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Objectives: The aim of this study is to present updated data on liver transplantation (LT) for hepatocellular carcinoma (HCC) of Inonu University, Liver Transplantation Institute, one of the largest volume liver transplant centers in the world. Methods: The data of 492 LT patients with HCC were analyzed retrospectively from the databank which is recorded prospectively and sequentially. Post-transplant recurrence rates and patient survival according to Milan, Malatya and Expanded Malatya criteria were calculated. Milan Expansion rate of the Malatya and Expanded Malatya criteria were also calculated. Results: Median follow-up period of the total cohort was 11.1±1.6 years (8.0-14.2, 95% CI) and the recurrence rate was 18.5 % (91/492). 5-year OS according to Milan, Malatya and Expanded Malatya criteria in our cohort were 80%, 79.3% and 78.4%, respectively. Post-transplant recurrence rates within these criteria were 3.2%, 3.8%, and 4.7%, respectively. Milan expansion rates were 25.2% for Malatya criteria and 35.2% for Expanded Malatya criteria. Conclusion: Milan criteria can be expanded reasonably by Expanded Malatya criteria. Low GGT and low AFP are good prognostic biomarkers that predict survival following LT in patients with HCC. Patients within Expanded Malatya Criteria had 78.4% 5-year OS, 4.7% post-transplant recurrence rate and Expanded Malatya criteria expanded the Milan criteria by 35.2%. Thus, 88 patients were beyond Milan criteria and were within Expanded Malatya criteria and so had an opportunity for LT. [ABSTRACT FROM AUTHOR]

Background: Treatment of established portal vein narrowing after living donor hepatectomy is challenging. We aimed to present a new approach termed the "elbow patch reconstruction technique" to correct the narrowed remnant portal vein just or late after right lobe living donor hepatectomy. Methods: Demographic and clinical data of 12 living liver donors with narrowed remnant portal veins and treated with the "elbow patch reconstruction technique" were prospectively collected and retrospectively evaluated. Anatomic variation of the portal vein was defined in accordance with the Nakamura classification; six of the living liver donors had type A, three had type B, and the remaining three had type C. In eight of the living liver donors with a narrowed remnant portal vein, diagnosis was detected by intraoperative Doppler ultrasonography and visual inspection by experienced transplant surgeons in the living donor hepatectomy procedure. In the remaining four living liver donors, diagnosis was performed postoperatively when elevation of liver enzymes was noticed during the routine liver function test and Doppler US. The diagnosis was confirmed by multidetector computed tomography. Results: Data from nine males and three females aged 18 to 54 years were analyzed. All of the living liver donors were followed up for a median of 1710 days (min-max: 1178–4447 days; IQR: 1516 days), and none of the living liver donors had any structural or functional complications in the portal vein. Conclusions: Narrowing remnant portal veins are rare, but they are a life-threatening complication in living liver donors, and this condition requires urgent management. Image guided interventions and narrowed segment resection with end-to-end anastomosis using a vascular graft carried a potential risk for thrombosis and restenosis. To avoid these complications, we shared a technique named "elbow patch reconstruction technique". This technique can be very effective in relieving the narrowing of the remnant portal vein after right lobe living donor hepatectomy. [ABSTRACT FROM AUTHOR]

