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Highlights • 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 of solitary recurrent HCC is a safe option. • It is associated with low morbidity and expected to have a good long-term survival., Introduction 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. Presentation 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. Discussion 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. Conclusion 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.

Introduction: Living donor liver transplantation (LDLT) is a complex surgery with high risk for massive bleeding and blood component transfusion. This retrospective study investigated the effect of adopting ROTEM based transfusion algorithm on blood products transfusion practice among LDLT recipients and the effect of this change on patient outcome. Material and methods: Data of 216 patients with predicted intraoperative massive bleeding (blood loss ≥70 ml blood/kg, or blood loss >150 ml/min with hemodynamic affection with continuing need for transfusion) were collected from our database. Patients were divided into two groups according to transfusion protocol applied; Pre-ROTEM group (n = 95), ROTEM group (n = 121). Basal characteristics, blood component transfusion, graft outcome and patient outcome (28-day mortality and one-year mortality) were compared between the two groups. Results: Transfused packed red blood cells (PRBCs) units, fresh frozen plasma (FFP) units, and application of massive transfusion protocol (MTP) were significantly lower in the ROTEM group compared to pre-ROTEM group [8(7) vs 4.5(5), p

Background Reduction of anesthesia cost has become a necessity, especially in developing countries. Recently, automated control of end-tidal sevoflurane concentration (EtSev) has been proposed as a new technique with both cost-effectiveness and safety profiles. In this study, sevoflurane consumption (primary outcome variable) was evaluated during living donor hepatectomy using automated control of EtSev (EtC) at fresh gas flow (FGF) of 0.5 and 2 L/min compared to manual control (MC) technique at FGF of 2 L/min. Materials and methods Prospective, randomized, controlled trial including 60 Potential donors scheduled for living donor right hepatectomy. patients were randomized into 3 equal groups (according to target control of sevoflurane), MC group, EtC-2L group, and EtC-0.5L group. In MC group: FGF was set to 2 L/min, inspired concentration of Sevoflurane (FiSev) was set to 1.5–2% in 0.4 fractional inspired oxygen concentration (FiO2), while in EtC-2L group: FGF was set to 2 L/min, EtSev was set to 1–1.5% with end tidal oxygen concentration (EtO2) target of 0.35. In EtC-0.5L group, FGF was set to minimal flow and EtSev target to 1–1.5% and EtO2 target of 0.35. Anesthetic gases consumption (sevoflurane ml, Oxygen L, and air consumption L) per anesthesia hour were recorded at the end of surgery. Other recorded data included intraoperative hemodynamics, the number of user adjustments, and extubation time. Results Significant reduction in sevoflurane consumption when EtC-0.5L is used (4.2 ± 1.3 ml/h, 12.6 ± 2.6 ml/h, and 15 ± 2.9 ml/h respectively, p . 0.001). Also, a significant decrease in overall numbers of user adjustments between the three groups (8 times for EtC-0.5L group, 7 times in EtC-2L group, 22 times for MC group, p . 0.008) was observed. Conclusion automated control of EtSev during anesthesia of living donor hepatectomy significantly lowers sevoflurane consumption and decreases required user interventions without deleterious effect on patient safety.

Introduction.The possible risk factors for chronic kidney disease in transplant recipients have not been thoroughly investigated after living-donor liver transplantation.Material and Methods.A retrospective cohort study of consecutive adults who underwent living-donor liver transplantation between May 2004 and October 2016, in a single center, was conducted. Kidney function was investigated successively for all the patients throughout the study period, with 12 months being the shortest follow-up. Postoperative renal dysfunction was defined in accordance with the Chronic Kidney Disease Epidemiology Collaboration criteria. The patients’ demographic data, preoperative and intraoperative parameters, and outcomes were recorded. A calcineurin inhibitor-based immunosuppressive regimen, either tacrolimus or cyclosporine, was used in all the patients.Results.Of the 413 patients included in the study, 33 (8%) who survived for ≥1 year experienced chronic kidney disease 1 year after living-donor liver transplantation. Twenty-seven variables were studied to compare between the patients with normal kidney functions and those who developed chronic kidney disease 1 year after living-donor liver transplantation. Univariate regression analysis for predicting the likelihood of chronic kidney disease at 1 year revealed that the following 4 variables were significant: operative time,P< 0.0005; intraoperative blood loss,P< 0.0005; preoperative renal impairment,P= 0.001; and graft-to-recipient weight ratio (as a negative predictor),P< 0.0005. In the multivariate regression analysis, only 2 variables remained as independent predictors of chronic kidney disease at 1 year, namely, operative time with a cutoff value of ≥714 minutes and graft-to-recipient weight ratio as a negative predictor with a cutoff value of Conclusion.In this study, prolonged operative time and small graft-to-recipient weight ratio were independent predictors of chronic kidney disease at 1 year after living-donor liver transplantation.

Highlights • Hepatic venous outflow obstruction is a rare serious complication after liver transplantation. • Hepatic venous outflow obstruction may result in graft loss and recipient death. • We report the use of the foley catheter to temporary fix the graft and correct the hepatic venous outflow obstruction. • It is a simple, cheap and safe device to correct the hepatic venous outflow obstruction. • It could be easily monitored and removed under Doppler US without any device related complications., 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.