The Effect of Pringle Maneuver Applied during Living Donor Hepatectomy on the Ischemia-Reperfusion Injury Observed in the Donors and Recipients

Background and Objectives: The aim of this study is to evaluate the clinical and laboratory changes of ischemia and reperfusion injury in the remnant livers of donors with and without Pringle maneuver. Furthermore, we evaluated the recipients who have been transplanted with liver grafts from these donors. Methods and Materials: A total of 108 patients (54 living liver donors and 54 liver recipients) who underwent donor hepatectomy and recipients who living donor liver transplantation, were included in this randomized double-blind study between February 2021 and June 2021. The donors were divided into two groups: Pringle maneuver applied (n = 27) and Pringle maneuver not applied (n = 27). Similarly, recipients with implanted liver obtained from these donors were divided into two groups as the Pringle maneuver was performed (n = 27) and not performed (n = 27). Blood samples from donors and recipients were obtained on pre-operative, post-operative 0 h day (day of surgery), post-operative 1st day, post-operative 2nd day, post-operative 3rd day, post-operative 4th day, post-operative 5th day, and liver tissue was taken from the graft during the back table procedures. Liver function tests and complete blood count, coagulation tests, IL-1, IL-2, IL-6, TNF-α, and β-galactosidase measurements, and histopathological findings were examined. Results: There was no statistically significant difference in the parameters of biochemical analyses for ischemia-reperfusion injury at all periods in the donors with and without the Pringle maneuver. Similarly, there was no statistically significant difference between in the recipients in who received liver grafts harvested with and without the Pringle maneuver. There was no statistically significant difference between the two recipient groups in terms of perioperative bleeding and early bile duct complications (p = 0.685). In the histopathological examinations, hepatocyte damage was significantly higher in the Pringle maneuver group (p = 0.001). Conclusions: Although the histological scoring of hepatocyte damage was found to be higher in the Pringle maneuver group, the Pringle maneuver did not augment ischemia-reperfusion injury in donors and recipients that was evaluated by clinical and laboratory analyses.

Effect of COVID-19 Pandemic on Patients Who Have Undergone Liver Transplantation: Retrospective Cohort Study

BACKGROUND

In liver transplant (LT) recipients, immunosuppressive therapy may potentially increase the risk of severe COVID-19 and may increase the mortality in patients. However, studies have shown conflicting results, with various studies reporting poor outcomes while the others show no difference between the LT recipients and healthy population. The aim of this study is to determine the impact of the COVID-19 pandemic on survival of LT recipients.

METHODS

This is a retrospective cohort study analyzing the data from 387 LT recipients diagnosed with COVID-19. LT recipients were divided into two groups: survival (n = 359) and non-survival (n = 28) groups. A logistic regression model was used to determine the independent risk factors for mortality. Machine learning models were used to analyze the contribution of independent variables to the mortality in LT recipients.

RESULTS

The COVID-19-related mortality rate in LT recipients was 7.2%. Multivariate analysis showed that everolimus use (p = 0.012; OR = 6.2), need for intubation (p = 0.001; OR = 38.4) and discontinuation of immunosuppressive therapy (p = 0.047; OR = 7.3) were independent risk factors for mortality. Furthermore, COVID-19 vaccination reduced the risk of mortality by 100 fold and was the single independent factor determining the survival of the LT recipients.

CONCLUSION

The effect of COVID-19 infection on LT recipients is slightly different from the effect of the disease on the general population. The COVID-19-related mortality is lower than the general population and vaccination for COVID-19 significantly reduces the risk of mortality.

Effect of the COVID-19 Pandemic on the Psychological Health of Patients Who Underwent Liver Transplantation Due to Hepatocellular Carcinoma

BACKGROUND

The primary aim of this study was to compare liver transplant (LT) recipients with and without hepatocellular carcinoma (HCC) in terms of COVID-19-related depression, anxiety, and stress.