Background and Aim: Patients with hepatocellular carcinoma (HCC) are managed in various hospital departments, which complicates the assessment of the overall picture. In our large liver transplant institute, we evaluate all HCC patients in a weekly multi-disciplinary liver tumor board, and their data are prospectively collected in an institutional HCC database to evaluate HCC causes, tumor features, treatments, and survival. Materials and Methods: Baseline data for patients (n=1322) were prospectively recorded, including hepatitis status, routine clinical serum parameters, radiological assessment of maximum tumor diameter (MTD), tumor number, presence of macroscopic portal vein thrombosis (PVT), and serum alpha-fetoprotein (AFP) levels. Results: Cirrhosis was found in 81.1% of patients; 58.5% had hepatitis B virus (HBV), 14.9% hepatitis C virus (HCV), 8.9% cryptogenic cirrhosis, and less than 2% had alcoholism. MTD was <5 cm in 61.95% of patients, and 31.9% had PVT. The median overall survival was more than six-fold greater for the 444 liver transplant patients than for those without surgery. Transplanted patients had smaller tumors, whereas larger tumors (MTD >10 cm) were primarily in the no-surgery group. Parallel differences were found for AFP levels (highest in the no-surgery group). PVT was present in similar proportions (25.0% for transplant, 28.0% for no-surgery). The presence of cirrhosis was higher in the transplant group. MTD and levels of serum AFP, gamma-glutamyl transferase (GGT), and blood platelets were prognostic parameters for transplant. Furthermore, AFP and GGT levels were prognostic for transplanted PVT patients. Only albumin was prognostic in the no-surgery patients. Conclusion: Transplanted HCC patients have longer survival, smaller tumors, and more severe liver damage than no-surgery patients. Prognostic subsets were identified within the surgery and the PVT groups. [ABSTRACT FROM AUTHOR]

Background and Aim: Alpha-fetoprotein (AFP), an oncofetal protein and biomarker in hepatocellular carcinoma (HCC), has unclear roles and actions. To evaluate the relationships between AFP, liver function tests, and HCC aggressiveness. Materials and Methods: A retrospective analysis of an HCC patient database was conducted to examine the relationships between baseline serum AFP values, liver function tests, and tumor characteristics. Results: Statistically significant positive trends were observed between AFP levels and both AST and bilirubin, along with negative trends between AFP and albumin. Significant correlations were also found between AFP and MTD, multifocality, and PVT. Increases in MTD, multifocality, and PVT were noted even at low AFP levels, indicating both AFP-independent and AFP-dependent processes. However, these parameter changes were minimal compared to the substantial changes in AFP levels. Relationships between AFP-related liver and tumor characteristics were found to be similar but inverse to those for albumin, with normal albumin levels associated with more favorable tumor characteristics. Additionally, serum levels of albumin and AFP were inversely related. Conclusion: AFP and albumin levels significantly, but inversely, correlate with tumor parameters, suggesting that albumin may suppress HCC functions and could serve as a potential prognostic marker. [ABSTRACT FROM AUTHOR]

Objectives: It is known that obesity is associated with increased complications and early recurrence after cancer surgery. This may also be the case in patients with hepatocellular carcinoma (HCC) who treated with liver transplantation (LT). Methods: This retrospective observational study aimed to investigate the potential impact of pre-transplant body mass index (BMI) on tumor recurrence and disease-free survival (DFS) in patients who underwent LT for HCC. The study analyzed data from 423 HCC patients who underwent LT at the Inonu University Liver Transplant Institute between 2006 and 2023. Results: The median age of the 423 patients included in the study was 56 years (range: 18-72), with 367 (86.8%) of them being male. The median BMI was 26 kg/m2 (range: 16.4-46.9). The recurrence rates were 24.3% in the non-obese group, 18.3% in the overweight group, and 16.7% in the obese group (p=0.239). The mean DFS durations were 8.4 years ± 0.6 in the non-obese group, 8.7 years ± 0.5 in the overweight group, and 9.7 years ± 0.9 in the obese group (p>0.05). Conclusion: This study suggests that obesity should not be considered a predictive factor for HCC recurrence when selecting candidates for liver transplantation. [ABSTRACT FROM AUTHOR]

Alveolar Echinococcosis (AE) is a zoonotic infestation with aggressive behavior1. Most patients are asymptomatic in the early period, and therefore they are often detected incidentally during radiological examinations performed for other reasons.[1] AE is considered a tumor-like disease because the disease grows in the liver by invading the surrounding tissue and metastasizes to distant organs in some patients.[2] Therefore, resection is recommended in surgical treatment according to oncological principles, that is, with clean surgical margins.[3] The present report aims to present our approach to a patient diagnosed with alveolar echinococcosis, which occupied the right lobe of the liver and included the part of the left hepatic vein flowing into the IVC, was prepared for liver transplantation and was saved from liver transplantation by liver resection. [ABSTRACT FROM AUTHOR]

