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Dar FS, Abbas Z, Ahmed I, Atique M, Aujla UI, Azeemuddin M, Aziz Z, Bhatti ABH, Bangash TA, Butt AS, Butt OT, Dogar AW, Farooqi JI, Hanif F, Haider J, Haider S, Hassan SM, Jabbar AA, Khan AN, Khan MS, Khan MY, Latif A, Luck NH, Malik AK, Rashid K, Rashid S, Salih M, Saeed A, Salamat A, Tayyab GUN, Yusuf A, Zia HH, Naveed A. National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma. World J Gastroenterol 2024; 30:1018-1042. [PMID: 38577184 PMCID: PMC10989497 DOI: 10.3748/wjg.v30.i9.1018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/03/2024] [Accepted: 01/29/2024] [Indexed: 03/06/2024] Open
Abstract
A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.
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Affiliation(s)
- Faisal Saud Dar
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Zaigham Abbas
- Department of Hepatogastroenterology and Liver Transplantation, Dr. Ziauddin University Hospital, Karachi 75600, Sindh, Pakistan
| | - Irfan Ahmed
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
- University of Aberdeen, Aberdeen B24 3FX, United Kingdom
| | - Muhammad Atique
- Department of Pathology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Usman Iqbal Aujla
- Department of Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | | | - Zeba Aziz
- Department of Oncology, Hameed Latif Hospital, Lahore 54000, Pakistan
| | - Abu Bakar Hafeez Bhatti
- Division of Hepatopancreatic Biliary Surgery & Liver Transplantation, Shifa International Hospital, Islamabad 44000, Pakistan
| | - Tariq Ali Bangash
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Shaikh Zayed Hospital and Post Graduate Medical Institute, Lahore 54000, Pakistan
| | - Amna Subhan Butt
- Department of Medicine, Aga Khan University Hospital, Karachi 74800, Pakistan
| | - Osama Tariq Butt
- Department of Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Abdul Wahab Dogar
- Department of Liver Transplant, Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences, Gambat 66020, Pakistan
| | - Javed Iqbal Farooqi
- Department of Medicine & Gastroenterology, Lifecare Hospital and Research Centre, Peshawar 25000, Khyber Pakhtunkhwa, Pakistan
| | - Faisal Hanif
- Department of Hepatopancreatobiliary & Liver Transplant, Bahria International Hospital, Lahore 54000, Pakistan
| | - Jahanzaib Haider
- Department of Surgery, Hepatopancreatobiliary & Liver Transplant, Dow University of Health Sciences, Karachi 74800, Pakistan
| | - Siraj Haider
- Department of Surgery, Hepatopancreatobiliary & Liver Transplant, Dow University of Health Sciences, Karachi 74800, Pakistan
| | - Syed Mujahid Hassan
- Department of Gastroenterology, Hepatology & Nutrition, Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences, Gambat 66020, Pakistan
| | | | - Aman Nawaz Khan
- Department of Radiology, Rehman Medical Institute, Peshawar 25000, Pakistan
| | - Muhammad Shoaib Khan
- Army Liver Transplant Unit, Pak Emirates Military Hospital, Rawalpindi 46000, Pakistan
| | - Muhammad Yasir Khan
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Amer Latif
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Shaikh Zayed Hospital and Post Graduate Medical Institute, Lahore 54000, Pakistan
| | - Nasir Hassan Luck
- Department of Gastroenterology, Sindh Institute of Urology and Transplantation, Karachi 75500, Pakistan
| | - Ahmad Karim Malik
- Department of Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Kamran Rashid
- Rashid Nursing Home and Cancer Clinic, Rashid Nursing Home and Cancer Clinic, Rawalpindi 46000, Pakistan
| | - Sohail Rashid
- Department of Hepatopancreatic Biliary Surgery & Liver Transplant, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Mohammad Salih
- Department of Gastroenterology and Hepatology, Shifa International Hospital, Islamabad 44000, Pakistan
| | - Abdullah Saeed
- Department of Radiology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
| | - Amjad Salamat
- Department of Gastroenterology and Hepatology, Quaid-e-Azam International Hospital, Rawalpindi 44000, Pakistan
| | - Ghias-un-Nabi Tayyab
- Department of Gastroenterology and Hepatology, Post Graduate Medical Institute, Lahore 54000, Pakistan
| | - Aasim Yusuf
- Department of Internal Medicine, Division of Gastroenterology, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore 54000, Pakistan
| | - Haseeb Haider Zia
- Division of Hepatopancreatic Biliary Surgery & Liver Transplantation, Shifa International Hospital, Islamabad 44000, Pakistan
| | - Ammara Naveed
- Department of Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute & Research Centre, Lahore 54000, Pakistan
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Aaraj S, Khan SA, Maroof F, Hussain SZ, Dar FS, Malik MI. Outcome of pediatric living donor liver transplant: Experience from Pakistan; a resource limited setting. Pediatr Transplant 2024; 28:e14634. [PMID: 37936530 DOI: 10.1111/petr.14634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION Liver transplantation (LT) has emerged as a lifesaving modality for many liver diseases in children. Pediatric LT is an established treatment in the Western world but is relatively a new procedure in resource-limited countries like Pakistan. The study aims to highlight the outcomes and survival of pediatric recipients from the first pediatric liver transplant center in Pakistan. METHOD A retrospective analysis of pediatric LT was done from 2012 to 2019. The study was conducted in the Hepatobiliary and liver transplant department of Shifa International Hospital (SIH), Islamabad. A detailed analysis for indications for pediatric LT, survival, and complications was done. RESULTS Forty-five patients under 18 years of age underwent Living donor liver transplant (LDLT) in SIH. Median age was 9 years and M:F of 2:1. Cryptogenic liver disease followed by Wilson disease were the two most common indications of LT. The majority of patients had chronic liver disease 34 (75%) while 11 (24%) had acute liver failure. The right lobe graft was the most common type of graft 19 (42.2%). Thirty days, 1-year, 3-year, and 5-year survival was 77.8%, 75.6%, 73.3%, and 60.6% respectively. Mortality was highest in patients with biliary atresia 4 (33%). Causes of death included pulmonary embolism, sepsis, surgical complications, and acute kidney injury. Mean survival was 88.850 months (±7.899) (CI 73.369-104.331). CONCLUSION Pediatric LDLT has offered disease-free survival for patients. Survival can improve further with nutritional rehabilitation and anticipation and management of post-operative complications.
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Affiliation(s)
- Sahira Aaraj
- Shifa Tameer e Millat University/Shifa College of Medicine, Shifa International Hospital, Islamabad, Pakistan
| | - Sabeen Abid Khan
- Shifa Tameer e Millat University/Shifa College of Medicine, Islamabad, Pakistan
| | - Fatima Maroof
- Shifa Tameer e Millat University/Shifa College of Medicine, Islamabad, Pakistan
| | | | - Faisal Saud Dar
- Section of Gastroenterology, Hepatology and Liver Transplant Centre, Shifa International Hospital, Islamabad, Pakistan
| | - Munir Iqbal Malik
- Shifa Tameer e Millat University/Shifa College of Medicine, Shifa International Hospital, Islamabad, Pakistan
- Section of Gastroenterology, Hepatology and Liver Transplant Centre, Shifa International Hospital, Islamabad, Pakistan
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Khalid A, Khan BA, Syed IA, Faiz Z, Haq I, Khan Y, Rashid S, Dar FS. Donor Safety First: Postoperative Hepatectomy Outcomes in Living Liver Donors. Transplant Proc 2023; 55:2114-2120. [PMID: 37748964 DOI: 10.1016/j.transproceed.2023.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/12/2023] [Accepted: 07/21/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Living donor liver transplantation (LDLT) has become a popular treatment option because some countries lack a deceased organ program and the growing demand for liver transplants. Although postoperative outcomes are similar to deceased donor liver transplants, there is still an element of risk to the donor. The Clavien-Dindo classification system has been used to standardize reporting across different institutions and surgeons to categorize surgical outcomes. METHODS Between January 1, 2022, and December 31, 2022, 207 living donors underwent hepatectomies at our center. All donors underwent a 3-step process of mandatory screening. Postsurgical complications were classified using the Clavien-Dindo classification. RESULTS A total of 207 donor hepatectomies for LDLT were performed during our study period. Most donors (92.8%) were aged between 18 and 39 years. The most common type of graft used was a right lobe without the middle hepatic vein (82.6%). Most donors (91.7%) experienced an intraoperative blood loss of ≤500 mL. A total of 140 patients had an ordinary postoperative course. Grade 1 complications were observed in 16.9%, grade 2 in 12.1%, and grade 3 in 3.4% of the remaining patients. No grade 4 or grade 5 (patient death) complications were observed in this cohort. CONCLUSIONS Living donor liver transplantation remains the most practiced liver transplant surgery in Pakistan. Our findings highlight the safety of the LDLT program with minimal risk of significant complications. The study also underscores the importance of careful screening and monitoring of living donors and the need for standardized reporting of surgical outcomes using the Clavien-Dindo classification system.
