The first 4-way liver paired exchange from an interdisciplinary collaboration between health care professionals and design economists

We report initial results of a liver paired exchange (LPE) program established at the Liver Transplant Institute at Inonu University through collaboration with design economists. Since June 2022, the program has been using a matching procedure that maximizes the number of living donor liver transplants (LDLTs) to the patients in the pool subject to the ethical framework and the logistical constraints of the program. In 1 4-way and 4 2-way exchanges, 12 LDLTs have been performed via LPE in 2022. The 4-way exchange, generated in the same match run with a 2-way exchange, is a first worldwide. This match run generated LDLTs for 6 patients, revealing the value of the capacity to carry out larger than 2-way exchanges. With only 2-way exchanges, only 4 of these patients would receive a LDLT. The number of LDLTs from LPE can be increased by developing the capacity to perform larger than 2-way exchanges in either high-volume centers or multicenter programs.

Screening, Surveillance, and Management of Hepatocellular Carcinoma During the COVID-19 Pandemic: a Narrative Review

PURPOSE

The COVID-19 pandemic has been a burden to the global community as a whole but the healthcare community had bore the brunt of it. The pandemic resulted in policy changes that interfered with effective healthcare delivery. The healthcare community attempted to cope with the pandemic by triaging and prioritizing emergency conditions especially COVID related, ahead of elective conditions like cancer care. There was also fear that patients with cancer were at an increased risk of sever COVID-19 with increased mortality. Hepatocellular carcinoma (HCC) was also affected by these policies.

METHODS

We reviewed the modified measures adopted in screening, surveillance, and management of HCC during the pandemic using PubMed, Medline, Index Medicus, EMBASE, SCOPUS, and Google Scholar databases.

RESULT

The main modification in surveillance and screening for HCC during the pandemic includes limiting the surveillance to those with very high risk of HCC. The interval between surveillan was also delayed by few months in some cases. The adoption of teleconferencing for multidisciplinary team meetings and patient consultation is one of the highlights of this pandemic all in an effort to reduce contact and spread of the virus. The treatment of early-stage HCC was also modified as needed. The role of ablative therapy in the management of early HCC was very prominent during the pandemic as the surgical therapy was significantly affected by the lacks of ventilators and intensive care unit space resulting from the pandemic. Transplantation, especially living donor liver transplantation, was suspended in few centers because of the risk of infection to the living donors.

CONCLUSION

As we gradually recover from the pandemic, we should prepare for the fallout from the pandemic as we may encounter increased presentation of those patients deferred from screening during the pandemic.

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.

Histopathological Evaluation of Gallbladder Specimens Obtained From Living Liver Donors

BACKGROUND

Cholecystectomy is routinely performed during living donor hepatectomy both to see the structure of the biliary tract and to determine the demarcation line based on the biliary tract junction. This study aims to present the general histopathological features of the gallbladder specimen obtained from living liver donors (LLD).

METHODS

Data from 2577 LLDs who underwent living donor hepatectomy (n = 2511) or aborted living donor hepatectomy (n = 66) in our Liver Transplantation Institute between September 2005 and June 2021 were analyzed retrospectively. Age, gender, macroscopic (length, diameter, and wall thickness), and microscopic (histopathological) features of the gallbladder of the LLDs were recorded for use in this study.

RESULTS

A total of 2493 LLDs (men: 1486, women: 1007) with a median age of 29 years (interquartile range [IQR]: 13) met the inclusion criteria in this study. The median length, width and wall thickness of the gallbladder specimens were measured as 70 mm (IQR: 20), 50 mm (IQR: 20), and 2 mm (IQR: 1), respectively. The most common histopathological findings are normal structure (2026; 81.3%), chronic cholecystitis (n = 446; 17.9%), adenomyomatosis (n = 9), and papillary hyperplasia (n = 6), respectively. The most common pathologic findings in the gallbladder lumen are cholesterolosis (n = 207; 0.4%), cholelithiasis (n = 53), cholesterol polyp (n = 31), and noncholesterol polyp (n = 19), respectively. Significant differences were detected between the male and female genders in terms of age (P < .001), height (P < .001), weight (P < .001), body mass index (P < .001), gallbladder width (P = .001), gallbladder length (P < .001), histopathological finding (content) (P < .001), and lymph node around the gallbladder (P = .015).

