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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.

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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.

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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.

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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.

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BACKGROUND AND STUDY AIMS: A study was undertaken to describe the management of post-cholecystectomy biliary fistula according to the type of cholecystectomy. PATIENTS AND METHODS: A retrospective analysis of 111 patients was undertaken. They were divided into open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) groups. RESULTS: Of the 111 patients, 38 (34.2 %) underwent LC and 73 (65.8 %) underwent OC. Endoscopic retrograde cholangiopancreatography (ERCP) diagnosed major bile duct injury (BDI) in 27 patients (38.6 %) in the OC group and in 3 patients (7.9 %) in the LC group (P = 0.001). Endoscopic management was not feasible in 15 patients (13.5 %) because of failed cannulation (n = 3) or complete ligation of the common bile duct (n = 12). Endoscopic therapy stopped leakage in 35 patients (92.1 %) and 58 patients (82.9 %) following LC and OC, respectively, after the exclusion of 3 patients in whom cannulation failed (P = 0 0.150). Major BDI was more commonly detected after OC (P < 0.001). Leakage was controlled endoscopically in 77 patients (98.7 %) with minor BDI and in 16 patients (53.3 %) with major BDI (P < 0.001). CONCLUSIONS: Major BDI is more common in patients presenting with bile leakage after OC. ERCP is the first-choice treatment for minor BDI. Surgery plays an important role in major BDI. Magnetic resonance cholangiopancreatogrphy (MRCP) should be used before ERCP in patients with bile leakage following OC or converted LC.

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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.

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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 an economic impact. Many strategies are adopted by other centers to expand the donor pool; however, they are not all applicable in our locality. We conclude that an active legalized deceased donor transplantation program is necessary to overcome the shortage of available liver grafts in Egypt.

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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.

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BACKGROUND/AIMS: Laparoscopic cholecystectomy (LC) combined with intraoperative endoscopic sphincterotomy (IOES) was compared to LC with laparoscopic common bile duct exploration (LCBDE) to define the best single-session minimally invasive treatment for cholecystocholedocholithiasis. METHODS: Between June 2009 and December 2010, patients with gallstones and common bile duct (CBD) stones diagnosed by preoperative ultrasonography and magnetic resonance cholangiopancreatography were randomized to LC-LCBDE or LC-IOES. The primary end point was complete clearance of CBD of stones. The secondary end points were operation time, conversion rate, length of hospital stay, complications and mortality. RESULTS: Two hundred and twenty-six patients were eligible. They were randomized to LC-LCBDE (n = 115) and LC-IOES (n = 111). There was no statistically significant difference in the success rate of CBD clearance between the two interventions (92% for LC-LCBDE vs. 97.2% for LC-IOES with a p value >0.05). There were no differences between the two groups in terms of surgical time and postoperative length of stay. Pancreatitis and bleeding sphincterotomy were significantly more prevalent in the LC-IOES group, while bile leakage and retained CBD stones were significantly more prevalent in the LC-LCBDE group. CONCLUSION: Both LC-IOES and LC-LCBDE were shown to be safe, effective, minimally invasive treatments for cholecystocholedocholithiasis, but the former option may be preferred when facilities and experience in endoscopic therapy exist.

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