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Affiliation(s)
- Abdullah Khalid
- Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Lahore, Pakistan.
| | - Bilal Ahmed Khan
- Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute and Research Center, Lahore, Pakistan
| | - Imran Ali Syed
- Gastroenterology and Hepatology, Pakistan Kidney & Liver Institute and Research Center, Lahore, Pakistan
| | - Zohaa Faiz
- Medical Student, Aga Khan University, Karachi, Pakistan
| | - Ihsan Haq
- Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute and Research Center, Lahore, Pakistan
| | - Yasir Khan
- Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute and Research Center, Lahore, Pakistan
| | - Sohail Rashid
- Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute and Research Center, Lahore, Pakistan
| | - Faisal Saud Dar
- Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute and Research Center, Lahore, Pakistan
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Khan BA, Syed IA, Ulhaq I, Rashid S, Khan MY, Khalid A, Shafi U, Aujla UI, Dar FS. Calcifying Nested Stromal-Epithelial Tumor: An Extremely Rare Hepatic Tumor. ACG Case Rep J 2023; 10:e01163. [PMID: 37799486 PMCID: PMC10550017 DOI: 10.14309/crj.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 08/29/2023] [Indexed: 10/07/2023] Open
Abstract
Calcifying nested stromal-epithelial tumor is a rare hepatic malignancy with approximately 50 cases reported in the literature. Its clinical presentation is nonspecific, and the diagnosis is mainly based on histology which shows nests of spindle and epithelioid cells along with a desmoplastic myofibroblastic stroma containing variable calcification and ossification. In this report, we present a case of a 24-year-old woman with a history of abdominal pain, distension, and dyspepsia. She had a palpable liver with normal liver function test results. Serum alpha-fetoprotein levels were within normal range, and serologies for hepatitis B and C virus remained negative. Radiological investigations (magnetic resonance imaging and computed tomography) showed a large, right hepatic lobe mass with tumor invasion into the right posterior portal vein, but the 2 modalities could not characterize the lesion. Finally, an ultrasound-guided biopsy of the liver lesion provided the diagnosis of calcifying nested stromal-epithelial tumor. The tumor was resected successfully.
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Affiliation(s)
- Bilal Ahmed Khan
- Pakistan Kidney and Liver Institute & Research Center, DHA Phase VI, Lahore, Pakistan
| | - Imran Ali Syed
- Pakistan Kidney and Liver Institute & Research Center, DHA Phase VI, Lahore, Pakistan
| | - Ihsan Ulhaq
- Pakistan Kidney and Liver Institute & Research Center, DHA Phase VI, Lahore, Pakistan
| | - Sohail Rashid
- Pakistan Kidney and Liver Institute & Research Center, DHA Phase VI, Lahore, Pakistan
| | - Muhammad Yasir Khan
- Pakistan Kidney and Liver Institute & Research Center, DHA Phase VI, Lahore, Pakistan
| | - Abdullah Khalid
- Pakistan Kidney and Liver Institute & Research Center, DHA Phase VI, Lahore, Pakistan
| | - Urfa Shafi
- Pakistan Kidney and Liver Institute & Research Center, DHA Phase VI, Lahore, Pakistan
| | - Usman Iqbal Aujla
- Pakistan Kidney and Liver Institute & Research Center, DHA Phase VI, Lahore, Pakistan
| | - Faisal Saud Dar
- Pakistan Kidney and Liver Institute & Research Center, DHA Phase VI, Lahore, Pakistan
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Khalid A, Saleem MA, Ihsan-Ul-Haq, Khan Y, Rashid S, Dar FS. Anatomical variations in living donors for liver transplantation-prevalence and relationship. Langenbecks Arch Surg 2023; 408:323. [PMID: 37597008 DOI: 10.1007/s00423-023-03066-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/14/2023] [Indexed: 08/21/2023]
Abstract
PURPOSE Living donor liver transplantation (LDLT) is a widely accepted option to address the lack of a deceased liver program for transplantation. Understanding vascular and biliary anatomy and their variants is crucial for successful and safe graft harvesting. Anatomic variations are common, particularly in the right hepatic lobe. To provide evidence for screening potential liver transplant donors, the presence of vascular and biliary anatomic variations in Pakistan's preoperative assessment of transplantation donor candidates was explored. METHODS This retrospective cross-sectional study evaluated the hepatic artery, portal vein, hepatic vein, and biliary variations in living liver donors. The study included 400 living liver donors; data were collected from March 2019 to March 2023. We used a CT scan and MRCP to assess the anatomical variations. RESULTS The study examined 400 liver donors aged 18 to 53 years. Conventional arterial anatomy was the most common (65.8%), followed by replaced right hepatic artery (16%) and replaced left hepatic artery (10.8%). Conventional type 1 biliary anatomy was seen in 65.8% of cases. The dominant right hepatic vein was found in 13.3% of donors. There was a significant association between the prevalence of variant portal venous anatomy with variant biliary anatomy. CONCLUSION Variations of the hepatic arterial, portal venous, and biliary systems are frequent and should be carefully evaluated while selecting a suitable living donor. A strong relationship between variant portal venous and biliary anatomy was found. These findings can aid in selecting suitable candidates and improving surgical planning for liver transplantation.
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Affiliation(s)
- Abdullah Khalid
- Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan.
| | - M Asad Saleem
- Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
| | - Ihsan-Ul-Haq
- Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
| | - Yasir Khan
- Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
| | - Sohail Rashid
- Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
| | - Faisal Saud Dar
- Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
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Khan BA, Khalid A, Saeed Z, Ihsan-Ul-Haq, Khan MY, Rashid S, Naveed A, Dar FS. Exploring safety and efficacy of rivaroxaban after living donor liver transplantation: a retrospective study. Langenbecks Arch Surg 2023; 408:308. [PMID: 37578661 DOI: 10.1007/s00423-023-03042-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/02/2023] [Indexed: 08/15/2023]
Abstract
PURPOSE Thromboembolic complications remain a significant concern in postoperative patients, particularly those who have undergone liver transplantation. Warfarin has been the standard oral anticoagulant. Direct oral anticoagulants (DOACs) have several advantages over warfarin, including rapid onset of action and standardized dose guidelines. We aimed to assess the safety of rivaroxaban in living donor liver transplantation (LDLT) recipients. METHODS This study was a single-center, retrospective descriptive analysis of LDLT recipients who received rivaroxaban between December 2020 and April 2022. A total of 27 recipients received rivaroxaban postoperatively. Liver function tests, immunosuppression levels, serum creatinine, and INR were recorded before the initiation of rivaroxaban and then on post-therapy days 1, 7, 14, 28, 90, and 180. RESULTS Among the 27 recipients receiving rivaroxaban postoperatively, portal venous thrombosis was the most prevalent indication for anticoagulation (44.4%), followed by Budd-Chiari syndrome (29.6%). Nine patients had a twofold increase in either ALT or AST values, two of whom were treated for biliary strictures and the others for rejection. Eighteen patients were given tacrolimus, and eight were on cyclosporine, with one patient switched from tacrolimus to cyclosporine due to insufficient therapeutic levels. There were no incidents of bleeding or re-thrombosis during the 180-day follow-up period. CONCLUSION Rivaroxaban may be a safe and effective alternative in LDLT recipients with no significant adverse incidents. Further studies with larger sample sizes are needed to confirm these findings and determine this population's optimal dose and duration of rivaroxaban therapy.
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Affiliation(s)
- Bilal Ahmed Khan
- Department of Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan.
| | - Abdullah Khalid
- Department of Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
| | - Zubair Saeed
- Department of Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
| | - Ihsan-Ul-Haq
- Department of Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
| | - Muhammad Yasir Khan
- Department of Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
| | - Sohail Rashid
- Department of Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
| | - Ammara Naveed
- Gastroenterology and Hepatology Department, PKLI&RC, Lahore, Pakistan
| | - Faisal Saud Dar
- Department of Hepatopancreatic Biliary Surgery and Liver Transplant Unit, Pakistan Kidney & Liver Institute & Research Center (PKLI&RC), DHA Phase VI, Lahore, Pakistan
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Bhatti ABH, Dar FS, Riyaz S, Khan NY, Qureshi NR, Khan NA. Survival after extended resections for gallbladder cancer. Ann Hepatobiliary Pancreat Surg 2023; 27:70-75. [PMID: 36575822 PMCID: PMC9947370 DOI: 10.14701/ahbps.22-075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/17/2022] [Accepted: 10/31/2022] [Indexed: 12/29/2022] Open
Abstract
Backgrounds/Aims Locally advanced gallbladder cancer (GBC) is associated with survival limited to a few months. Extended resections (ER) are occasionally performed in this group and outcomes remain inconclusive. This study assessed outcomes after ER for locally advanced GBC. Methods Patients who underwent ER for GBC between 2011 and 2020 were reviewed. ER was defined as a major hepatectomy alone (n = 9), a pancreaticoduodenectomy (PD) with or without minor hepatectomy (n = 3), a major hepatectomy with PD (HPD) (n = 3) or vascular resection and reconstruction (n = 4). We assessed 30-day morbidity, mortality, and 2-year overall survival (OS). Results Among 19 patients, negative margins were achieved in 14 (73.6%). The 30-day mortality was 1/9 (11.1%) for a major hepatectomy, 0/3 (0%) for a minor HPD, 2/3 (66.7%) for a major HPD, and 1/4 (25.0%) for vascular resection. All short term survivors (< 6 months) (n=8) had preoperative jaundice and 6/8 (75.0%) underwent a major HPD or vascular resection. There were five (26.3%) long term survivors. The median OS in patients with and without preoperative jaundice was 4.1 months (0.7-11.1 months) and 13.7 months (12-30.4 months), respectively (p = 0.009) (2-year OS = 7% vs. 75%; p = 0.008). The median OS in patients who underwent a major hepatectomy alone or a minor HPD was 11.3 months (6.8-17.3 months) versus 1.4 months (0.3-4.1 months) (p = 0.02) in patients who underwent major HPD or vascular resection (2 year OS = 33% vs. not reached) (p = 0.010) respectively. Conclusions In selected patients with GBC, when ER is limited to a major hepatectomy alone, or a minor HPD, acceptable survival can be achieved.