CONCLUSIONS

The results we obtained in this study are true gallbladder pathologies that can be detected in healthy people. In this study, it was shown that the diameter and size of the gallbladder were larger in men, whereas the incidence of cholesterolosis and cholelithiasis was higher in women.

Measurement of Heavy Metal and Antioxidant-Oxidant Levels in Tissues Obtained From Three Different Localizations of Explant Hepatectomy of Patients With Hepatocellular Carcinoma

BACKGROUND

To reveal any difference in terms of heavy metal and antioxidant/oxidant levels of liver tissues obtained from 3 different locations of hepatectomy specimens of patients with hepatocellular carcinoma (HCC).

METHODS

Total hepatectomy materials of patients who underwent liver transplantation for HCC were objects of this study. Three liver tissue samples were obtained from each material, one from HCC tissue, one adjacent from the border of HCC, and one at least 3 cm distant from HCC, each 10 × 10 mm in diameter. Samples are preserved at -70°C. Levels of heavy metals (As, Cd, Cu, Mn, Pb, Se, and Zn) and oxidant-antioxidant parameters (catalase, glutathione peroxidase [GSHPx], superoxide dismutase [SOD], nitric oxide, prolidase, glutathione, malondialdehyde, total oxidant status, antioxidant status, oxidative stress index, total-thiol, native thiol, and disulphid) are measured.

RESULTS

This study included 22 patients (18 men, 4 women with an age range of 3 to 66 years. There were significant differences in terms of Cd, Pb, Zn, GSHPx, SOD, nitric oxide, and native thiol levels between liver tissues derived from 3 different locations. Cd, Pb, and Zn levels were significantly different in tumor tissues, whereas GSHPx and SOD levels were significantly different in tumor and neighboring tissues. Nitric oxide levels were relatively different in tumor tissues compared with tumor-neighboring tissues. Native thiol levels differed significantly in tumor tissues compared with tissues distant from tumor.

CONCLUSIONS

The aim of this study is unique in medical literature, which reveals that the amount of heavy metals and antioxidant/oxidant accumulation are variable in the same liver tissue in different locations because of multiple and yet unknown factors.

Management and Survival Analysis of Gastrointestinal Neuroendocrine Tumors by Different Tumor Characteristics: Tertiary Center Experience

BACKGROUND

Gastrointestinal neuroendocrine tumor (GI-NET) is a group of neoplasia consisting of amine and acid producing cells with different hormonal profiles. Although the entire GIS accounts for about 2% of tumors, recent research reveals that the incidence rate has increased. Given the increasing incidence in GI-NETs, more and more extensive research is needed on this subject. In this regard, the demographic and clinicopathological features of the patients diagnosed with GI-NET and their relationship with survival were investigated in the present study.

METHODS

Thirty-four patients diagnosed with GI-NETs between January 2009 and December 2019 at the Department of Gastroenterology, Inonu University Faculty of Medicine were analyzed retrospectively. Gender, age, tumor localization, metastasis status, tumor number, tumor diameter, tumor grade, Ki-67 index, and the relationships of these factors with overall survival were examined.

RESULTS

Of the patients, 61.8% included in the study were male and 38.2% were female. The average age of the patients was 60.74 years. The most common tumor location was in the stomach (26.5%) and liver (26.5%). Apart from this, 17.6% of NETs were seen in the pancreas, 11.8% in the colon, 8.8% in the rectum, 5.9% in the small intestine, and 2.9% in the appendix. No significant relationship was observed between tumor location and gender (p = .326) and age (p = .641). The tumor diameter ranged from 0.2 cm to 13.91 cm, but the average tumor diameter was 3.84 cm. Solitary tumor was found in 51.5% of cases and multiple tumors in 48.5% of cases. The most common grade was Grade 1 with 41.2% of occurrence. The average of Ki-67 index was 18.36%. There was metastasis in 52.9% of cases. The rate of medical treatment was 48.5%. The median overall survival time of the patients was 23.1 months. In addition, 1-year overall survival was 74.9%, 2-year overall survival was 44.6%, and 5-year overall survival was 35.7%. A statistically significant difference was found between tumor grade and the presence of metastasis, and the overall survival (p = .003 and p = .005).