Summary: This study aimed to demonstrate the efficacy of our diagnostic and therapeutic management algorithm and catheter‐assisted (percutaneous transhepatic biliary tract drainage [PTBD] or transanastomotic feeding tube) hepaticojejunostomy (HJ) procedures in living liver donors (LLDs) with biliary complications. Living donor hepatectomy (LDH) was performed between September 2005 and April 2021 in 2 489 LLDs. Biliary complications developed in 220 LLDs (8.8%), 136 of which were male, and the median age was 29 (interquartile range [IQR]: 12) years. Endoscopic sphincterotomy ± stenting was performed in 132 LLDs, which was unsuccessful in 9 LLDs and required HJ. Overall, 142 LLDs underwent interventional radiologic procedures. Fifteen LLDs with biliary complications underwent HJ (PTBD catheter = 6 and transanastomotic feeding tube = 9) at a median of 44 days (IQR: 82). Following HJ, 14 LLDs did not have any complications throughout the median follow‐up period of 1619 days (IQR: 1454). However, percutaneous dilation for HJ anastomotic stricture was performed in one patient. Biliary complications are very common following LDH; therefore, surgeons in the field should have a low threshold to perform HJ for biliary complications that persist after other treatments. Our catheter‐assisted HJ techniques demonstrated a high success rate and aided HJ in a hostile abdomen during revisional surgery. [ABSTRACT FROM AUTHOR]

Background/Aim: With the COVID‐19 pandemic, managing the process of solid organ transplantation has become a significant matter for transplant centres. In this study, we report our experiences on evaluating the effects of COVID‐19 in patients with recent liver transplants. Materials and Methods: We evaluated patients who received liver transplants during three close consecutive periods of time. For transplants conducted between October 1 and December 31, 2019, January 1 and March 10, 2020 and March 11 and June 22, 2020, the lung tomographies of patients were inspected for radiological signs of viral pneumonia. For patients after March 11, 2020, the hospital's electronic database system was scanned for preoperative and postoperative SARS‐CoV‐2 testing from Real‐time Polymerase Chain Reaction (RT‐PCR) of the respiratory tract samples. Results: A total of 149 patients over the age of 18 who received liver transplants at our centre between October 1, 2019 and June 22, 2020 were evaluated. During this time span, our centre conducted liver transplants on patients from 34 different provinces and also abroad. Within this time period, a total of nine patients had respiratory samples with a positive SARS‐CoV‐2 RT‐PCR test. PCR of respiratory tract samples was performed in 21 (14%) patients to identify the other potential infective agents in the respiratory tracts; Rhinovirus and Influenza A were detected in two and respiratory syncytial virus (RSV) was detected in one patient. During the transplant periods, 99 (67.1%) patients were evaluated with computed tomography (CT). The CT findings of 18 (12%) patients were consistent with viral pneumonia. There was a statistically significant difference between the groups only in terms of air bronchogram findings (P =.012). Conclusion: The clinical status of our short‐term liver transplant patients was far better than we originally anticipated, but it remains obvious that the necessary precautions should continue to be taken. [ABSTRACT FROM AUTHOR]

Aim: To analyze developing infections after living donor hepatectomy (LDH) in living liver donors (LLDs). Methods: Demographic and clinical characteristics of 1106 LLDs were retrospectively analyzed in terms of whether postoperative infection development. Therefore, LLDs were divided into two groups: with (n = 190) and without (n = 916) antimicrobial agent use. Results: The median age was 29.5 (min‐max: 18‐55). A total of 257 (23.2%) infection attacks (min‐max: 1‐8) was developed in 190 (17.2%) LLDs. The patients with the infection that were longer intensive care unit (ICU) and hospital stays, higher hospital admissions, emergency transplantation, invasive procedures for ERCP, PTC biloma, and abscess drainage, and the presence of relaparatomies and transcystic catheters. Infection attacks are derived from a 58.3% hepatobiliary system, 13.2% urinary system, 6.6% surgical site, and 5.8% respiratory system. The most common onset symptoms were fever, abdominal pain, nausea, and vomiting. A total of 125 positive results was detected from 77 patients with culture positivity. The most detected microorganisms from the cultures taken are Extended‐Spectrum β‐lactamases (ESBL) producing Klebsiella pneumonia (16.8%) and Escherichia coli (16%), Methicillin‐Resistant Staphylococcus aureus [(MRSA) (9.6%)], Methicillin‐susceptible Saureus [(MSSA) (9.6%)], and Pseudomonas aeruginosa (8.8%), respectively. The average number of ICU hospitalization days was 3 ± 2 (min 1‐max 30, IQR:1) and hospitalization days was 14 ± 12 (min 3‐max 138, IQR: 8). All infection attacks were successfully treated. No patients died because of infection or another surgical complication. Conclusion: Infections commonly observed infected biloma, cholangitis, and abscess arising from the biliary system and other nosocomial infections are the feared complications in LLDs. These infections should be managed multidisciplinary without delay and carefully. [ABSTRACT FROM AUTHOR]