METHOD

A total of 504 LT recipients with (HCC group; n = 252) and without HCC (non-HCC group; n = 252) were included in the present case-control study. Depression Anxiety Stress Scales (DASS-21) and Coronavirus Anxiety Scale (CAS) were used to evaluate the depression, stress, and anxiety levels of LT patients. DASS-21 total and CAS-SF scores were determined as the primary outcomes of the study. Poisson regression and negative binomial regression models were used to predict the DASS and CAS scores. The incidence rate ratio (IRR) was used as a coefficient. Both groups were also compared in terms of awareness of the COVID-19 vaccine.

RESULTS

Poisson regression and negative binomial regression analyses for DASS-21 total and CAS-SF scales showed that the negative binomial regression method was the appropriate model for both scales. According to this model, it was determined that the following independent variables increased the DASS-21 total score: non-HCC (IRR: 1.26; p = 0.031), female gender (IRR: 1.29; p = 0.036), presence of chronic disease (IRR: 1.65; p < 0.001), exposure to COVID-19 (IRR: 1.63; p < 0.001), and nonvaccination (IRR: 1.50; p = 0.002). On the other hand, it was determined that the following independent variables increased the CAS score: female gender (IRR:1.75; p = 0.014) and exposure to COVID-19 (IRR: 1.51; p = 0.048). Significant differences were found between the HCC and non-HCC groups in terms of median DASS-21 total (p < 0.001) and CAS-SF (p = 0.002) scores. Cronbach's alpha internal consistency coefficients of DASS-21 total and CAS-SF scales were calculated to be 0.823 and 0.783, respectively.

CONCLUSION

This study showed that the variables including patients without HCC, female gender, having a chronic disease, being exposed to COVID-19, and not being vaccinated against COVID-19 increased anxiety, depression, and stress. High internal consistency coefficients obtained from both scales indicate that these results are reliable.

Evaluation of the Turkish Population’s Perspective on COVID-19 Vaccine Hesitancy and Routine Childhood Vaccine Applications: National Survey Study

Background: It is important to evaluate the attitude of society towards vaccines to understand the rates of acceptance and hesitance towards vaccination, which are essential components of public health and epidemiology. This study aimed to evaluate the perspective of the Turkish population on COVID-19 status, rate of vaccination, and also to evaluate the reasons for refusal to vaccinate, vaccine hesitancy, and related factors. Methods: A total of 4539 participants were included in this population-based descriptive and cross-sectional study. The Nomenclature of Territorial Units for Statistics (NUTS-II) was used to obtain a representative sample and for this purpose Turkey was divided into 26 regions. Participants were randomly selected based on the demographic features and population ratios of the selected regions. The following parameters were evaluated: sociodemographic characteristics and perspectives on COVID-19 vaccines, Vaccine Hesitancy Scale Adapted to Pandemics (VHS-P), and Anti-Vaccine Scale-Long Form (AVS-LF) questions. Results: A total of 4539 participants, 2303 (50.7%) male and 2236 (49.3%) female, aged between 18 and 73 years, were included in this study. It was observed that 58.4% of the participants had hesitations towards COVID-19 vaccination, and 19.6% were hesitant about all childhood vaccinations. Those who did not have the COVID-19 vaccine, who did not think that the COVID-19 vaccine was protective, and who had hesitation to vaccinate against COVID-19 had significantly higher median scores on the VHS-P and AVS-LF scales, respectively (all p < 0.01). Those who did not have their children vaccinated in childhood and who were hesitant about childhood vaccinations, had significantly higher median scores on the VHS-P and AVS-LF scales, respectively (all p < 0.01). Conclusion: Although the rate of vaccination for COVID-19 was 93.4% in the study, hesitation to vaccinate was 58.4%. The median score of the scales of those who were hesitant about childhood vaccinations was higher than individuals who did not have any hesitation. In general, the source of concerns about vaccines should be clearly seen, and precautions should be taken.

Assessment of Liver Regeneration in Patients Who Have Undergone Living Donor Hepatectomy for Living Donor Liver Transplantation

BACKGROUND

Inflammation and the associated immune pathways are among the most important factors in liver regeneration after living donor hepatectomy. Various biomarkers, especially liver function tests, are used to show liver regeneration. The aim of this study was to evaluate the course of liver regeneration following donor hepatectomy (LDH) by routine and regeneration-related biomarkers.