CONCLUSIONS

The tumor grade and the presence of metastasis in gastrointestinal neuroendocrine tumors were found to be the most important prognostic factors affecting overall survival.

Squamous Cell Carcinoma Arising from Perianal Buschke-Lowenstein Tumor (Giant Condyloma Acuminatum): Comprehensive Literature Review

PURPOSE

This study aims to provide an overview of the literature on carcinoma arising from giant perianal condyloma acuminatum.

METHODS

We present a new case of squamous cell carcinoma arising from giant perianal condyloma acuminatum. We also conducted a systematic search of the medical literature using PubMed, Medline, Google, and Google Scholar related to carcinoma arising from giant perianal condyloma acuminatum. The following search terms were used in various combinations: condyloma acuminatum, giant condyloma acuminatum, Buschke-Lowenstein tumor, squamous cell carcinoma, and verrucous carcinoma. The search included articles published before in the English language November 2020.

RESULTS

A total of 55 article concerning 97 patients with carcinoma (squamous cell carcinoma, verrucous carcinoma, basaloid cell carcinoma, carcinoma insitu) arising from giant perianal condyloma acuminatum meeting the aforementioned criteria were included. The patients were aged from 24 to 82 years (median: 49.6, IQR: 21); 20 were female (median age: 52.5, IQR: 20.5), and 75 were male (median age: 53, IQR: 17.5). The gender data of the remaining two patients could not be obtained. The histopathological features of tumors arising from giant condyloma acuminatum are as follows: squamous cell carcinoma (n = 56), squamous cell carcinoma in situ (n = 16), verrucous carcinoma (n = 19) and basaloid cell carcinoma (n = 1), squamous cell carcinoma + verrucous carcinoma (n = 1), squamous cell carcinoma + squamous cell carcinoma in situ (n = 1), squamous cell carcinoma + basaloid cell carcinoma (n = 1) and malignant behavior (n = 2).

CONCLUSION

Giant condyloma acuminatum is a rare variant of anogenital warts. It is known that this tumor, which is mostly thought to be benign, has a high potential for local recurrence and transformation into invasive cancer. Therefore, it is vital that the tumor is resected with clean surgical margins, even if it looks benign, and that aggressive treatment options are not avoided when necessary.

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

Course of blood procalcitonin levels by days.

Can the Limits of Liver Transplantation Be Expanded in Perihilar Cholangiocarcinoma?

The most common location of cholangiocarcinomas is the perihilar region with a frequency of 50-70%. Current standard treatment for perihilar cholangiocarcinomas (pCCA) is surgical resection. In cases where resection treatment is possible, the 5-year survival rate is 8-40%. However, using a very strict patient selection, neoadjuvant radiochemotherapy (NRCT), staging laparotomy, and liver transplantation (LT), called "the Mayo protocol," 5-year survivals of up to 70% in pCCA were reported. This treatment protocol clearly requires an intensive workforce and a harmonious multidisciplinary approach. Reoperation and retransplantation rates are high, which is a reflection of the NRCT. Multicenter studies, systemic reviews, and meta-analysis results, comparing both resection and LT in pCCA treatment and evaluating only LT results, pointed to LT with strict patient selection and full compliance with the treatment. The results of centers experienced in LT are better in treating pCCA. According to Mayo clinical data, histopathological diagnosis could not be obtained in half of the patients with pCCA before NRCT was given. This situation can be explained by the necrosis of the tumor due to the effect of NRCT and the fact that the tumor cannot be detected in the explant liver. This situation raises the following questions: did all patients actually have pCCA? Were these good results due to some patients not having pCCA? The 5-year survival rate was worse in patients with a pathological diagnosis than those without a pathological diagnosis. However, interestingly, recurrence rates were statistically similar in both groups. There was no difference in survival between LT and resection in the R₀N₀ subgroup in de novo pCCA. There are still many issues that need to be addressed and corrected in pCCA, which is one of the most problematic indications for LT. Significant success has been achieved with NRCT, staging laparotomy, and LT in selected patients with pCCA developing on the basis of PSC or early-stage unresectable de novo pCCA. It can be expected that new NRCT modalities will provide better survival by expanding the indications for LT in pCCA.

