42.6, and 32.7 % in LC group, and 74.1, 57.6, 55.3, 50.2 % in non-LC group. LLR for HCC is feasible in patients with LC. Cirrhotic patients showed comparable perioperative and long-term outcomes to non-cirrhotic patients.

We report the first case series from Africa and the Middle East on choledochal cyst, a disease which shows significant geographical distribution with high incidence in the Asian population. In this study, the epidemiological data of the patients are presented and analyzed. Attention was paid to diagnostic imaging and its accuracy in the diagnosis and classification of choledochal cyst. Most cases of choledochal cyst disease have type I and IV-A cysts according to the Todani classification system, which support the etiological theories of choledochal cyst, especially Babbitt's theory of the anomalous pancreaticobiliary duct junction, which are clearly stated. The difficulties and hazards of surgical management and methods used to avoid operative complications are clarified. Early and late postoperative complications are also included. This study should be followed by multicenter studies throughout Egypt to help assess the incidence of choledochal cysts in one of the largest popul...

We report our experience with potential donors for living donor liver transplantation (LDLT), which is the first report from an area where there is no legalized deceased donation program. This is a single center retrospective analysis of potential living donors (n = 1004) between May 2004 and December 2012. This report focuses on the analysis of causes, duration, cost, and various implications of donor exclusion (n = 792). Most of the transplant candidates (82.3%) had an experience with more than one excluded donor (median = 3). Some recipients travelled abroad for a deceased donor transplant (n = 12) and some died before finding a suitable donor (n = 14). The evaluation of an excluded donor is a time-consuming process (median = 3 d, range 1 d to 47 d). It is also a costly process with a median cost of approximately 70 USD (range 35 USD to 885 USD). From these results, living donor exclusion has negative implications on the patients and transplant program with ethical dilemmas and a...

Surgical resection is the only hope for patients with cholangiocarcinoma (CC). This study is designed to assess the impact of cirrhosis on the outcome of surgical management for CC. We retrospectively studied all patients who underwent surgical resection for hilar CC. Group I (patients with cirrhotic liver) and Group II (patients with non-cirrhotic liver). Preoperative demographic data, intra-operative data, and postoperative details were collected. Only 102/243 patients (41.9%) had cirrhotic liver. Caudate lobe resection was more frequently performed in the non-cirrhotic group (P = <0.001). There was no difference between both groups regarding intraoperative blood loss and the need for blood transfusion. The median postoperative stay was higher in the cirrhotic group (P = 0.063). The incidence of early postoperative liver cell failure was significantly higher in the cirrhotic group (P = <0.001). Cirrhosis was associated with significantly lower overall survival (P = <0.001). Patients with concomitant liver cirrhosis and hilar CC should not be precluded from surgical resection and should be considered for resection at high volume centers with expertise available to manage liver cirrhosis. The incidence of early postoperative liver cell failure was significantly higher in the cirrhotic group.