METHOD

Data from 63 living liver donors (LLDs) who underwent LDH in Inonu University Liver Transplant Institute were prospectively analyzed. Serum samples were obtained on the preoperative day and postoperative days (POD) 1, 3, 5, 10, and 21. Regenerative markers including alfa-fetoprotein (AFP), des carboxy prothrombin (DCP), ornithine decarboxylase (ODC), retinol-binding protein 4 (RBP4), and angiotensin-converting enzyme isotype II (ACEII) and liver function tests including alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transferase (GGT), alkaline phosphatase (ALP) and total bilirubin levels were all analyzed.

RESULTS

The median age of the LLDs was 29.7 years and 28 LLDs were female. Eight LLDs developed postoperative complications requiring relaparotomy. The routine laboratory parameters including AST (<0.001), ALT (<0.001), ALP (<0.001), and total bilirubin (<0.001) showed a significant increase over time until postoperative day (POD) 3. For the regeneration-related parameters, except for the RBP4, all parameters including ACEII (p = 0.006), AFP (p = 0.002), DCP (p = 0.007), and ODC (p = 0.002) showed a significant increase in POD3. The regeneration parameters showed a different pattern of change. In right-lobe liver grafts, ACEII (p = 0.002), AFP (p = 0.035), and ODC (p = 0.001) showed a significant increase over time. DCP (p = 0.129) and RBP4 (p = 0.335) showed no significant changes in right-lobe liver grafts.

CONCLUSIONS

Regenerative markers are increased in a sustained fashion following LDH. This is more prominent following right-lobe grafts which are indicative of progenitor-associated liver regeneration.

Histopathological Features of Gallbladder Specimens Obtained From Liver Recipients

BACKGROUND

To evaluate the histopathological features of gallbladder specimens obtained from liver transplantation (LT) recipients and to find the correlation between these findings with the clinical features of patients.

METHODS

The 1985 patients who underwent LT in our institute between March 2002 and January 2021 and whose data regarding pathologic analysis of gallbladder could retrospectively be obtained were included in the study. The data of the patients including age, gender, the reason for LT (fulminant or nonfulminant), presence of ascites, macroscopic characteristics of gallbladder (the length, diameter, and wall thickness), and microscopic findings were all obtained and analyzed in the present study.

RESULTS

A total of 1985 patients (men = 1300 and women = 685) with a median age of 39.4 years were included in this study. LT was performed in 249 patients because of fulminant liver failure, and abdominal ascites were detected in 933 patients during LT. There were statistical differences in terms of age (P < .001), gallbladder length (P < .001). and width (P < .001) among the both gender, but there was no difference in terms of histopathologic characteristics and presence of gallstones. On the other hand, there were significant differences in terms of age (P < .001), gallbladder length (P < .001), width (P < .001), wall thickness (P = .021), presence of gallstones (P < .001), and histopathologic characteristics (P < .001) between the patients with fulminant and nonfulminant liver failure etiologies. Similar results were obtained when characteristics of patients with and without ascites were compared.

CONCLUSIONS

This the first study analyzing the histopathological analysis of gallbladder specimens in LT recipients. Chronic liver disease, presence of ascites and gender are the factors affecting the macroscopic and microscopic features of the gallbladder.

High-Level Procalcitonin in Patient with Mixed Fibrolamellar Hepatocellular Carcinoma: A Case Report and Literature Review

Course of blood procalcitonin levels by days.

Effect of the COVID-19 pandemic on patients with presumed diagnosis of acute appendicitis

BACKGROUND

Acute appendicitis (AAp) is the most frequent cause of acute abdominal pain, and appendectomy is the most frequent emergency procedure that is performed worldwide. The coronavirus disease 2019 (COVID-19) pandemic has caused delays in managing diseases requiring emergency approaches such as AAp and trauma.

AIM

To compare the demographic, clinical, and histopathological outcomes of patients with AAp who underwent appendectomy during pre-COVID-19 and COVID-19 periods.

