We report the case of a 56-year-old male with pancreatic cancer and 25 liver metastases. The patient underwent a distal pancreatectomy with 11 metastasectomies in the left liver lobe. Histological examination demonstrated a moderately differentiated ductal adenocarcinoma with pT3N0M1, Stage IVb. Three weeks later, we performed transarterial chemoembolization for the right lobe of the liver, and after 6 weeks we started systemic chemotherapy with FOLFIRINOX. After 31 months, computer tomography examination showed increases in size of the remaining lesions at segment VII/VIII of the right lobe. All liver metastases were surgically removed and a new chemotherapy was initiated. Nevertheless, after 40 months the patient developed two brain metastases. One was surgically resected and the smaller lesion was treated by gamma knife. Unfortunately, the patient died 42 months after the first presentation. Conclusively, in very selected patients with synchronic liver metastasis, multimodal treatment including repeated surgery, TACE and chemotherapy may prolong survival.

Ischemic reperfusion injury (IRI) after liver transplantation is a common cause of early allograft dysfunction with high mortality. The purpose of this case report series is to highlight an unusual clinical course in which complete recovery can occur following the identification of severe hepatic IRI post-transplantation and the implications of this finding on management strategies in patients with IRI post-transplant. Here, we include three cases of severe IRI following liver transplantation that are putatively resolved without retransplantation or definitive therapeutic intervention. All patients recovered until their final follow-up visits to our institution and developed no significant complications from their injury throughout the course of patient care by our institution after discharge from the hospital.

Pyogenic liver abscesses (PLAs) are relatively rare but often fatal if left untreated. Antibiotic therapy combined with percutaneous procedures has replaced surgery as the cornerstone of treatment. However, open surgical drainage or liver resection may be a last resort. This study aimed to review our experience in treating PLA, with a focus on the conditions requiring partial liver resection as the last viable curative option. Medical records of patients with PLA admitted to Jordan Hospital between October 2014 through October 2020 were retrospectively reviewed. Medical and demographic data of all 43 patients admitted to our facility with a diagnosis of PLA were extracted. We reviewed these patients and extracted the cases that required surgical intervention. Four (three males and one female) of the 43 patients with PLA required surgical intervention. The underlying causes of liver abscesses were as follows: one traumatic due to shrapnel injury from an explosion, one following chemoembolization for hepatocellular carcinoma, and two patients with no apparent etiology. All patients were diagnosed with a computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast. Two patients had negative cultures. All patients received broad-spectrum antibiotics, and all underwent CT- or ultrasound-guided percutaneous drainage or aspiration. All four patients required partial hepatic resection due to treatment failure or inaccessible percutaneous procedures with clinical improvement. Although antimicrobial and interventional therapy remains the primary treatment option in PLA, the surgical option with open surgical drainage or partial liver resection remains viable and curative in selected patients.

Background: In an effort to increase donor safety in living donor liver transplantation, the utilization of vascular staplers for the division of the right portal and hepatic veins in patients undergoing right lobe liver donation for living donor liver transplantation (LDLT) was implemented. In here we report our experience with vascular staplers in patients undergoing LDLT and evaluate the subsequent feasibility and safety for donors. Material and methods: 17 cases of living donor liver transplant were retrospectively analyzed. The right portal vein was transected directly at the bifurcation of the main portal vein, the right hepatic vein was resected directly at the wall of the inferior vena cava using a vascular stapler device. Results: We registered a complication rate of 41.2% (7 donors). According to the Clavien-Dindo classification, grade II and grade III complications were each observed in 5.9% and grade IIIb complications in 29.4%, whereas catastrophic bleeding, complications with residual disability or the necessity of re-laparatomy did not occur. Upon 6 weeks, all donors were able to return to their previous occupation in fully recovered condition. Conclusions: The utilization of vascular staplers in donors during open LDLT presents an encouraging alternative to manual over-sewing of vascular stumps. Apart from its timesaving aspect, the technique reduces the potential risk of life-threatening clamp slippage with subsequent uncontrolled blood loss.

Postoperative biliary complications remain a substantial challenge after living donor liver transplantation, especially due to its heterogeneous clinical presentation.