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Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Division of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Islamabad, Pakistan,Shifa Tameer-e-Millat University Islamabad, Islamabad, Pakistan,Corresponding author: Abu Bakar Hafeez Bhatti, MBBS, FCPS, FRCS Division of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Sector H-8/4, Pitras Bukhari Road, Islamabad 44000, Pakistan Tel: +92-52-8464216, Fax: +92-51-4863182, E-mail: ORCID: https://orcid.org/0000-0002-4875-603X
| | - Faisal Saud Dar
- Division of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Islamabad, Pakistan
| | - Shahzad Riyaz
- Shifa Tameer-e-Millat University Islamabad, Islamabad, Pakistan,Division of Gastroenterology, Shifa International Hospital Islamabad, Islamabad, Pakistan
| | - Nusrat Yar Khan
- Division of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Islamabad, Pakistan
| | - Najla Rahman Qureshi
- Division of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Islamabad, Pakistan
| | - Nasir Ayub Khan
- Division of Anesthesiology, Shifa International Hospital Islamabad, Islamabad, Pakistan
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Khan SA, Ali N, Dar FS, Malik MI. Biliary atresia-An experience from the first pediatric liver transplant center in Pakistan. Pediatr Transplant 2023; 27:e14357. [PMID: 35831918 DOI: 10.1111/petr.14357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 05/09/2022] [Accepted: 06/28/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Biliary atresia (BA) is the most common cause of neonatal cholestatic syndrome. The true incidence of BA in Pakistan is largely unknown. AIM This study aimed to report the clinical features, age at diagnosis and outcomes of biliary atresia from the first pediatric liver transplant center in Pakistan. METHODS The study was done in Shifa International hospital from 2013 to 2020. All babies who had biliary atresia confirmed by laboratory investigation were included. Demographic data, age of presentation, clinical presentation, supporting investigations like liver function tests, ultrasound abdomen, HIDA scan and liver biopsy were noted. Outcome related to Kasai portoenterostomy, liver transplant, complications and immunosuppressant agents were noted. RESULT A total of 42 children were included, 23 (54.7%) males and 19 (45.2%) were females. Jaundice was seen in all patients (100%) followed by acholic stools (81%). Associated malformations were noted in 6 (14.2%) patients. Liver function tests confirmed obstructive cholestasis (p 0.04). Kasai was done in 19 (45%) patients only, living donor liver transplant was performed in 6 (14%) patients. Age range of transplant patients was from 3 months to 1 year. Indication for liver transplant was failed Kasai in 1(16.7%) patient and chronic liver disease in 5 (83.3%) patients. LDLT survivors were 10 months to 1 year of age at the time of transplant, mean age was 10.6 months. Maximum survival noted so far is 7 years. Acute complications seen post-transplant were sepsis (three patients), surgical site infections (two patients), biliary leaks and acute cellular rejection in one patient each. Chronic graft rejection, portal vein stricture needing stenting was done in one patient. DISCUSSION All patients underwent LDLT from related donors wih no donor related mortality. All are deceased patients were yonger and had advanced disease. BA remains third most commo indication of transplant in our center. CONCLUSION Liver transplant is the only lifesaving procedure after failed Kasai or as primary liver transplant due to advance liver disease. The advent of liver transplantation services offers survival and improving outlook of the disease.
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Affiliation(s)
- Sabeen Abid Khan
- Pediatrics, Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Naurin Ali
- Pediatrics, Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Faisal Saud Dar
- Hepatobiliary Surgeon in Shifa International Hospital, Pakistan Kidney Liver Institute (PKLI), Lahore, Pakistan
| | - Munir Iqbal Malik
- Pediatric Gastroenterology, Shifa International Hospital, Shifa College of Medicine, Islamabad, Pakistan
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Salman S, Arsalan M, Dar FS. Launching Liver Exchange and the First 3-Way Liver Paired Donation. JAMA Surg 2023; 158:210-211. [PMID: 36477814 DOI: 10.1001/jamasurg.2022.5440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This article discusses the successful implementation of a liver exchange mechanism that led to 3 liver allotransplants and 3 hepatectomies between 3 incompatible patient-donor pairs.
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Affiliation(s)
- Saad Salman
- Harvard School of Public Health, Harvard University, Boston, Massachusetts
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Atiq M, Ammar AS, Ali RM, Haider S, Ahmed I, Dar FS. Primary squamous cell carcinoma of liver. First case report from Pakistan and South Asia. Int J Surg Case Rep 2022; 99:107655. [PMID: 36126461 PMCID: PMC9568749 DOI: 10.1016/j.ijscr.2022.107655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/07/2022] [Accepted: 09/10/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction and importance Primary squamous cell carcinoma (PSCC) of liver is quite rare and very few cases reported in literature. It has high metastatic rate with poor prognosis. The pathogenesis is unclear, but is generally considered to be correlated with the long-term inflammation or metaplasia of biliary epithelial cells or congenital cyst of the liver. We report here a case of PSCC of liver which mimicked a complex hydatid cyst. Case presentation A 25 years male admitted with right hypochondrium pain associated with fever and yellowish discoloration of eyes for 20 days. He was jaundiced with epigastric tenderness and deranged liver function tests. When thoroughly investigated with ultrasound, CT abdomen and MRI liver, he was found to have a large cystic lesion in right lobe of the liver. He underwent right hepatectomy, peri-cystectomy of the cyst and T-tube placement in common bile duct. Histopathology of the resected sample showed primary squamous cell carcinoma of liver. Patient was discharged after 7 days and died after 6 months due to acute liver failure. Clinical discussion Because of a very low incidence of hepatic SCC, there is not a single definite therapeutic regime and various different methods of management include surgical resection, generalized chemotherapy, radiotherapy, Hepatic Arterial ChemoEmbolization (HACE) and the combinations of these therapies. Conclusion PSCC is a rare condition of the liver and is associated with other benign liver conditions such as non-parasitic and epidermoid cysts. Histopathology with radiological investigations are needed to diagnose and treat this aggressive tumor before it metastasizes. Primary squamous cell carcinoma (PSCC) is a rare tumor of liver and only 31 cases are reported till date since 1970. PSCC is very aggressive tumor and generally patients present after the tumor metastasize. The pathogenesis is not clear but most of the patients had liver cysts showing chronic inflammation of liver cells. CECT scan of abdomen, MRI and biopsy of the tumor lesion should be done in all cases of liver cyst. In operable cases surgery is usually the treatment of choice followed by chemotherapy Recurrence rate is high and mean survival rate is less than 12 months.
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Affiliation(s)
- Muhammad Atiq
- Quaid e Azam International Hospital, Islamabad, Pakistan
| | | | | | - Siraj Haider
- Quaid e Azam International Hospital, Islamabad, Pakistan
| | - Imran Ahmed
- Shifa International Hospital Islamabad, Pakistan
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Aaraj S, Khan SA, Ali N, Iqbal Malik MI, Dar FS. Wilson Disease in Children; Chelation Therapy or Liver Transplantation? A 10-Year Experience from Pakistan. Ann Transplant 2021; 26:e932606. [PMID: 34608110 PMCID: PMC8501894 DOI: 10.12659/aot.932606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Wilson disease (WD) is a rare genetic disorder with vast clinical presentations and a higher incidence in areas where consanguinity is common. Most patients can be treated with oral chelation, but some require advanced surgical intervention, like liver transplantation (LT). This study aims to review outcomes of WD patients presenting to a tertiary care center over a period of 10 years. Material/Methods This retrospective analysis was conducted at Shifa International Hospital, Islamabad, Pakistan. Patients <18 years who were diagnosed with WD per ESPAGHAN guidelines from 2010 to 2020 were included. Presentation, diagnosis, treatment, and LT and its complications were recorded. Follow-ups were recorded, and patients were contacted by phone in cases of interrupted follow-up. Frequencies and percentages of variables were calculated. Results A total of 48 patients with WD were identified. Symptomatic disease was seen in 45 patients, with 3 diagnosed on screening. The hepatic form was common (62.2%). Mean age at diagnosis was 9.74 (range 5–17) years, 28 (58.3%) were male, while 17 (35.4%) were female. Urinary copper was increased in all patients (645.82±528.40). Oral treatment with penicillamine was given to 34 (75.5%) patients; 4 (8.9%) died while on oral treatment. Living donor LT was performed in 11 (22.9%) patients, who had a mean King’s Wilson index of 11 (range, 6–14). Currently, all LT patients are alive, with maximum graft survival of 7 years. Conclusions LT offers a promising treatment with good outcomes in pediatric WD. However, timely diagnosis and management with oral chelation therapy can prolong survival without LT.