METHODS

The demographic, clinical, biochemical, and histopathological parameters were evaluated and compared in patients who underwent appendectomy with the presumed diagnosis of AAp in the pre-COVID-19 (October 2018-March 2020) and COVID-19 (March 2020-July 2021) periods.

RESULTS

Admissions to our tertiary care hospital for AAp increased 44.8% in the COVID-19 period. Pre-COVID-19 (n = 154) and COVID-19 (n = 223) periods were compared for various parameters, and we found that there were statistically significant differences in terms of variables such as procedures performed on the weekdays or weekends [odds ratio (OR): 1.76; P = 0.018], presence of AAp findings on ultrasonography (OR: 15.4; P < 0.001), confirmation of AAp in the histopathologic analysis (OR: 2.6; P = 0.003), determination of perforation in the appendectomy specimen (OR: 2.2; P = 0.004), the diameter of the appendix (P < 0.001), and hospital stay (P = 0.003). There was no statistically significant difference in terms of interval between the initiation of symptoms and admission to the hospital between the pre-COVID-19 (median: 24 h; interquartile range: 34) and COVID-19 (median: 36 h; interquartile range: 60) periods (P = 0.348). The interval between the initiation of symptoms until the hospital admission was significantly longer in patients with perforated AAp regardless of the COVID-19 or pre-COVID-19 status (P < 0.001).

CONCLUSION

The present study showed that in the COVID-19 period, the ultrasonographic determination rate of AAp, perforation rate of AAp, and duration of hospital stay increased. On the other hand, negative appendectomy rate decreased. There was no statistically significant delay in hospital admissions that would delay the diagnosis of AAp in the COVID-19 period.

Liver transplantation for hepatocellular carcinoma: Historical evolution of transplantation criteria

Liver transplantation (LT) for hepatocellular carcinoma is still a hot topic, and the main factor that is associated with the success of treatment is to determine the patients who will benefit from LT. Milan criteria have been defined 25 years ago and still is being used for patient selection for LT. However, in living donor LT, the Milan criteria is being extended. Current criteria for patient selection do not only consider morphologic characteristics such as tumor size and number of tumor nodules but also biologic markers that show tumor aggressiveness is also being considered. In the present review article, we have summarized all the criteria and scoring systems regarding LT for hepatocellular carcinoma. All criteria have 5-year overall survival rates that were comparable to the Milan Criteria and ranged between 60%-85%. On the other hand, it was seen that the recurrence rates had increased as the Milan criteria were exceeded; the 5-year recurrence rates ranged between 4.9% to 39.9%. Treatment of hepatocellular carcinoma needs a multidisciplinary approach. Ideal selection criteria are yet to be discovered. The same is true for treatment modalities. The goal will be achieved by a harmonic interplay between basic science researchers and clinicians.

Impact of COVID-19 pandemic on clinicopathological features of transplant recipients with hepatocellular carcinoma: A case-control study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic had a significant impact on the management of all diseases. Various diseases such as cancer have a higher risk of COVID-19-related death. Despite this fact, any delay or alteration in treatment of cancer may have fatal consequences. Hepatocellular carcinoma (HCC) is an aggressive liver cancer that requires multimodality treatment to improve survival.

AIM

To evaluate the impact of COVID-19 on the management of patients with HCC by determining changes in demographic, clinical and histopathological variables.

METHODS

Demographic, clinical and pathological variables of patients with HCC who had undergone liver transplantation between March 2020 and June 2021 (Pandemic group, n = 48) were retrospectively compared with that of the patients with HCC transplanted between November 2018 and March 2020 (Pre-pandemic group, n = 61).

RESULTS

The median age of the patients in the study was 56 (interquartile range = 15). Ninety-seven patients (89%) were male and 12 were female (11%). The most common etiology of liver disease was hepatitis B virus (n = 52, 47.7%). According to our results, there was a 21.3% drop in the number of patients transplanted for HCC. There was no difference in the demographic, clinical and pathological characteristics of the patients except blood alkaline phosphatase levels (P = 0.029), lymphovascular invasion (P = 0.019) and type of the liver graft that was transplanted (P = 0.017).

CONCLUSION

It is important to develop a surveillance strategy for liver transplant centers. The liver transplantation for HCC is justified and safe provided that strict surveillance protocols are applied.