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.

Management of granulomatous lobular mastitis: an international multidisciplinary consensus (2021 edition)

Granulomatous lobular mastitis (GLM) is a rare and chronic benign inflammatory disease of the breast. Difficulties exist in the management of GLM for many front-line surgeons and medical specialists who care for patients with inflammatory disorders of the breast. This consensus is summarized to establish evidence-based recommendations for the management of GLM. Literature was reviewed using PubMed from January 1, 1971 to July 31, 2020. Sixty-six international experienced multidisciplinary experts from 11 countries or regions were invited to review the evidence. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Experts discussed and concluded 30 recommendations on historical definitions, etiology and predisposing factors, diagnosis criteria, treatment, clinical stages, relapse and recurrence of GLM. GLM was recommended as a widely accepted definition. In addition, this consensus introduced a new clinical stages and management algorithm for GLM to provide individual treatment strategies. In conclusion, diagnosis of GLM depends on a combination of history, clinical manifestations, imaging examinations, laboratory examinations and pathology. The approach to treatment of GLM should be applied according to the different clinical stage of GLM. This evidence-based consensus would be valuable to assist front-line surgeons and medical specialists in the optimal management of GLM.

Assessment of Knowledge and Attitudes Toward Organ Donation Among School Teachers: First National Survey Study

BACKGROUND AND AIM

The most important factors affecting organ donation are socioeconomic, educational, and cultural factors. The aim of this study was to evaluate the attitudes, knowledge levels, and behaviors of school teachers toward organ donation METHODS: This study surveyed 2400 school teachers working in official public schools. Turkey was divided into 26 regions based on the similarity of social, economic, and geographic factors identified by the Turkish Statistical Institute. Teachers were distributed equally in the city center and towns based on population. The survey procedures were carried out using computer-assisted personal interviewing.

RESULTS

Among teachers, 89.6% had a bachelor's degree and 8.5% had a master's degree. In addition, 32.5% worked in primary schools, 33.1% worked in secondary schools, and 34.4% worked in high schools. Furthermore, 0.7% had donated an organ; 66.5% were not considering organ donation in the future, of whom 9.0% indicated religion as the reason for not donating an organ, and 34.8% did not indicate any reason. In addition, 96.6% considered organ donation to be proper behavior for humanity and 68% believed that organ donation is appropriate in religious terms.

CONCLUSIONS

This study showed that school teachers have inadequate knowledge and attitudes toward organ donation. Encouraging children and adolescents to make a well-informed decision about organ donation and to register this choice will depend largely on preparing school teachers with adequate knowledge and motivation toward creating generations with a positive attitude toward organ donation.

In memoriam of Thomas Earl Starzl, the pioneer of liver transplantation

Starzl’s nearly 3000 publications that contribute to the science of transplantation in every field have been the most important resources for every scientist working in this field. For those of us who work in the liver transplant field, his contributions throughout his life have shaped our career and passion, even for those who have never met, spoken to, or worked with him. If we are able to help patients with liver failure today by offering them the chance of transplantation, it is because of Starzl’s passionate work and efforts. Thanks to Starzl’s scientific legacy, hundreds of scientists serve humanity and thousands of patients can hold on to life. It has been an honor for us to write this article about Professor Starzl.

Autoimmune hepatitis and liver transplantation: Indications, and recurrent and de novo autoimmune hepatitis

Autoimmune hepatitis is a chronic inflammatory disease of the liver that is characterized by circulating autoantibodies and elevated serum globulin levels. Liver transplantation may be required for patients with acute liver failure, decompensated cirrhosis, and hepatocellular carcinoma. Recurrence is defined as development of the same disease in the allograft following liver transplantation. Autoimmune hepatitis recurs in 36%-68% of the recipients 5 years after liver transplantation. De novo autoimmune hepatitis is the development of autoimmune hepatitis like clinical and laboratory characteristics in patients who had undergone liver transplantation for causes other than autoimmune hepatitis. Diagnostic work up for recurrent and de novo autoimmune hepatitis is similar to the diagnosis of the original disease, and it is usually difficult. Predniso(lo)ne with or without azathioprine is the main treatment for recurrent and de novo autoimmune hepatitis. Early diagnosis and treatment are vital for patient prognosis because de novo autoimmune hepatitis and recurrent autoimmune hepatitis cause graft loss and result in subsequent retransplantation if medical treatment fails.