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Affiliation(s)
- Sahira Aaraj
- Department of Pediatrics, Shifa Tameer-e-Millat University, Shifa College of Medicine, Islamabad, Pakistan
| | - Sabeen Abid Khan
- Department of Pediatrics, Shifa Tameer-e-Millat University, Shifa College of Medicine, Islamabad, Pakistan
| | - Naurin Ali
- Department of Pediatrics, Shifa Tameer-e-Millat University, Shifa College of Medicine, Islamabad, Pakistan
| | - Munir I Iqbal Malik
- Department of Pediatrics, Shifa Tameer-e-Millat University, Shifa College of Medicine, Shifa International Hospital, Islamabad, Pakistan
| | - Faisal Saud Dar
- Department of Gastroenterology and Liver Transplant, Shifa Tameer-e-Millat University, Shifa College of Medicine, Shifa International Hospital, Islamabad, Pakistan
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Hafeez Bhatti AB, Jafri RZ, Sahaab E, Dar FS, Zia HH, Khan NY. Long term outcomes after pancreaticoduodenectomy: A single center experience from Pakistan. J PAK MED ASSOC 2021; 71:1838-1842. [PMID: 34410258 DOI: 10.47391/jpma.501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To report long-term outcomes after pancreaticoduodenectomy from a single centre. METHODS The retrospective study was conducted at Shifa International Hospital, Islamabad and comprised pancreaticoduodenectomy procedures performed by four surgeons at a single centre from January 2011 to June 2019. Outcome was assessed on the basis of morbidity, in-hospital mortality and survival. Data was analysed using SPSS 20. RESULTS Of the 155 patients, 103(66.5%) were males. The overall mean age was 56.8±13.5 years (range: 8-85 years). Overall morbidity was 84 (54.2%). Multivisceral and venous resections were performed in 22(14.2%) and 20(12.9%) patients respectively. Grade B pancreatic fistula was seen in 5(3.2%) patients and grade C in 6(3.8%). In-hospital mortality was 5(3.2%). The difference between the estimated 5-year overall survival for pancreatic and non-pancreatic cancers was non-significant (p=0.2), while the difference in the estimated 3-year overall survival rate was significant (p<0.05). CONCLUSIONS With standardisation of operative technique and peri-operative management, low in-hospital mortality and acceptable long-term outcomes were achieved with standard and extended pancreaticoduodenectomy.
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Affiliation(s)
| | - Roshni Zahra Jafri
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Eraj Sahaab
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Faisal Saud Dar
- Department of HPB and Liver Transplantation, Shifa International Hopsital, Islamabad
| | - Haseeb Haider Zia
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Nusrat Yar Khan
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
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Bhatti ABH, Naqvi W, Khan NY, Zia HH, Dar FS, Khan ZA, Rana A. Living donor liver transplantation for advanced hepatocellular carcinoma including macrovascular invasion. J Cancer Res Clin Oncol 2021; 148:245-253. [PMID: 34117916 PMCID: PMC8752562 DOI: 10.1007/s00432-021-03665-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/13/2021] [Indexed: 02/05/2023]
Abstract
Background The indications for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) continue to evolve. The aim of this study was to report outcomes in patients who underwent living donor liver transplantation (LDLT) for HCC outside traditional criteria including macrovascular invasion (MVI). Methods We reviewed outcomes in patients who met the University of California San Francisco (UCSF) criteria (n = 159) and our center-specific criteria (UCSF+) (largest tumor diameter ≤ 10 cm, any tumor number, AFP ≤ 1000 ng/ml) (n = 58). We also assessed outcomes in patients with MVI (n = 27). Results The median follow was 28 (10.6–42.7) months. The 5 year overall survival and risk of recurrence (RR) in the UCSF and UCSF + group was 71% vs 69% (P = 0.7) and 13% vs 36% (P = 0.1) respectively. When patients with AFP > 600 ng/ml were excluded from the UCSF + group, RR was 27% (P = 0.3). Among patients with MVI who had downstaging (DS), 4/5(80%) in low-risk group (good response and AFP ≤ 100 ng/ml) and 2/10 (20%) in the high-risk group (poor response or AFP > 100 ng/ml) were alive at the last follow-up. When DS was not feasible, 3/3 (100%) in the low-risk group (AFP ≤ 100 ng/ml + Vp1-2 MVI) and 1/9 (9.1%) in the high-risk group (AFP > 100 or Vp3 MVI) were alive. The 5 year OS in the low-risk MVI group was 85% (P = 0.003). Conclusion With inclusion of AFP, response to downstaging and degree of MVI, acceptable survival can be achieved with LDLT for HCC outside traditional criteria. Supplementary Information The online version contains supplementary material available at 10.1007/s00432-021-03665-9.
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Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Sector H-8/4, Pitras Bukhari Road, Islamabad, 44000, Pakistan. .,Department of Surgery, Shifa Tameer-e-Millat University Islamabad, Islamabad, Pakistan.
| | - Wajih Naqvi
- Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Sector H-8/4, Pitras Bukhari Road, Islamabad, 44000, Pakistan
| | - Nusrat Yar Khan
- Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Sector H-8/4, Pitras Bukhari Road, Islamabad, 44000, Pakistan
| | - Haseeb Haider Zia
- Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Sector H-8/4, Pitras Bukhari Road, Islamabad, 44000, Pakistan
| | - Faisal Saud Dar
- Division of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Shifa International Hospital Islamabad, Sector H-8/4, Pitras Bukhari Road, Islamabad, 44000, Pakistan
| | - Zahid Amin Khan
- Division of Radiology, Shifa International Hospital Islamabad, Islamabad, Pakistan
| | - Atif Rana
- Division of Radiology, Shifa International Hospital Islamabad, Islamabad, Pakistan
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Abstract
Background. The role of preoperative biliary stenting (PBS) before pancreaticoduodenectomy (PD) in patients with obstructive jaundice is debatable. The objective of the current study was to assess PD outcomes after upfront surgery or PBS and determine the impact of stent to surgery duration on PD outcomes. Methods. We reviewed patients who underwent PD between 2011 and 2019. Patients were grouped based on whether they underwent upfront surgery (n = 67) or PBS (n = 66). We further assessed outcomes based on stent to surgery duration. Results. There was no significant difference in 30-day mortality (3% vs. 2.9%, P = 1), 90-day mortality (7.5% vs. 4.4%, P = .4), and Grade B-C pancreatic fistula rates (7.5% vs. 4.4%, P = .4) in the PBS and upfront surgery groups, respectively. A significant increase in wound infections (22.7% vs. 7.4%, P = .01) and readmissions (10.6% vs. 0, P = .006) was seen in the PBS group. The highest rate of wound infection was seen when stent to surgery duration was 4-6 weeks (41.6%). The wound infection rates in the upfront surgery group, high-risk PBS group (4-6 weeks), and low-risk PBS group were 5/67(7.4%), 5/12(41.6%), and 7/36(19.4%), respectively (P = .008). Conclusions. PBS increases postoperative wound infections when compared with upfront surgery. Patients operated between 4 and 6 weeks after stenting have the highest rate of wound infection.
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Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of Hepato-pancreatico-biliary Surgery and Liver Transplantation, 525444Shifa International Hospital, Pakistan
| | - Roshni Z Jafri
- Department of Hepato-pancreatico-biliary Surgery and Liver Transplantation, 525444Shifa International Hospital, Pakistan
| | | | - Faisal Saud Dar
- Department of Hepato-pancreatico-biliary Surgery and Liver Transplantation, 525444Shifa International Hospital, Pakistan
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Bhatti ABH, Qureshi AI, Tahir R, Dar FS, Khan NY, Zia HH, Riyaz S, Rana A. When to call it off: defining transplant candidacy limits in liver donor liver transplantation for hepatocellular carcinoma. BMC Cancer 2020; 20:754. [PMID: 32787864 PMCID: PMC7425141 DOI: 10.1186/s12885-020-07238-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/29/2020] [Indexed: 02/08/2023] Open
Abstract
Background Living donor liver transplantation (LDLT) is an acceptable treatment option for hepatocellular carcinoma (HCC). Traditional transplant criteria aim at best utilization of donor organs with low risk of post transplant recurrence. In LDLT, long term recurrence free survival (RFS) of 50% is considered acceptable. The objective of the current study was to determine preoperative factors associated with high recurrence rates in LDLT. Methods Between April 2012 and December 2019, 898 LDLTs were performed at our center. Out of these, 242 were confirmed to have HCC on explant histopathology. We looked at preoperative factors associated with ≤ 50%RFS at 4 years. For survival analysis, Kaplan Meier curves were used and Cox regression analysis was used to identify independent predictors of recurrence. Results Median AFP was 14.4(0.7–11,326.7) ng/ml. Median tumor size was 2.8(range = 0.1–11) cm and tumor number was 2(range = 1–15). On multivariate analysis, AFP > 600 ng/ml [HR:6, CI: 1.9–18.4, P = 0.002] and microvascular invasion (MVI) [HR:5.8, CI: 2.5–13.4, P < 0.001] were independent predictors of 4 year RFS ≤ 50%. When AFP was > 600 ng/ml, MVI was seen in 88.9% tumors with poor grade and 75% of tumors outside University of California San Francisco criteria. Estimated 4 year RFS was 78% for the entire cohort. When AFP was < 600 ng/ml, 4 year RFS for well-moderate and poor grade tumors was 88 and 73%. With AFP > 600 ng/ml, RFS was 53% and 0 with well-moderate and poor grade tumors respectively (P < 0.001). Conclusion Patients with AFP < 600 ng/ml have acceptable outcomes after LDLT. In patients with AFP > 600 ng/ml, a preoperative biopsy to rule out poor differentiation should be considered for patient selection.