Adipose-derived stem cells in the treatment of hepatobiliary diseases and sepsis

Determination of the mesenchymal stem cells is one of the greatest and most exciting achievements that tissue engineering and regenerative medicine have achieved. Adipose-derived mesenchymal stem cells (AD-MSC) are easily isolated and cultured for a long time before losing their stem cell characteristics, which are self-renewal and pluripotency. AD-MSC are mesenchymal stem cells that have pluripotent lineage characteristics. They are easily accessible, and the fraction of stem cells in the adipose tissue lysates is highest among all other sources of mesenchymal stem cells. It is also HLA-DR negative and can be transplanted allogenically without the need for immunosuppression. These advantages have popularized its use in many fields including plastic reconstructive surgery. However, in the field of hepatology and liver transplantation, the progress is slower. AD-MSC have the potential to modulate inflammation, ameliorate ischemia-reperfusion injury, and support liver and biliary tract regeneration. These are very important for the treatment of various hepatobiliary diseases. Furthermore, the anti-inflammatory potential of these cells has paramount importance in the treatment of sepsis. We need alternative therapeutic approaches to treat end-stage liver failure. AD-MSC can provide a means of therapy to bridge to definitive therapeutic alternatives such as liver transplantation. Here we propose to review theoretic applications of AD-MSC in the treatment of hepatobiliary diseases and sepsis.

Portal vein reconstruction with cryopreserved vascular grafts: A two-edged sword

BACKGROUND

Portal vein anastomotic complications related to size discrepancy are important causes of morbidity and mortality in pediatric liver transplantation. Interposed vascular grafts in portal vein anastomosis can solve this problem. The aim of this study is to evaluate the results of pediatric liver transplantations performed using cryopreserved interposed vascular grafts between graft portal vein and superior mesenteric vein (SMV)-splenic vein (SpV) confluence.

METHODS

Twenty-nine pediatric patients received liver transplantation using cryopreserved venous grafts in our Liver Transplant Institute between 2013 and 2020 were included in this study. Demographic, clinical, and operative characteristics and postoperative follow-up were analyzed.

RESULTS

Sixteen patients (55.2%) had portal hypoplasia and five patients (17.2%) had portal vein thrombosis. In total, six patients (20.6%) suffered portal vein thrombosis in the early postoperative period. Three patients (10.3%) experienced portal vein thrombosis in the late postoperative period. Late portal vein thrombosis rate was significantly higher in patients with early portal vein thrombosis (3/6 patients [50%] versus 0/23 patients [0%]; p = .034). Lack of portal flow was significantly higher in patients with both early (50% versus 0%; p = .002) and late portal vein thrombosis (66.7% versus 6.7%; p = .03).

CONCLUSION

Preoperative portal vein thrombosis and insufficient flow are important factors affecting success of liver transplant in children. The use of interposed vein grafts in problematic portal anastomoses can overcome portal flow problems.

Hepatocellular Carcinoma Tumor Microenvironment and Its Implications in Terms of Anti-tumor Immunity: Future Perspectives for New Therapeutics

PURPOSE

Hepatocellular cancer is an insidious tumor that is often diagnosed in a later stage of life. The tumor microenvironment is the key to tumorigenesis and progression. Many cellular and non-cellular components orchestrate the intricate process of hepatocarcinogenesis. The most important feature of hepatocellular cancer is the immune evasion process. The present review aims to summarize the key components of the tumor microenvironment in the immune evasion process.

METHODS

Google Scholar and PubMed databases have been searched for the mesh terms "Hepatocellular carcinoma" or "Liver Cancer" and "microenvironment." The articles were reviewed and the components of the tumor microenvironment were summarized.

RESULTS

The tumor microenvironment is composed of tumor cells and non-tumoral stromal and immune cells. HCC tumor microenvironment supports aggressive tumor behavior, provides immune evasion, and is an obstacle for current immunotherapeutic strategies. The components of the tumor microenvironment are intratumoral macrophages (tumor-associated macrophages (TAM)), bone marrow-derived suppressor cells, tumor-associated neutrophils (TAN), fibroblasts in the tumor microenvironment, and the activated hepatic stellate cells.