Coronavirus Precautions: Experience of High Volume Liver Transplant Institute

BACKGROUND

To present the struggle of a high volume liver transplant center against coronavirus infectious disease-2019 pandemic.

METHODS

Between March 2020 and December 2020, the demographic and clinical data of staff and liver transplant candidates diagnosed with coronavirus infectious disease-2019 in our Liver Transplant Institute were prospectively analyzed.

RESULTS

First, 32 healthcare staff were diagnosed with coronavirus infectious disease-2019, and 6 of them were surgeons. Six staff were asymptomatic, while 24 staff had mild or moderate and 2 staff had severe coronavirus infectious disease-2019. All the staff recovered from the disease without any permanent sequela and returned to duty after 2 consecutive negative polymerase chain reaction results within 24-hour intervals. Second, during the preoperative investigation, 6 living liver donor candidates and 13 recipients were tested positive for coronavirus infectious disease-2019 (son = 6, unrelated = 3, cousin = 3, daughter = 2, cadaveric = 1). Eleven patients received favipiravir and 8 did not receive any treatment because they were asymptomatic. Only one recipient who had severe coronavirus infectious disease-2019 died due to multiple organ failure syndrome. One recipient died in the early postoperative period. The median duration from the initial diagnosis of the patients till the transplant procedure was 21 days (min-max: 14-105 days). During the time of operation, the polymerase chain reaction tests of the donors and the recipients were negative, and the thorax tomography images showed no signs of viral pneumonia.

CONCLUSION

Meticulous precautions, multidisciplinary approach, team effort, and organization of facilities can increase the quality of care of these patients in the coronavirus infectious disease-2019 era. Healthcare workers have shown tremendous effort and are the true heroes of this era.

Microscopic Portal Vein Invasion in Relation to Tumor Focality and Dimension in Patients with Hepatocellular Carcinoma

BACKGROUND

Microscopic portal vein invasion (microPVI) and tumor multifocality are hepatocellular carcinoma (HCC) prognosis factors. To investigate whether microPVI and multifocality are directly related to each other.

METHODS

We retrospectively analyzed the relationships between microPVI, multifocality, and maximum tumor diameter (MTD) in prospectively collected transplanted HCC patients.

RESULTS

HCCs with 1, 2, or ≥ 3 foci had more microPVI in larger than in smaller HCCs, with microPVI being present in 52.24% of single large foci. Conversely, microPVI patients had similar percentages of single and multifocal lesions. A linear regression model of MTD, showed microPVI best associated with MTD, with 2.49 as coefficient, whereas multifocality had a 0.83 coefficient. A logistic regression model of microPVI showed significant association with tumor multifocality, especially for small HCCs. Trends for microPVI and multifocality in relation to MTD revealed that both increased with MTD but more significantly for microPVI. Survival was similar in patients with small HCCs, with or without microPVI, but was significantly worse in microPVI patients with larger HCCs. No patient survival differences were found in relation to focality.

CONCLUSIONS

MTD had stronger associations with microPVI than with multifocality. microPVI was associated with worse survival in patients with large HCCs, but survival was not impacted by number of tumor foci. microPVI and multifocality appear weakly related, having different behavior in relation to MTD and survival.

Gastrointestinal Kaposi Sarcoma Involving Stomach and Colon: Diagnostic Pitfall for Pathologists with Expression of CD117

Kaposi sarcoma (KS) is a low-grade vascular tumor caused by human herpes virus type 8 (HHV8). Gastrointestinal involvement of KS is rare and most commonly clinically silent. Gastrointestinal KS may mimic gastrointestinal stromal tumors (GISTs) histologically as the tumor formed by morphologically spindle-shaped cells, which is mostly located in the mucosa and submucosa. In the present study, we describe a case of Kaposi sarcoma that was first diagnosed in the gastrointestinal tract of a 73-year-old female patient who presented to the clinic with nausea and diarrhea. Immunohistochemical staining showed cytoplasmic CD117 expression both in stomach and colon biopsies. Although involvement of KS is rarely seen in the gastrointestinal tract (GIT), the differential diagnosis of low-grade spindle cell lesions without significant pleomorphism, KS should definitely be considered, and it should be known that CD117 positivity is also present in these neoplasms.