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Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Division of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan.
| | - Ammal Imran Qureshi
- Division of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Rizmi Tahir
- Division of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Faisal Saud Dar
- Division of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Nusrat Yar Khan
- Division of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Haseeb Haider Zia
- Division of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Shahzad Riyaz
- Division of Transplant Hepatology, Shifa International Hospital, Islamabad, Pakistan
| | - Atif Rana
- Division of Radiology, Shifa International Hospital, Islamabad, Pakistan
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Bhatti ABH, Sahaab E, Dar FS, Manan F. Successful Outcome after Single Step Surgery for Portal Biliopathy. J Coll Physicians Surg Pak 2020; 30:453-454. [PMID: 32513375 DOI: 10.29271/jcpsp.2020.04.453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 07/31/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Eraj Sahaab
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Faisal Saud Dar
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Fazal Manan
- Department of Hepatology, Shifa International Hospital, Islamabad, Pakistan
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Bhatti ABH, Sahaab E, Dar FS, Manan F. Successful Outcome after Single Step Surgery for Portal Biliopathy. J Coll Physicians Surg Pak 2020. [PMID: 32513375 DOI: 10.29271/jcpsp.2020.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Eraj Sahaab
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Faisal Saud Dar
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Fazal Manan
- Department of Hepatology, Shifa International Hospital, Islamabad, Pakistan
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Raja AM, Ciociola E, Ahmad IN, Dar FS, Naqvi SMS, Moaeen-ud-Din M, Raja GK, Romeo S, Mancina RM. Genetic Susceptibility to Chronic Liver Disease in Individuals from Pakistan. Int J Mol Sci 2020; 21:ijms21103558. [PMID: 32443539 PMCID: PMC7278956 DOI: 10.3390/ijms21103558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 02/07/2023] Open
Abstract
Chronic liver disease, with viral or non-viral etiology, is endemic in many countries and is a growing burden in Asia. Among the Asian countries, Pakistan has the highest prevalence of chronic liver disease. Despite this, the genetic susceptibility to chronic liver disease in this country has not been investigated. We performed a comprehensive analysis of the most robustly associated common genetic variants influencing chronic liver disease in a cohort of individuals from Pakistan. A total of 587 subjects with chronic liver disease and 68 healthy control individuals were genotyped for the HSD17B13 rs7261356, MBOAT7 rs641738, GCKR rs1260326, PNPLA3 rs738409, TM6SF2 rs58542926 and PPP1R3B rs4841132 variants. The variants distribution between case and control group and their association with chronic liver disease were tested by chi-square and binary logistic analysis, respectively. We report for the first time that HSD17B13 variant results in a 50% reduced risk for chronic liver disease; while MBOAT7; GCKR and PNPLA3 variants increase this risk by more than 35% in Pakistani individuals. Our genetic analysis extends the protective role of the HSD17B13 variant against chronic liver disease and disease risk conferred by the MBOAT7; GCKR and PNPLA3 variants in the Pakistani population.
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Affiliation(s)
- Asad Mehmood Raja
- University Institute of Biochemistry and Biotechnology, Pir Mehr Ali Shah Arid Agriculture University Rawalpindi, Rawalpindi 46300, Pakistan; (A.M.R.); (S.M.S.N.); (G.K.R.)
| | - Ester Ciociola
- Department of Molecular and Clinical Medicine, The Sahlgrenska Academy at the University of Gothenburg, Wallenberg Laboratory, 413 45 Gothenburg, Sweden;
| | - Imran Nazir Ahmad
- Department of Pathology and Laboratory Medicine, Shifa International Hospitals Ltd., Islamabad 44790, Pakistan;
| | - Faisal Saud Dar
- Liver Transplantation, Hepatobiliary and Pancreatic Services Unit, Shifa International Hospitals Ltd., Islamabad 44790, Pakistan;
| | - Syed Muhammad Saqlan Naqvi
- University Institute of Biochemistry and Biotechnology, Pir Mehr Ali Shah Arid Agriculture University Rawalpindi, Rawalpindi 46300, Pakistan; (A.M.R.); (S.M.S.N.); (G.K.R.)
| | - Muhammad Moaeen-ud-Din
- Department of Animal Breeding and Genetics/National Center for Livestock Breeding, Genetics & Genomics, Pir Mehr Ali Shah Arid Agriculture University Rawalpindi, Rawalpindi 46300, Pakistan;
| | - Ghazala Kaukab Raja
- University Institute of Biochemistry and Biotechnology, Pir Mehr Ali Shah Arid Agriculture University Rawalpindi, Rawalpindi 46300, Pakistan; (A.M.R.); (S.M.S.N.); (G.K.R.)
| | - Stefano Romeo
- Department of Molecular and Clinical Medicine, The Sahlgrenska Academy at the University of Gothenburg, Wallenberg Laboratory, 413 45 Gothenburg, Sweden;
- Department of Cardiology, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden
- Clinical Nutrition Unit, Department of Medical and Surgical Sciences, University Magna Graecia, 88100 Catanzaro, Italy
- Correspondence: (S.R.); (R.M.M.); Tel.: +46-(0)313-426-735 (S.R.); +46-(0)31342186 (R.M.M.)
| | - Rosellina Margherita Mancina
- Department of Molecular and Clinical Medicine, The Sahlgrenska Academy at the University of Gothenburg, Wallenberg Laboratory, 413 45 Gothenburg, Sweden;
- Correspondence: (S.R.); (R.M.M.); Tel.: +46-(0)313-426-735 (S.R.); +46-(0)31342186 (R.M.M.)
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Azam F, Khan M, Bhatti ABH, Dar FS, Ahmad A, Javed N. Clinical Efficacy and Safety of Tacrolimus in Pakistani Living Donor Liver Transplant Recipients. J Coll Physicians Surg Pak 2020; 29:1048-1052. [PMID: 31659960 DOI: 10.29271/jcpsp.2019.11.1048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/11/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the association between tacrolimus trough levels and dosage in Pakistani patients undergoing live donor liver transplantation (LDLT), and the efficacy and adverse effects at different tacrolimus trough levels and dosages. STUDY DESIGN An observational study. PLACE AND DURATION OF STUDY Shifa International Hospital, Shifa Tameer-e-Millat University, Islamabad and Basic Medical Sciences Institute, Karachi, from September 2016 to October 2018. METHODOLOGY Sixty liver transplant recipients were included. Demographics, clinical data, tacrolimus trough levels and doses were monitored as per routine protocol. Electrochemiluminescence immunoassay (ECLIA) was used to measure tacrolimus trough levels. Acute cellular rejection (ACR), sepsis and other adverse events were monitored at different tacrolimus trough levels in early post-transplantation period. RESULTS Mean age of transplant recipients was 49.1 ± 10.6 years. Mean tacrolimus trough levels were 6.1 ± 2.2 ng/ml and mean dose was 0.94 ± 0.3 mg. Sepsis (27%) psychosis (20%), seizures (10%), and renal insufficiency (13%) were the most common adverse effects. Acute cellular rejection (ACR) was observed in 15% patients. Patients with sepsis had significantly high mean tacrolimus levels of 7.7 ± 2.5 ng/ml versus 5.5 ± 1.9 ng/ml (p=0.001). Mean tacrolimus trough levels in patients with ACR were significantly lower (4.05 ± 1.6 ng/ml vs. 6.43 ± 2.2ng/ml, p=0.003). None of the patients with a single tacrolimus trough level >10 ng/ml experienced ACR. CONCLUSION A tacrolimus trough level between 5 to 7.5 ng/ml appears to be safe in Pakistani liver transplant recipients significantly minimising the risk of ACR and other adverse events.
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Affiliation(s)
- Fahad Azam
- Department of Pharmacology and Therapeutics, Shifa College of Medicine, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Moosa Khan
- Department of Pharmacology and Therapeutics, Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad, Pakistan
| | - Abu Bakar Hafeez Bhatti
- Department of Hepatobiliary and Liver Transplant, Shifa International Hospital, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Faisal Saud Dar
- Department of Hepatobiliary and Liver Transplant, Shifa International Hospital, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Arsalan Ahmad
- Department of Neurology, Shifa International Hospital, Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - Nismat Javed
- Medical Student, Shifa College of Medicine, Islamabad, Pakistan
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Dar FS, Atiq M, Shahzadi N, Ainy SK, Rana A, Bhatti ABH. Outcomes after Surgical Resection of Hilar Cholangiocarcinoma. J Coll Physicians Surg Pak 2019; 29:874-877. [PMID: 31455485 DOI: 10.29271/jcpsp.2019.09.874] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/08/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To report long term outcomes after surgical resection of hilar cholangiocarcinoma (hCCA). STUDY DESIGN Cohort study. PLACE AND DURATION OF STUDY Department of Liver Transplant and Hepatopancreaticobiliary Surgery, Shifa International Hospital, Islamabad, Pakistan, from October 2011 to April 2018. METHODOLOGY A prospective review of maintained database of patients who underwent surgical resection for hCCA was performed. A total of 24 patients were included. Outcome was assessed, based upon 90-day morbidity and mortality, 5-year recurrence-free survival (RFS) and overall survival (OS). RESULTS Median age was 49 (23-73) years. Male to female ratio was 1.4:1. Median CA 19-9 level was 113 (2-1200) U/ml. Nine patients (37.5%) underwent right hepatectomy, six had right trisectionectomy (25%), three had central hepatectomy (12.5%) and left hepatectomy (12.5%) each, while three (12.5%) had other surgical procedures. In addition, two (8.3%) patients required portal vein resection and reconstruction. Median blood loss was 1350 (100-2000) ml. Median ICU stay was 4 (2-13) days, while hospital stay was 10 (6-32) days. Sixteen (66.7%) patients experienced at least one morbidity within 90 days, while 90-day mortality was 1/24 (4.1%). The overall recurrence rate was 6/18 (33.4%) and mortality was 9/18 (50%). The actuarial 5-year RFS was 60% and OS was 39%. CONCLUSION hCCA remains a technically challenging surgical problem. Outcomes comparable to international standards can be achieved in experienced centres.