CONCLUSION

There are intricate mechanisms that drive hepatocarcinogenesis. The tumor microenvironment is at the center of all the complex and diverse mechanisms. Effective and multistep immunotherapies should be developed to target different components of the tumor microenvironment.

Recommendations for the ethical guidelines for publication of scientific studies: The responsibilities of editors, reviewers and the authors

OBJECTIVE

We aimed to evaluate the role of anesthesiologist in the management of hydatid disease from the perspective of the editors, reviewers and the authors.

METHODS

We searched the PubMed/Medline database using the following keywords: (hydatid* OR echinococc*) AND (disease OR cyst) AND (anesthesiology). We have evaluated the authors, their institutions and department, and the aim of the studies. We also evaluated the studies published by anesthesiologists in terms of content.

RESULTS

The literature search showed 6344 articles published between February 2010 to 2021. Sixty-three had at least one anesthesiologist in the author list. Anesthesiologists were leading authors in 35 studies; and in 19 of them, all the authors were anesthesiologist. Sixteen (84.2%) of these articles defined the outcomes of surgical therapy and there was no information regarding anesthesia technique.

CONCLUSION

The results of our study emphasize an important controversy regarding jurisdiction of different departments in terms of scientific research ethics. We believe that different disciplines can work together to evaluate a scientific problem and can publish a study in collaboration. But collaboration is very important and violating the subject of another field without collaboration is a deontological problem.

Management of irreducible giant rectal prolapse: A case report and literature review

INTRODUCTION AND IMPORTANCE

Rectal prolapse is defined as herniation of mucosa or full-thickness of the rectal wall through the anal canal. It has a negative impact on the quality of life and therefore, it should be treated as soon as diagnosis is confirmed. Definitive treatment is surgical and it depends on the clinical characteristics of the patients. We aimed to present the one of the largest rectal prolapse case in the literature.

CASE PRESENTATION

A 32- years- old male patient with a history of severe constipation was admitted to our institution with a giant rectal prolapse. The prolapsed segment was incarcerated, and a semi-emergent procedure was performed though a mid-line laparotomy. The sigmoid colon was redundant and therefore sigmoid colon and the upper two thirds of rectum were resected and end to end anastomosis was performed. The patient was discharged postoperative day 7 without any complication.

CLINICAL DISCUSSION

Rectal prolapse has a negative impact on quality of life and should be operated as soon as the diagnosis is reached. The surgical strategy depends on the compliance of the patient as well as the experience of the surgical team.

CONCLUSION

Clinicians should know that chronic constipation together with other factors may result in rectal prolapse which may become disproportionately large in size.

Diagnostic and therapeutic management algorithm for biliary complications in living liver donors

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

Short-term experiences of a liver transplant centre before and after the COVID-19 pandemic

BACKGROUND/AIM

With the COVID-19 pandemic, managing the process of solid organ transplantation has become a significant matter for transplant centres. In this study, we report our experiences on evaluating the effects of COVID-19 in patients with recent liver transplants.

MATERIALS AND METHODS

We evaluated patients who received liver transplants during three close consecutive periods of time. For transplants conducted between October 1 and December 31, 2019, January 1 and March 10, 2020 and March 11 and June 22, 2020, the lung tomographies of patients were inspected for radiological signs of viral pneumonia. For patients after March 11, 2020, the hospital's electronic database system was scanned for preoperative and postoperative SARS-CoV-2 testing from Real-time Polymerase Chain Reaction (RT-PCR) of the respiratory tract samples.

RESULTS

A total of 149 patients over the age of 18 who received liver transplants at our centre between October 1, 2019 and June 22, 2020 were evaluated. During this time span, our centre conducted liver transplants on patients from 34 different provinces and also abroad. Within this time period, a total of nine patients had respiratory samples with a positive SARS-CoV-2 RT-PCR test. PCR of respiratory tract samples was performed in 21 (14%) patients to identify the other potential infective agents in the respiratory tracts; Rhinovirus and Influenza A were detected in two and respiratory syncytial virus (RSV) was detected in one patient. During the transplant periods, 99 (67.1%) patients were evaluated with computed tomography (CT). The CT findings of 18 (12%) patients were consistent with viral pneumonia. There was a statistically significant difference between the groups only in terms of air bronchogram findings (P = .012).