Spindle Variant Primary Diffuse Large B Cell Lymphoma of the Colon: Case Report and Literature Review

Diffuse large B cell lymphoma (DLBCL) with spindle cell morphology is a rare variant that can be seen in extranodal regions. Because the spindle cell dominant morphology in lymphoma is extremely unusual, the diagnosis can easily be missed in many organ systems. We present a case of an 82-year-old male patient with complaints of abdominal pain and swelling. He operated with the preliminary diagnosis of cecum tumor and ileum perforation. Tumoral proliferation was observed originating from the submucosa and infiltrating the muscularis propria, with the features of mostly spindle-shaped, having round-shaped nuclei in some of the cells, and having relatively narrow cytoplasm. A panel of immunohistochemical stains were performed to rule out the possibilities of sarcoma, carcinoma, or melanoma. Diffuse strong positive reaction was observed for CD45, CD20, CD19, CD22, Pax5, and CD30. The case was reported as spindle cell variant of DLBCL based on the present findings. As far as we know, this is the first case described in the colon. We emphasize that pathologists should be reminded of lymphoma as a differential diagnosis of spindle cell tumors.

Current Barriers to Clinical Liver Xenotransplantation

Preclinical trials of pig-to-nonhuman primate liver xenotransplantation have recently achieved longer survival times. However, life-threatening thrombocytopenia and coagulation dysregulation continue to limit preclinical liver xenograft survival times to less than one month despite various genetic modifications in pigs and intensive pharmacological support. Transfusion of human coagulation factors and complex immunosuppressive regimens have resulted in substantial improvements in recipient survival. The fundamental biological mechanisms of thrombocytopenia and coagulation dysregulation remain incompletely understood. Current studies demonstrate that porcine von Willebrand Factor binds more tightly to human platelet GPIb receptors due to increased O-linked glycosylation, resulting in increased human platelet activation. Porcine liver sinusoidal endothelial cells and Kupffer cells phagocytose human platelets in an asialoglycoprotein receptor 1-dependent and CD40/CD154-dependent manner, respectively. Porcine Kupffer cells phagocytose human platelets via a species-incompatible SIRPα/CD47 axis. Key drivers of coagulation dysregulation include constitutive activation of the extrinsic clotting cascade due to failure of porcine tissue factor pathway inhibitor to repress recipient tissue factor. Additionally, porcine thrombomodulin fails to activate human protein C when bound by human thrombin, leading to a hypercoagulable state. Combined genetic modification of these key genes may mitigate liver xenotransplantation-induced thrombocytopenia and coagulation dysregulation, leading to greater recipient survival in pig-to-nonhuman primate liver xenotransplantation and, potentially, the first pig-to-human clinical trial.

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.

Hepatitis B/D-Related Hepatocellular Carcinoma. A Clinical Literature Review

AIM

Given the current literature data, this article aims to shed light on the epidemiological and clinical effects of HBV, as well as its impact on the development of hepatocellular carcinoma (HCC).

METHODS

A review of the English language literature based on a MEDLINE (PubMed) database was searched. The keywords were cirrhosis, hepatocellular carcinoma, epidemiology, hepatitis delta virus, hepatitis B virus, and co-infection. All references from retrieved papers were reviewed systematically to find additional collection of reports.

RESULTS

The study has broadly confirmed the contribution of HDV viremia to liver disease and cirrhosis. However, uncertainty over the mechanism of action on HCC development remains. As the recent data has demonstrated, the HCC-HDV has a unique molecular profile which is distinct from that of HBV-HCC.

CONCLUSION

Owing to the dependence of HDV on HBV, it is not clear whether HCC is a consequence of the cumulative effect of both HBV and HDV, an effect of the underlying cirrhosis, or a direct oncogenic effect of HDV. Many questions concerning the oncogenic role of HDV remain unanswered. To better understand the role of HDV in carcinogenesis, studies at the molecular level that consider genotype differences should be increased. Multicenter, high-volume, and prospective studies that compare HBV/HDV co-infected and HBV-infected individuals will be pivotal in determining the oncogenic role of HDV.