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Affiliation(s)
- Faisal Saud Dar
- Department of BPB Surgery and Liver Transplant, Shifa International Hospital, Islamabad, Pakistan
| | - Muhammad Atiq
- Department of BPB Surgery and Liver Transplant, Shifa International Hospital, Islamabad, Pakistan
| | - Neelam Shahzadi
- Department of BPB Surgery and Liver Transplant, Shifa International Hospital, Islamabad, Pakistan
| | - Seemab Khalid Ainy
- Department of BPB Surgery and Liver Transplant, Shifa International Hospital, Islamabad, Pakistan
| | - Atif Rana
- Department of Radiology, Shifa International Hospital, Islamabad, Pakistan
| | - Abu Bakar Hafeez Bhatti
- Department of BPB Surgery and Liver Transplant, Shifa International Hospital, Islamabad, Pakistan
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Bhatti ABH, Dar FS, Qureshi AI, Haider S, Khan NA. Saphenous vein conduits for hepatic arterial reconstruction in living donor liver transplantation. Langenbecks Arch Surg 2019; 404:293-300. [PMID: 30859361 DOI: 10.1007/s00423-019-01774-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/01/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Sector H-8/4 Pitras Bukhari Road, Islamabad, Pakistan.
| | - Faisal Saud Dar
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Sector H-8/4 Pitras Bukhari Road, Islamabad, Pakistan
| | - Ammal Imran Qureshi
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Sector H-8/4 Pitras Bukhari Road, Islamabad, Pakistan
| | - Siraj Haider
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Sector H-8/4 Pitras Bukhari Road, Islamabad, Pakistan
| | - Nasir Ayub Khan
- Department of Anesthesiology, Shifa International Hospital, Sector H-8/4 Pitras Bukhari Road, Islamabad, Pakistan
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Bhatti ABH, Haq IU, Ahmed IN, Bilal R, Dar FS. Utility of Routine Gall Bladder Histopathology after Living Donor Hepatectomy in Liver Transplantation. J Coll Physicians Surg Pak 2018; 28:490-491. [PMID: 29848433 DOI: 10.29271/jcpsp.2018.06.490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 04/18/2018] [Indexed: 02/05/2023]
Abstract
Intraoperative cholangiogram with cholecystectomy is a routinely performed procedure in living donor liver transplantation (LDLT).The objective of this study was to determine the frequency of gall bladder pathology in healthy living donors and whether routine histopathology can be omitted. This was a retrospective review of 366 donors who underwent donor hepatectomy between 2012 and 2016. Primary outcome of interest was frequency of abnormal histopathology findings in removed gall bladder specimen; and if their distribution was different with respect to gender, age and BMI. Male to female ratio was 2.1:1. Median age was 26 (18-50) years. Median BMI was 23.9 (15.7-35) Kg/m2. The most common finding was chronic cholecystitis in 189 (51.6%). Gall bladder pathology was more frequently seen in donors with BMI >25 Kg/m2, i.e. 69.3 % versus 30.7% (p<0.001). Due to high frequency of abnormal findings, gall bladder should be sent routinely for histopathology in healthy liver donors after cholecystectomy.
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Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad
| | - Ihsan Ul Haq
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad
| | | | - Raenah Bilal
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad
| | - Faisal Saud Dar
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad
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Hashmi SS, Hafeez Bhatti AB, Malik MI, Rana A, Nasir H, Dar FS, Khan EA. Spectrum of histopathological diagnosis in paediatric patients with liver disorders in Pakistan. J Pak Med Assoc 2017; 67:266-269. [PMID: 28138183 DOI: pmid/28138183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To document spectrum of paediatric liver disorders confirmed on liver biopsy. METHODS The retrospective review of patients was conducted at Shifa International Hospital, Islamabad, Pakistan, and comprised data of all children who underwent ultrasound-guided percutaneous liver biopsy between December 2008 and June 2015. Frequency of individual diagnosis was assessed and compared on gender basis. SPSS 16 was used for statistical analysis. RESULTS There were medical records of 74 patients in the study with an overall median age of 6.9 years (interquartile range: 0.2-17.7 years). Metabolic 27(36.5%) and inflammatory 19(25.6%) disorders were the most common aetiologies. At presentation 29(39.1%) patients had cirrhosis; and 25(34%) children were <5 years of age. Metabolic disorders were the most common aetiology in children upto 10 years of age with 19(25.6%) patients. Above the age of 10 years, inflammatory disorders were more frequent and were seen in 10(13.5%). Based on gender, a trend towards significance was observed for metabolic disorders (p=0.08) and children who presented with cirrhosis (p= 0.07), but it was not statistically significant. CONCLUSIONS Metabolic disorders were the most common cause of liver disorders. A number of children at presentation had underlying cirrhosis.
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Affiliation(s)
| | | | | | - Atif Rana
- Department of Radiology, Shifa International Hopsital, Islamabad
| | - Humaira Nasir
- Department of Pathology, Shifa International Hopsital, Islamabad
| | - Faisal Saud Dar
- Department of HPB and Liver Transplantation, Shifa International Hopsital, Islamabad
| | - Ejaz Ahmed Khan
- Department of Pediatrics, Shifa International Hopsital, Islamabad
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Shah NH, Dar FS, Bhatti ABH, Rana A, Salih M. Assigning Treatment to HCC Patients for Transplantation: Utility of a New Decision-Making Tool. Ann Transplant 2016; 21:668-674. [PMID: 27789901 DOI: 10.12659/aot.899715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The Barcelona clinic liver cancer (BCLC) staging system is considered the standard of care for hepatocellular carcinoma (HCC) management. It has various limitations, including lack of second-line treatment options and combination therapy. We prospectively collected data on our HCC patients based on a new decision-making tool (NDT). The objective of this study was to determine the applicability of this tool and compare it with BCLC for treatment allocation, in particular with respect to liver transplantation. MATERIAL AND METHODS We retrospectively reviewed HCC patients who were managed based on an NDT that was developed in 2012. All patients whose treatment decision was based on this tool between 2012 and 2015 were included. Comparison was made with BCLC. Survival was compared for patients who underwent liver transplantation. RESULTS Based on the NDT, 406 (40.6%) patients were eligible for curative treatment versus only 22 (2.2%) patients based on BCLC. A total of 58 (5.8%) patients underwent liver transplant based on the NDT, while only 2 (0.2%) were transplantable based on BCLC. Estimated 3-year survival for transplanted patients based on the NDT was 73%. There were 41 (4.1%) stage C and 15 (1.5%) stage D BCLC patients who received transplant based on the NDT. Estimated 3-year survival for stage A, C, and D BCLC patients who received transplantation was 100%,72%, and 67%, respectively (P=0.6). CONCLUSIONS The NDT correctly identified a group of HCC patients for liver transplantation who would otherwise have received palliative treatment based on the BCLC algorithm.
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Affiliation(s)
- Najmul Hassan Shah
- Department of Gastroenterology and Hepatology, Shifa International Hospital, Islamabad, Pakistan
| | - Faisal Saud Dar
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Abu Bakar Hafeez Bhatti
- Department of HPB Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Atif Rana
- Department of Radiology, Shifa International Hospital, Islamabad, Pakistan
| | - Mohammad Salih
- Department of Gastroenterology and Hepatology, Shifa International Hospital, Islamabad, Pakistan
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Jehangir M, Nazir R, Jang A, Rana A, Rafique S, Dar FS. Macrovesicular steatosis in living related liver donors: correlation of biopsy findings with CT liver attenuation index and body mass index. Clin Transplant 2016; 30:1016-20. [PMID: 27291347 DOI: 10.1111/ctr.12782] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Hepatic steatosis threatens post-transplant graft survival; therefore, pre-operative quantification of steatosis is crucial. Gold standard for evaluation is donor liver biopsy but it is invasive. An alternative non-invasive method is a calculation of CT liver attenuation index. BMI can be an independent factor predicting grade of steatosis but it is necessary to re-define appropriate BMI cut-off points that are specific for Asians. OBJECTIVE To retrospectively analyze CT LAI and BMI for quantitative assessment of macrovesicular steatosis in living related liver donors, using histological analysis as gold standard. MATERIALS AND METHODS A radiologist blinded to histological grading calculated mean CT hepatic attenuation in 48 potential living related liver donors. RESULTS CT-derived LAI correctly predicted steatosis in all except 1 patient. Parametric analysis for CT LAI and BMI showed overall weak positive correlation. No significant association was found between BMI and biopsy findings. CONCLUSION Liver biopsy remains a gold standard for evaluation of steatosis. CT LAI of ≤0 correlates well with significant hepatic steatosis and biopsy may be avoided in such cases. Biopsy may be reserved for patients with CT LAI between 1 and 5. BMI alone is not a good predictor of hepatic steatosis in our study population.
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Affiliation(s)
- Maham Jehangir
- Department of Radiology, Shifa International Hospital, Islamabad, Pakistan.
| | - Rashed Nazir
- Department of Radiology, Shifa International Hospital, Islamabad, Pakistan
| | - Aisha Jang
- Department of Radiology, Shifa International Hospital, Islamabad, Pakistan
| | - Atif Rana
- Department of Radiology, Shifa International Hospital, Islamabad, Pakistan
| | - Salman Rafique
- Department of Radiology, Shifa International Hospital, Islamabad, Pakistan
| | - Faisal Saud Dar
- Department of Gastroenterology and Liver Transplant, Shifa International Hospital, Islamabad, Pakistan
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Hafeez Bhatti AB, Dar FS, Sahaab E, Khan NY, Zia H, Rana A, Salih M, Shah NH. Survival advantage with para aortic lymphadenectomy in peri-ampullary cancer: A retrospective cohort study. Int J Surg 2016; 31:58-62. [PMID: 27262530 DOI: 10.1016/j.ijsu.2016.05.069] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/15/2016] [Accepted: 05/28/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Metastatic para aortic lymph nodes (PALN) in patients with peri ampullary cancer entail poor prognosis. Role of curative surgery in these patients remains debatable. The objective of the current study was to evaluate outcome after extended pancreaticoduodenectomy (PD) in patients with and without positive PALN. METHODS We reviewed 65 patients who underwent extended PD with PALN removal between 2011 and 2014. Patients were divided into two groups; those with positive PALN and those without. Patients were sub classified for pancreatic and non-pancreatic cancer. Outcome was determined based on median and estimated 3 year overall survival. RESULTS Median age was 57 (32-85) years. PALN were involved in 15 (23%) patients. Overall 3 year survival for patients with and without positive PALN was 60% and 54% (P = 0.7). Significant difference in survival was present between patients with pancreatic cancer and positive PALN [9 (3-12) months] versus non-pancreatic cancers with positive PALN [17.5 (13-38) months] (P = 0.02). Four out of five patients with pancreatic cancer and positive PALN had survival >6 months and 3 out of these 5 patients were alive at the last follow up. CONCLUSION Curative surgery may benefit some patients with pancreatic cancer and positive PALN and should be considered selectively.