CONCLUSION

The clinical status of our short-term liver transplant patients was far better than we originally anticipated, but it remains obvious that the necessary precautions should continue to be taken.

Comment on: Acute rejection after liver transplantation is less common, but predicts better prognosis in HBV-related hepatocellular carcinoma patients

• There is a strong correlation between acute rejection episodes in the postoperative first month and primary etiology that requires liver transplantation. • This difference substantially disappears after the postoperative first month which suggest the effcet of removal of the tumor. • The functional immune status of the patients determines the prognosis following liver transplantation.

Comment on gallbladder polyps: Correlation of size and clinicopathologic characteristics based on updated definitions

• There was strong correlation between polyp diameter (≥ 10 mm vs <10 mm) and the risk of gallbladder cancer (OR=54; r=0.704). • There was moderate correlation between polyp diameter (10-19 mm vs <10 mm) and the risk of gallbladder cancer (OR=23; r=0.534). • There was moderate correlation between polyp diameter (≥ 20 mm vs <20 mm) and the risk of gallbladder cancer (OR=300; r=0.559). • There was moderate correlation between polyp diameter (≥ 20 mm vs <10 mm) and the risk of gallbladder cancer (OR=551; r=0.697). • Our results suggest that as the diameter of the polyp reaches 20 mm, it is necessary to plan a surgical treatment strategy as if the patient has gallbladder cancer.

Living Liver Donor With Fasciola Hepatica: First Case Report in the Literature

The major advantage of preoperative magnetic resonance cholangiopancreatography is that living liver donor candidates with complicated biliary tracts may not be exposed to unnecessary laparotomy. To the best of our knowledge, the case presented here features a condition so far not seen by the Liver Transplantation Society. A 27-year-old woman who presented to our clinic as a living liver donor candidate was evaluated but did not have a preoperative magnetic resonance cholangiopancreatography due to technical factors. After parenchymal transection, the right hepatic duct was incised just distal to the bifurcation when 8 fasciola hepatica parasites left the orifice of the remnant bile duct. The common bile duct was then irrigated, and the remnant bile duct orifice was closed, followed by a cholangiography, which showed no suspicious lesions in the biliary tracts. In addition, no suspicious lesions were identified during the postoperative cholangiography of the graft implanted in the recipient. The donor and recipient had postoperative enzyme-linked immunosorbent assay immunoglobulin G antibody titers of 12 and 4 U/mL (cutoff value = 10) for fasciola hepatica, respectively. Both the recipient and the donor received 2 doses of triclabendazole (10 mg/kg) during the postoperative period.

Comment on the Correlation between Complete Blood Count Parameters and Appendix Diameter for the Diagnosis of Acute Appendicitis

We read the recent article published by Daldal and colleague with great interest [...].

Comment on surgical approaches for definitive treatment of hepatic alveolar echinococcosis: results of a survey in 178 patients

Echinococcus multilocularis causes alveolar echinococcosis which is a chronic, progressive zoonotic disease that mainly affects the liver. Hepatic alveolar echinococcosis is insidious and the patients are asymptomatic most of the time. Generally, it is incidentally found on imaging studies performed for other reasons. Specific symptoms may evolve if the vascular and biliary structures of the liver are affected. Hepatic alveolar echinococcosis shows a similar pattern to malignancies in terms of radiologic and clinical features. For this reason, oncological surgical principles should be applied during the resection of hepatic alveolar echinococcosis. The gold standard surgical treatment is resection with negative surgical margin. However, in patients whose radical resection is not possible other therapeutic options include palliative resection which has no benefit to the patient, and other curative major surgical options such as ex vivo liver resection, and autotransplantation and ultimately liver transplantation. The remnant liver volume has paramount importance if resection is going to be performed. For this reason, occasionally, remnant liver volume hypertrophy is induced by employing either two-stage hepatectomy or associating liver partition and portal vein ligation for staged hepatectomy.