A Combination of Blood Lymphocytes and AST Levels Distinguishes Patients with Small Hepatocellular Carcinomas from Non-cancer Patients

PURPOSE

HCC patients typically present at an advanced tumor stage, in which surgical therapies cannot be used. Screening ultrasound exams can increase the numbers of patients diagnosed with small tumors, but are often not used in patients at risk for HCC. We evaluated clinically available and cheap potential blood tests as biomarkers for screening patients at risk for HCC.

METHODS

A comparison was made of commonly used blood count and liver function parameters in a group of patients (n = 101) with small HCCs (≤ 3 cm) or without HCC (n = 275), who presented for liver transplantation in our institute.

RESULTS

Significant differences were found for blood lymphocytes and AST levels. This 2-parameter combination was found to be significantly different between patients with small HCCs versus no HCC. Using the combination of lymphocytes and AST levels to dichotomize the HCC patients, only blood levels of alpha-fetoprotein among the tumor characteristics were found to be significantly different among the 2 HCC groups, as well as levels of blood total bilirubin, ALKP, and PLR ratio. The results were confirmed using a separate smaller cohort of non-transplanted small size HCC patients.

CONCLUSION

The combination of elevated blood levels of lymphocyte counts and AST levels holds promise for screening of patients with chronic liver disease who are at risk for HCC.

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.

Factors affecting anxiety, depression, and self-care ability in patients who have undergone liver transplantation

BACKGROUND

Depression, anxiety, and altered self-care ability are among the most important factors affecting the quality of life of liver transplant recipients. Depending on the severity of the underlying liver disease, signs and symptoms of anxiety and depression may become more pronounced.

AIM

To evaluate the factors affecting depression, anxiety and self-care abilities of liver transplant recipients.

METHODS

Recipients who are ≥ 18 years and who underwent liver transplantation at Inonu University Liver Transplantation Institute were included in this descriptive and cross-sectional study. Sample size analysis showed that the minimum number of recipients should be 301 (confidence level = 95%, confidence interval = 2.5, population = 1382). Three hundred and twenty recipients were interviewed and 316 recipients that have answered the questionnaires accurately were analyzed. The dependent variables were the Beck Depression Scale, State-Trait Anxiety Scale (Form I and II), and Self-Care Agency Scale. The independent variables of the study were sociodemographic characteristics, biliary complications, hepatocellular carcinoma, recommending liver transplantation to other patients, and the interval of out-patient clinic visits.

RESULTS

Self-care ability scores were lower (P = 0.002) and anxiety scores were higher (P = 0.004) in recipients with biliary complications. On the other hand, in recipients with hepatocellular carcinoma, self-care scores were lower (P = 0.006) while depression (P = 0.003) and anxiety scores (P = 0.009) were higher. Liver transplantation recipients with a monthly income < 3000 Turkish liras had higher depression (P < 0.001) and anxiety (P = 0.003) scores. The recipients who stated that they would not recommend liver transplantation to others had lower self-care scores (P = 0.002), higher depression (P < 0.001), higher state anxiety (P = 0.02), and trait anxiety (P < 0.001) scores.

CONCLUSION

Presence of biliary complications and hepatocellular carcinoma, low income level, and an obligation for monthly visits to the outpatient clinic are factors that are found to affect self-care capability, depression, and anxiety.

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.

A Recipient and Donor Both Have COVID-19 Disease. Should We Perform a Liver Transplant?

Coronavirus 2019 (COVID-19) is a new infectious disease that continues to spread globally. There is growing concern about donor-induced transmission of Coronavirus 2 (SARS -CoV-2). For liver transplantation, the COVID-19 PCR test is routine, in addition to epidemiological history and clinical and radiological examination 24-48 h before surgery. One of the liver transplant candidates was found to be infected with COVID-19, as well as the planned donor candidate. Since COVID-19 will be a high-risk operation for both the recipient and the donor, the operation was postponed by giving medical treatment. After the treatment and quarantine process was over, the patient and the donor then had a negative COVID-19 PCR test and the patient received a living donor liver transplant. We present a case of donor and recipient who initially both tested positive for COVID-19. This liver transplantation scenario has not previously been reported in the literature.