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Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan.
| | - Faisal Saud Dar
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Eraj Sahaab
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Nusrat Yar Khan
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Haseeb Zia
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Atif Rana
- Department of Radiology, Shifa International Hospital, Islamabad, Pakistan
| | - Muhammad Salih
- Department of Gastroenterology and Hepatology, Shifa International Hospital, Pakistan
| | - Najmul Hassan Shah
- Department of Gastroenterology and Hepatology, Shifa International Hospital, Pakistan
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Bhatti ABH, Dar FS, Hashmi SS, Zia H, Malik MI, Shah NH. Paediatric Living Donor Liver Transplantation: ASingle Centre Experience from Pakistan. J Coll Physicians Surg Pak 2016; 26:476-480. [PMID: 27353983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 03/11/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To determine the outcomes of paediatric living donor liver transplantation (LDLT) recipients from Pakistan in terms of 90-day morbidity and mortality. STUDY DESIGN Cohort study. PLACE AND DURATION OF STUDY Shifa International Hospital, Islamabad, Pakistan, between April 2012 and April 2015. METHODOLOGY All patients in paediatric age group (≤ 17 years) who underwent LDLT with a minimum follow-up of 3 months, were included. All grade 2 and above complications on Clavien-Dindo system were included as morbidity. The main outcome measure was 90-day morbidity and mortality. RESULTS Fourteen paediatric LDLTs were performed. Median age of the recipients was 8.5 years ranging between 6 months and 17 years. Wilson's disease and cryptogenic cirrhosis were the most common etiologies (28.6% each). Acute liver failure was present in 5 (35.7%) patients. Overall 90-day morbidity and mortality was 71.4% and 14.2%; both were attributable to pulmonary infection. No difference was observed in morbidity (21.3% vs. 42.8%, p=0.3) and mortality rates (20% vs. 11%, p=1.0) between patients with acute and chronic liver failure. Estimated 3-year survival was 85%. CONCLUSION Paediatric LDLT offers a promising treatment option for acute and chronic liver failure. Mortality was attributable to post-transplant pulmonary infections.
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Affiliation(s)
| | - Faisal Saud Dar
- Department of HPB and Liver Transplantation, Shifa International Hospital, Karachi
| | | | - Haseeb Zia
- Department of HPB and Liver Transplantation, Shifa International Hospital, Karachi
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28
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Dar FS, Bhatti ABH, Hashmi SS, Zia H, Malik MI. Auxiliary partial orthotopic liver transplant for Criggler-Najjar Syndrome: Report of 2 cases from Pakistan. J Pak Med Assoc 2016; 66:615-7. [PMID: 27183949 DOI: pmid/27183949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Auxiliary partial orthotopic liver transplant (APOLT) is a treatment option for certain liver disorders where liver structure is preserved. It includes Criggler Najjar syndrome (CNS), urea cycle defects and familial hypercholesterolaemia. Liver transplant as a treatment modality has only recently become available in Pakistan. Here we report two paediatric cases of CNS type 1 where auxiliary liver transplant was performed to correct jaundice and prevent inevitable brain damage. Both recipients and their respective living donors had successful surgery and are doing well.
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Affiliation(s)
- Faisal Saud Dar
- HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | | | - Syeda Shaheera Hashmi
- Department of Paediatrics and Paediatric Hepatology, Shifa International Hospital, Islamabad, Pakistan
| | - Haseeb Zia
- HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Munir Iqbal Malik
- Department of Paediatrics and Paediatric Hepatology, Shifa International Hospital, Islamabad, Pakistan
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Dar FS, Zia H, Hafeez Bhatti AB, Rana A, Nazer R, Kazmi R, Khan EUD, Khan NA, Salih M, Shah NH. Short Term Donor Outcomes After Hepatectomy in Living Donor Liver Transplantation. J Coll Physicians Surg Pak 2016; 26:272-276. [PMID: 27097696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 12/11/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To determine the outcome of living-donor liver transplant (LDLT) donors from the first liver transplant program in Pakistan. STUDY DESIGN Cohort study. PLACE AND DURATION OF STUDY Shifa International Hospital, Islamabad, from April 2012 to August 2014. METHODOLOGY A total of 100 live donors who underwent hepatectomy were included. Demographics, etiologies, graft characteristics and operative variables were retrospectively assessed. Outcome was assessed based on morbidity and mortality. RESULTS Median donor age was 28 (17 - 45) years and median body mass index (BMI) was 24 kg/m2 (15 - 36). Male to female ratio was 1.5:1. Hepatitis B and C were the most common underlying etiologies and accounted for 79/100 (79%) of LDLT&#039;s. Overall, 93/100 (93%) donors donated a right lobe graft. Median estimated graft weight to recipient body weight (GW/BW) ratio was 1.03 (0.78 - 2). Standard arterial anatomy was present in 56% donors. The 90-day morbidity was 13/100 (13%) and overall morbidity was 17/100 (17%). Bile leak was encountered in 3 (3%) patients. There was no donor mortality. CONCLUSION Acceptable short-term donor outcomes were achieved in an LDLT program in Pakistan with careful donor selection and planning.
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Affiliation(s)
- Faisal Saud Dar
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad
| | - Haseeb Zia
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad
| | | | - Atif Rana
- Department of Radiology, Shifa International Hospital, Islamabad
| | - Rashid Nazer
- Department of Radiology, Shifa International Hospital, Islamabad
| | - Rubab Kazmi
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad
| | | | - Nasir Ayub Khan
- Department of Anesthesia, Shifa International Hospital, Islamabad
| | - Muhammad Salih
- Department of Hepatology, Shifa International Hospital, Islamabad
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30
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Dar FS, Bhatti ABH, Dogar AW, Zia H, Ulhaq I, Rana A, Khan NA, Liaqat A, Salih M, Shah NH. Is pancreaticodoudenectomy with vascular resection a safe procedure in developing country? Early outcomes and review of national literature. Int J Surg 2015; 21:8-13. [PMID: 26163885 DOI: 10.1016/j.ijsu.2015.06.073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/09/2015] [Accepted: 06/24/2015] [Indexed: 02/05/2023]
Affiliation(s)
- Faisal Saud Dar
- Department of HPB and Liver Transplantation, Shifa International Hospital Islamabad, Pakistan
| | - Abu Bakar Hafeez Bhatti
- Department of HPB and Liver Transplantation, Shifa International Hospital Islamabad, Pakistan.
| | - Abdul Wahab Dogar
- Department of HPB and Liver Transplantation, Shifa International Hospital Islamabad, Pakistan
| | - Haseeb Zia
- Department of HPB and Liver Transplantation, Shifa International Hospital Islamabad, Pakistan
| | - Ihsan Ulhaq
- Department of HPB and Liver Transplantation, Shifa International Hospital Islamabad, Pakistan
| | - Atif Rana
- Department of Radiology, Shifa International Hospital Islamabad, Pakistan
| | - Nasir Ayub Khan
- Department of Anesthesiology, Shifa International Hospital Islamabad, Pakistan
| | - Amna Liaqat
- Department of HPB and Liver Transplantation, Shifa International Hospital Islamabad, Pakistan
| | - Muhammad Salih
- Department of Gastroenterology/Hepatology, Shifa International Hospital Islamabad, Pakistan
| | - Najmul Hassan Shah
- Department of Gastroenterology/Hepatology, Shifa International Hospital Islamabad, Pakistan
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Dar FS, Bhatti ABH, Dogar AW, Zia H, Amin S, Rana A, Nazer R, Khan NA, Khan EUD, Rajput MZ, Salih M, Shah NH. The travails of setting up a living donor liver transplant program: Experience from Pakistan and lessons learned. Liver Transpl 2015; 21:982-90. [PMID: 25891412 DOI: 10.1002/lt.24151] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 04/07/2015] [Indexed: 02/05/2023]
Abstract
Living donor liver transplantation (LDLT) is the only treatment option for patients with end-stage liver disease (ESLD) where cadaveric donors are not available. In developing countries, the inception of LDLT programs remains a challenge. The first successful liver transplantation program in Pakistan started transplantation in 2012. The objective of this study was to report outcomes of 100 LDLT recipients in a developing country and to highlight the challenges encountered by a new LDLT program in a resource-limited setting. We retrospectively reviewed recipients who underwent LDLT between April 2012 and August 2014. Demographics, etiology, graft characteristics, and operative variables were assessed. Outcome was assessed on the basis of morbidity and mortality. All complications of ≥ 3 on the Clavien-Dindo grading system were included as morbidity. Estimated 1-year survival was calculated using Kaplan-Meier curves, and a Log-rank test was used to determine the significance. Outcomes between the first 50 LDLTs (group 1) and latter 50 LDLTs (group 2) were also compared. Median age was 46.5 (0.5-72) years, whereas the median MELD score was 15.5 (7-37). The male to female ratio was 4:1. ESLD secondary to hepatitis C virus was the most common indication (73% patients). There were 52 (52%) significant (≥ grade 3) complications. The most common morbidities were bile leaks in 9 (9%) and biliary strictures in 14 (14%) patients. Overall mortality in patients who underwent LDLT for ESLD was 10.6%. Estimated 1-year survival was 87%. Patients who underwent transplantation in the latter period had a significantly lower overall complication rate (36% versus 68%; P = 0.01). Comparable outcomes can be achieved in a new LDLT program in a developing country. Outcomes improve as experience increases.