Transplantation Using Renal Grafts With Multiple Renal Arteries: A Putative Study on the Impact of Arterial Reconstruction Technique and Site of Implantation on Outcomes

BACKGROUND

In the present retrospective study, we analyzed the outcomes of patients transplanted with grafts with multiple renal arteries (MRAs).

PATIENTS AND METHODS

In total, 89 patients were transplanted with renal grafts with MRAs from 2003 to 2018. Demographic characteristics; type of donor; warm and cold ischemia times; arterial anastomosis technique; complications; graft function at first month, first year, and last outpatient clinic visit; and patient and graft survival were all retrospectively evaluated.

RESULTS

The mean age of the patients was 40.4 ± 13.3 years. Fifty-six patients (62.9%) were male. In total, 42 patients (47.2%) received renal grafts from living related donors. In group A (n = 24; 27%), anastomosis was performed separately to the recipient external or internal iliac arteries; in group B (n = 38; 42.7%), the secondary artery was anastomosed to the main artery in a side-to-side fashion to form a single common orifice; in group C (n = 27; 30.3%), secondary arteries were anastomosed to the main renal artery in an end-to-side fashion. Creatinine clearance at the first month was significantly lower for deceased-donor grafts compared to living-donor renal grafts (P < .05). Creatinine clearance in the first postoperative month was significantly lower in group A and creatinine clearance in the first year was significantly lower in group C (P < .05). The best survival was found for anastomosis to the internal iliac artery (P < .05).

CONCLUSION

MRAs can be safely used and the reconstruction technique does not matter if the graft kidney's arterial supply is preserved and the internal iliac artery is chosen for anastomosis.

Intraperitoneal rupture of the hydatid cyst disease: Single-center experience and literature review

BACKGROUND

The primary aim of this study was to present our experience on intraperitoneal rupture of the hydatid cyst in guidance of literature data.

METHODS

Demographical, clinical, radiological and postoperative follow-up data of 29 patients who underwent surgical treatment in our institution with an indication of intraperitoneal rupture of the hydatid cyst from January 2003 to July 2020 were analysed retropectively.

RESULTS

Among the 29 patients with an age range of from 16 to 79 years ( median= 39, IQR=25.5), 16 were male (55.2%) and 13 were female (44.8%). Intraperitoneal rupture of the hydatid cyst was spontaneous in 21 (72.4%), traumatic in 7 (24.13%) (2 of them were iatrogenic) and was due to shotgun in one patient. Vast majority of the patients were admitted to the emergency department in the first 24 hours after the onset of sign and symptoms. WBC varied from 8.600 to 30.900/mm3 (median=12.100, IQR=5.7). Ruptured cysts were localised in liver (n=25, 86.2%), in spleen (n=2, 6.89%) or in pelvis (n=2, 6.89%) and diameter varied from 40 to 200 mm (median= 90, IQR=50). Among the cysts ruptured in liver, 19 (76%) of them were localised in right lobe. Among the ruptured cysts of liver, 20 (80%) of them underwent conservative surgery (partial pericystectomy etc), remaining 5 patients (20%) underwent a radical surgical treatment (pericystectomy etc). A biliary orifice was diagnosed during surgical exploration in either cyst cavity or cut surface of liver in 12 (48%) of the patients. Patients with a dilated common bile duct or a visible biliary duct orifice in cystic cavity underwent common bile duct exploration and T-tube drainage procedure (n=6, 24%). One patient died on postoperative day one, due to cardiopulmonary complications secondary to cyst rupture. All along the postopeartive follow-up of median 1416 days, seven (24.1%) patients were diagnosed for diseased recurrence.

CONCLUSION

Intraperitoneal rupture of the hydatid cyst is a life-threatening complication of hydatid cyst disease, for which diagnosis without delay and timing of surgical treatment is essential. Anaphylactic shock cases require rapidly initiation of medical treatment against allergic reactions. Despite scolocidal agents, vesicular spread into peritoneal cavity account for the major risk factor for disease recurrence. Hence, abdominal cavity should be explored cautiously.