Evaluation of clinical characteristics and outcomes of postoperative ınfections in living liver donors

AIM

To analyze developing infections after living donor hepatectomy (LDH) in living liver donors (LLDs).

METHODS

Demographic and clinical characteristics of 1106 LLDs were retrospectively analyzed in terms of whether postoperative infection development. Therefore, LLDs were divided into two groups: with (n = 190) and without (n = 916) antimicrobial agent use.

RESULTS

The median age was 29.5 (min-max: 18-55). A total of 257 (23.2%) infection attacks (min-max: 1-8) was developed in 190 (17.2%) LLDs. The patients with the infection that were longer intensive care unit (ICU) and hospital stays, higher hospital admissions, emergency transplantation, invasive procedures for ERCP, PTC biloma, and abscess drainage, and the presence of relaparatomies and transcystic catheters. Infection attacks are derived from a 58.3% hepatobiliary system, 13.2% urinary system, 6.6% surgical site, and 5.8% respiratory system. The most common onset symptoms were fever, abdominal pain, nausea, and vomiting. A total of 125 positive results was detected from 77 patients with culture positivity. The most detected microorganisms from the cultures taken are Extended-Spectrum β-lactamases (ESBL) producing Klebsiella pneumonia (16.8%) and Escherichia coli (16%), Methicillin-Resistant Staphylococcus aureus [(MRSA) (9.6%)], Methicillin-susceptible S aureus [(MSSA) (9.6%)], and Pseudomonas aeruginosa (8.8%), respectively. The average number of ICU hospitalization days was 3 ± 2 (min 1-max 30, IQR:1) and hospitalization days was 14 ± 12 (min 3-max 138, IQR: 8). All infection attacks were successfully treated. No patients died because of infection or another surgical complication.

CONCLUSION

Infections commonly observed infected biloma, cholangitis, and abscess arising from the biliary system and other nosocomial infections are the feared complications in LLDs. These infections should be managed multidisciplinary without delay and carefully.

Hepatic Venous Outflow Obstruction After Living-Donor Liver Transplant: Single Center Experience

OBJECTIVES

In this study, we share our approach for care of patients with hepatic venous outlet obstruction after living-donor liver transplant.

MATERIALS AND METHODS

We retrospectively examined the demographic, clinical, and radiologic data of 35 patients who developed hepatic venous outlet obstruction after living-donor liver transplant. Patients were subgrouped on the basis of onset (8 patients with early onset [< 30 days posttransplant] and 27 patients with late onset [≥ 30 days posttransplant]) and postoperative survival (24 survivors, 11 nonsurvivors).

RESULTS

Patients ranged in age from 1 to 61 years (24 adults and 11 children). All adult patients had undergone right lobe living-donor liver transplant. In the pediatric group, 8 had undergone left lateral segment and 3 had undergone left lobe living-donor liver transplant. Nineteen adult patients and all 11 pediatric patients underwent hepatic venous reconstruction, with all procedures based on common large-opening drainage models using various vascular graft materials. Development of hepatic venous outlet obstruction occurred at mean posttransplant day 233 ± 298.5 in the adult patients and mean posttransplant day 139 ± 97.8 in the pediatric patients. After development of obstruction, the patients underwent 1-6 sessions (1.5 ± 1.1 sessions) of balloon angioplasty. After the first balloon angioplasty procedure, 25% of the adults and 36.3% of the pediatric patients developed recurrence. The early-onset and late-onset subgroups showed statistically significant differences in serum albumin (P = .01), underlying causes (P < .001), time from transplant to obstruction (P = .02), and time from transplant to last visit (P = .02). The survivor and nonsurvivor subgroups showed statistically significant differences in total bilirubin (P = .03) and time from transplant to last visit (P = .03).

CONCLUSIONS

Common large-opening reconstruction minimizes hepatic venous outlet obstruction development after living-donor liver transplant. Balloon angioplasty and/or stenting is almost always the first option in the care of this complication.