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Affiliation(s)
- Faisal Saud Dar
- Departments of Hepato-Pancreato-Biliary and Liver Transplant Surgery
| | | | - Abdul-Wahab Dogar
- Departments of Hepato-Pancreato-Biliary and Liver Transplant Surgery
| | - Haseeb Zia
- Departments of Hepato-Pancreato-Biliary and Liver Transplant Surgery
| | - Sadaf Amin
- Departments of Hepato-Pancreato-Biliary and Liver Transplant Surgery
| | | | | | | | | | | | - Muhammad Salih
- Transplant Hepatology, Shifa International Hospital, Islamabad, Pakistan
| | - Najmul Hassan Shah
- Transplant Hepatology, Shifa International Hospital, Islamabad, Pakistan
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Bhatti ABH, Dar FS, Zia H. Where angels fear to tread: donor bile duct division in living donor liver transplant. Transpl Int 2015; 28:1445-6. [PMID: 26016706 DOI: 10.1111/tri.12613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
| | - Faisal Saud Dar
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan.
| | - Haseeb Zia
- Department of HPB and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan
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Qureshi MO, Dar FS, Khokhar N. Cancer Antigen-125 as a marker of ascites in patients with liver cirrhosis. J Coll Physicians Surg Pak 2015; 24:232-5. [PMID: 24709233 DOI: 04.2014/jcpsp.232235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 11/05/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the correlation between Cancer Antigen-25 (CA-125) levels with the amount of ascites in patients with liver cirrhosis. STUDY DESIGN Observational, analytical study. PLACE AND DURATION OF STUDY Shifa International Hospital, Islamabad, from March 2012 to February 2013. METHODOLOGY A total of 130 patients with liver cirrhosis (with and without ascites) had serum CA-125 levels measured. The amount of ascites was classified according to physical examination and ultrasound (USG) findings. CA-125 levels were compared and correlated with amount of ascites. RESULTS Majority of patients (57%) had hepatitis C virus and 60% were in class Child Pugh C. There was moderate correlation between amount of ascites and CA-125 levels (r = 0.642, p < 0.001) with significant raised levels of CA-125 in patients with ascites (p < 0.001). CONCLUSION There was a moderate correlation between CA-125 levels and presence and amount of ascites.
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Affiliation(s)
| | - Faisal Saud Dar
- Department of Gastroenterology, Shifa International Hospital, Islamabad
| | - Nasir Khokhar
- Department of Gastroenterology, Shifa International Hospital, Islamabad
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Qureshi MO, Dar FS, Khokhar N. Authors reply. J Coll Physicians Surg Pak 2014; 24:873-874. [PMID: 25556262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Qureshi MO, Shafqat F, Dar FS, Salih M, Khokhar N. Renal failure in patients with end stage liver disease and its impact on clinical outcome. J Coll Physicians Surg Pak 2014; 24:628-31. [PMID: 25233964 DOI: 09.2014/jcpsp.628631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 04/22/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the prevalence of renal failure (RF) in the patients of end stage liver disease (ESLD), to determine the causes of RF in these patients and its impact on patient's outcome. STUDY DESIGN Descriptive, analytical study. PLACE AND DURATION OF STUDY Shifa International Hospital, Islamabad, Pakistan, from May 2011 to March 2013. METHODOLOGY A total of 523 patients with end stage liver disease (ESLD) were evaluated, renal failure (RF) and its causes were recognized in these patients according to established criteria. Outcome of these patients was assigned as reversal of RF or mortality. Data was analyzed using SPSS version 16. Chi-square test was used for comparing proportions and t-test was used for comparing mean values. P < 0.05 was considered significant. RESULTS Out of 523 patients, 261 (49.9%) had RF. Acute kidney injury (AKI) was the most common presentation seen in 160 (61%) patients. Hypovolemia and infections were the most frequent causes of RF. Mortality was significantly higher in the patients with RF, when compared to the patients without RF (31% vs. 4.5%, p < 0.001). Reversal of RF was seen in 98 (37%) of the affected patients. Reversal was more common in the patients with hypovolemia. The mortality was higher in the patients with hepatorenal syndrome (HRS) and infections. CONCLUSION Renal failure in the end stage liver disease is an important prognostic factor. Etiology of RF is the key factor in patients' outcome. Patients of ESLD with RF had higher mortality. Majority of the cases of RF were reversible in patients of ESLD coming in the setup.
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Affiliation(s)
| | - Farzana Shafqat
- Department of Gastroenterology, Shifa International Hospital, Islamabad
| | - Faisal Saud Dar
- Department of Gastroenterology, Shifa International Hospital, Islamabad
| | - Mohammad Salih
- Department of Gastroenterology, Shifa International Hospital, Islamabad
| | - Nasir Khokhar
- Department of Gastroenterology, Shifa International Hospital, Islamabad
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Hafeez Bhatti AB, Dar FS, Pervez M. Adrenal angiomyolipoma. J Coll Physicians Surg Pak 2014; 23:663-4. [PMID: 24034195 DOI: 09.2013/jcpsp.663664] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 10/15/2012] [Indexed: 02/05/2023]
Abstract
Adrenal angiomyolipoma is a rare tumour arising from the mesenchymal tissue containing fat cells. A 72 years old lady presented with right upper quadrant pain. She underwent laparotomy after relevant imaging and investigations and was found to have a right sided adrenal angiomyolipoma confirmed on histopathology, which was encasing the inferior vena cava and renal veins. Due to its diagnostic difficulty, potential to achieve large size and possible complications; surgeons and pathologists should keep angiomyolipoma in mind when dealing with an adrenal mass.
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Zahid MA, Waqar SH, Shamsuddin S, Ahmed I, Dar FS. Leiomyoma of oesophagus. J Coll Physicians Surg Pak 2003; 13:347-9. [PMID: 12814536 DOI: 06.2003/jcpsp.347349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2002] [Accepted: 04/26/2003] [Indexed: 11/06/2022]
Abstract
We present a case of leiomyoma oesophagus which was presented in our surgical outpatient department with symptom of dysphagia for the last one year. Patient was investigated and diagnosed as a case of benign oesophageal neoplasm. She was successfully treated by transthoracic enucleation in our surgical unit at PIMS, Islamabad.
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Affiliation(s)
- M A Zahid
- Department of Surgery, Unit I, Pakistan Institute of Medical Sciences, Islamabad
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Zahid MA, Bakhsh R, Dar FS, Akhter N, Malik ZI. Comparison of single dose and three dose antibiotic prophylaxis with cefotaxime sodium in cholecystectomy. J Ayub Med Coll Abbottabad 2003; 15:38-40. [PMID: 12870316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
BACKGROUND This study was conducted in Surgical Unit-I at Pakistan Institute of Medical Sciences (PIMS), Islamabad from October 2000 to March 2002. The objective of the study was to compare the results of single dose versus three-dose prophylaxis by cefotaxime sodium in patients undergoing elective cholecystectomy. METHODS Intravenous Cefotaxime sodium as a prophylaxis was used in 150 patients who underwent elective cholecystectomy. Half of the patients were given single dose one hour before surgery (Group A) while the other half (Group B) was given three doses, first one hour before surgery, second and third were given at 8 hour interval after surgery. Postoperative hospital stay of all but two patients was not more than three days. Evidence of wound infection was observed for 4 weeks post-operative in surgical out patient department in both groups. RESULTS Three patients in group A and four in group B got wound infection. The difference was not statistically significant. CONCLUSION Single preoperative dose can be recommended in cholecystectomy as it is less costly and has the same prophylactic benefits as of single dose.
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Affiliation(s)
- M A Zahid
- Pakistan Institute of Medical Sciences, Islamabad
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Bakhsh R, Zahid MA, Dar FS, Malik ZI, Akhtar N, Akhtar S. Iatrogenic bile duct injuries: experience at PIMS. J Ayub Med Coll Abbottabad 2002; 14:16-8. [PMID: 12688095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
BACKGROUND Cholecystectomy is one of the most familiar and commonly performed elective operation in general surgery. However, bile duct injury is a rare but one of the worst complications of this procedure. Although infrequent in expert hands, it is usually encountered when comparatively inexperienced surgeons are operating. These injuries present at variable time after the primary surgery. The prompt recognition and active management affects the morbidity and mortality associated with it. We evaluated the data of the hospital to find out the nature of injuries inflicted to extra hepatic bile duct and its management. METHODS This is a study of 20 cases of iatrogenic bile duct injury managed at the Department of Surgery Unit I, PIMS. The study includes cases that had undergone cholecystectomy, open or laparoscopic in previous 11 years and sustained injury to the biliary tree and were managed accordingly. Patients with hepatobiliary malignancy were excluded. RESULTS Twenty cases were found to have various types of bile duct injuries. All patients were females, and their average age was 35 years. In four cases the injury occurred during surgery at our hospital, while remaining 16 cases were referred from other hospitals. All the patients, were explored and managed accordingly. They had uneventful recovery and had good outcome at 6 months. CONCLUSION Although the fact is that, the sooner an injury is recognized and treated, the better is the outcome. However, in this study the duration of injury had no effect on final outcome.
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