Purpose: Hepatocellular carcinoma is the most common primary cancer of the liver. It is almost always associated with cirrhosis and it is usually diagnosed in later stages of the disease. Furthermore, recurrence rate following liver transplantation ranges between 15 and 30%. The most important factor determining the recurrence is vascular invasion. Methods: In this review, the issue of microvascular invasion causing hepatocellular carcinoma recurrence is reviewed. Macroscopic vascular invasion is almost easy to diagnose on radiologic evaluation. However, microscopic vascular invasion is almost always diagnosed with pathologic evaluation. On the other hand, microscopic vascular invasion is associated with early recurrences and reduced disease-free survival. The type of vessel that is invaded determines the nature of the spread of the tumor cells. Invasion of the hepatic venous tributaries leads to systemic metastasis whereas portal venous invasions lead to intrahepatic spread of the tumor. Microscopic vascular invasion should be diagnosed before liver transplantation or liver resection in order to deliver the appropriate therapy to the patients. Results: Yet, there is no ideal marker to suggest microscopic vascular invasion before any intervention. Markers such as alpha-fetoprotein, des carboxy prothrombin, or gamma-glutamyl transferase have been found to be correlated with microscopic vascular invasion. These parameters are not very efficient to be used in routine clinical practice. Conclusion: Therefore, further research is needed to define ideal marker associated with microscopic vascular invasion. [ABSTRACT FROM AUTHOR]

Aim: Prımary hyperparathyroidism (PHPT) is a clinical entity characterized by an excess synthesis of parathormone due to one or more autonomic parathyroid gland. The present study aims to evaluate the outcomes of parathyroidectomies performed due to PHPT. Material and Methods: The results of 52 parathyroidectomies performed due to PHPT between September 2014 and October 2018 were retrospectively evaluated for demographic, clinical, imaging and pathologic characteristics. Results: Fifty-two patients with primary hyperparathyroidism were included in the study. The mean age of the patients was 50±14.5 years. Forty-three (82.9%) patients were female and 9 (17.4%) were male. The most common complaints at admission were generalized muscle and bone pain in 13 patients (15.3%). In 2 patients (3.8%) osteoporosis and another 2 (3.8%) patients, nephrolithiasis was identified. Thirty-five (67.3%) patients had no complaints. The mean preoperative calcium level was 11.21±0.88 mg/dl. Mean preoperative phosphate level was 2.58±0.72 mg/dl. Mean preoperative parathormone level was 278.65±317.67 pg/ml. Technetium 99m-sestamibi scintigraphy was obtained for 41 patients. Cervical ultrasonography was performed in 43 patients. The surgical localization of the parathyroid adenoma showed that the accuracy of ultrasonography was 60.4% whereas the accuracy of Technetium 99m-sestamibi scintigraphy was 80.4%. Three of the 12 (25%) patients with no localization in ultrasonography had parathyroid hyperplasia as the pathologic diagnosis. There were two patients in whom ultrasonography and scintigraphy could not localize the pathologic parathyroid tissue and all of them (100%) were found to have parathyroid hyperplasia as the pathologic evaluation. Pathologic evaluation of the surgical specimens showed that there was adenoma in 40 patients (76.9%), hyperplasia in 5 (9.6%), normal parathyroid tissue in 5 (9.6%), tumor with undetermined biologic potential in 1 patient (1.9%) and adenomatous parathyroid tissue in 1 patient (1.9%). In fifteen patients (28.8%) concomitant total thyroidectomy, right lobectomy in 7 patients (13.4%)and left lobectomy in 4 patients (7.6%) were performed. Conclusion: Parathyroid adenoma can be localized in places other than the expected locations; despite the advances in imaging technologies. Surgeons experience and accurate localization before the operation are important for a successful parathyroid operation. If scintigraphy and ultrasonography cannot localize the pathologic parathyroid tissue, hyperplasia should be suspected. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To determine the relationship between a transplant center's experience and life‐threatening or nearly life‐threatening complications during living donor hepatectomy (LDH). Methods: The medical records of 1140 patients who underwent LDH were analyzed. To determine the relationship between life‐threatening complications and a transplant center's experience, the following comparisons between LDH cases were performed: first 100 vs subsequent 100; first 100 vs subsequent 1040; first 200 vs subsequent 940; right hepatectomy vs left hepatectomy; and first 5 years of experience vs subsequent 5 years. Results: A total of 36 life‐threatening or nearly life‐threatening complications developed in 34 of 1140 (2.98%) healthy individuals undergoing LDH. Of these, 5 occurred intraoperatively, 26 within 1 month, and 5 beyond 1 month. The most common complications were biliary problems and postoperative bleeding. None of the donors died at follow‐up. One donor underwent deceased donor liver transplantation (DDLT) for severe hepatic failure. Only 2 comparisons were significantly different with regard to life‐threatening complications: the first 100 vs the subsequent 1040 (P = .03) and the first 200 vs the subsequent 940 (P = .01). Conclusion: This study indicates that the incidence of life‐threatening or nearly life‐threatening complications are reduced by increased center experience (>200 LDHs). [ABSTRACT FROM AUTHOR]

Postoperative adhesions (PAs) are usually clinically asymptomatic. Symptomatic cases, however, may present with chronic abdominal and pelvic pain, infertility, and intestinal obstruction; and they may require intensive, costly therapeutic modalities. Various agents have been used to prevent PAs, but the results indicate general suboptimal effectiveness. Our objective was to evaluate the comparative effectiveness of two pharmacologic agents for preventing PA: nadroparine calcium (low-molecular-weight heparin, or LMWH) and aprotinin, as well as a barrier agent, sodium hyaluronate/carboxymethycellulose (SCMC). Our subjects were 40 male Wistar-Albino rats divided into four groups, each consisting of 10 rats, which underwent standard cecal abrasion preceding midline laparotomy. In the control group (group 1) 1 ml of 0.9% NaCl was administered intraperitoneally before abdominal closure. In the three preventive groups, 100 U AXa (anti factor X activity) LMWH, 1800 IU aprotinin, and SCMC were administered intraperitoneally to groups 2, 3, and 4, respectively. Relaparotomy was performed on the 14th postoperative day. Visceral and abdominal wall adhesions were scored in a blinded fashion. The adhesion scores (mean ± SD) for groups 1, 2, 3, and 4 were 2.00 ± 0.67, 0.6.00 ± 0.84, 1.10 ± 0.74, and 0.20 ± 0.42, respectively. The differences in the adhesion scores among all three preventive groups (groups 2, 3, 4) were statistically significant when compared with the control group (p<0.001,p= 0.017,p<0.001, respectively). Intraperitoneal SCMC and administration of LMWH were more effective than giving aprotinin. [ABSTRACT FROM AUTHOR]

Authors describe a case of 78 years old female who presented with the right upper abdominal pain. Ultrasonography showed a gallstone. The patient underwent laparascopic cholecystectomy. The laparoscopic procedure was converted to laparotomy because the adhesions between gallblader and stomach could not be dissected on the correct plane. A gallstone impacted to the stomach antrum wall was observed during dissection. When dense adhesions are noted between the gallbladder and stomach during a routine laparascopic cholecystectomy, one should consider an impacted gallstone on the gastric wall via a cholecystogastric connection. [ABSTRACT FROM AUTHOR]