Introduction: Liver abscess is relatively rare and could be lethal if left untreated. Current advances in the management include diagnostic and interventional radiology that have decreased the rate of mortality. The aim of this study is to present four cases of patients with liver abscess who were cured by hepatectomy after failing CT-guided and surgical drainage. Case Description/Methods: Four cases of patients with liver abscess due to post-radiofrequency ablation in HCC-patient (case 1), unknown etiology (cases 2 and 3), and foreign body injury from a shrapnel (case 4); were selected (Table 1). All of them were treated initially with empiric antibiotics and underwent CT-guided and surgical drainage. They subsequently underwent liver resection as their clinical condition failed to improve. On follow-up, the patients improved and repeat abdominal ultrasonography was negative for recurrence of abscess. Discussion: Although rare, liver abscess has a high mortality rate. Hence, there is an urgent need to treat this condition upon diagnosis. Recently, percutaneous drainage in addition to empiric antibiotics have been the initial approach for treating the liver abscesses. However, surgical drainage or liver resection can sometimes be considered to treat hepatic abscess in selected cases where the abscess is not accessible to CT-guided percutaneous drainage, if it is ruptured, or if the patient failed to improve with optimized medical therapy and percutaneous drainage. These cases highlight the importance of considering liver resection in curing patients with liver abscess who did not improve with medical therapy and CT or surgical drainage. Table 1. - Characteristics and laboratory findings of the four patients with liver abscess selected Case I Case II Case III Case IV Age 75 48 44 24 Gender Male Female Male Male Cause of liver abscess Post-radiofrequency ablation in HCC-patient Cryptogenic Cryptogenic Foreign body injury from a shrapnel Chronic Hep Positive Negative Negative Negative Preop CRP 249 mg/l 240 mg/l 2 mg/l 250 mg/l Culture E. Coli (ESBL) and Enterococcus Faecium No growth No growth Pseudomonas aeruginosa and Candida

Introduction: Severe ischemia-reperfusion injury is a potential deadly complication after liver transplantation that is characterized by a significant elevation of liver enzymes. It is usually complicated by severe organ dysfunction, rejection, and re-transplantation. In this case series, we report three cases of severe ischemia-reperfusion injury following liver transplantation with unexpected clinical course. Case Description/Methods: Three cases of patients with autoimmune hepatitis, alcoholic cirrhosis, and idiopathic liver cirrhosis were selected. All of them underwent liver transplantation. Few hours after the surgery, their liver enzymes started to rise to the thousands raising concern for ischemia-reperfusion injury (Image 1). Patients remained clinically stable with reduced but preserved urine output and state of consciousness. Doppler-ultrasound of the graft revealed patent hepatic artery, hepatic vein, and portal vein. Therefore, the patients received supportive care. After few days of observation, liver enzymes started to decrease unexpectedly reaching a normal level after a week. The patients gradually improved and their liver function remained stable upon follow-up after discharge from the hospital. Discussion: Severe ischemia-reperfusion injury is a potential deadly complication of liver transplantation. Liver function test abnormalities following liver transplantation are a hallmark of the clinical presentation. Upon diagnosis, the outcome is usually poor without re-transplantation. In this study, we presented three cases of patients with increased LFTs following liver transplantation, who improved with supportive measures alone. Although LFTs are commonly accepted as indicators of liver injury post-transplant, these cases highlight the importance of taking into account other parameters such as the clinical picture and radiological findings before determining the outcome of the ischemia-reperfusion injury following liver transplant; therefore, avoiding unnecessary and invasive measures.Figure 1.: Post-transplant AST and ALT levels in patient with autoimmune hepatitis (a), alcoholic cirrhosis (b), and liver cirrhosis of unknown origin (c).

OBJECTIVES:Early hepatic artery thrombosis is a serious complication that may follow living donor liver transplant. Acute graft loss and patient morbidity and mortality are possible consequences. The therapeutic algorithm includes surgical or interventional revascularization, conservative approaches, or retransplantation.MATERIALS AND METHODS:Among 155 patients who underwent living donor liver transplant at our transplant center from 2004 to 2020, there were 5 who developed hepatic artery thrombosis. From our 13- year experience, we herein present their demographic and clinical characteristics, radiological imaging findings, perioperative courses, and the postoperative follow-up.RESULTS:All patients displayed advanced liver disease with a Child-Pugh score of C and a mean Model for End-Stage Liver Disease score of 32. Underlying causes for end-stage liver disease included hepatitis B and C infection and cryptogenic liver cirrhosis. The mean patient age was 49 years; 2 patients were female. Living donor liver transplant was performed with donor tissue from immediate kin, according to Jordanian allocation rules. The diagnosis of hepatic artery thrombosis was made by Doppler ultrasonography and confirmed via computed tomography. After surgical revision of the anastomosis, our first patient experienced thrombotic recurrence. All patients received interventional catheterization with local thrombolysis and subsequently developed rethrombosis. Despite prevalent thrombosis, 4 patients achieved long-term survival without further deterioration of liver function. Cumulative 1-year, 5-year, and 10-year survival rates were 80%, 80%, and 60%, respectively. Spontaneous recanalization of the hepatic artery was observed in 1 patient.CONCLUSIONS:Favorable long-term outcomes are achievable in patients with persistent hepatic artery thrombosis. When retransplant is not feasible and interventional approaches fail, conservative treatment with careful observation of liver function should be implemented. Attentive observation of collateral circulation toward the liver, distal of the thrombosis, may be beneficial to both graft and patient survival.

ObjectiveTo define optimal intact parathyroid hormone (iPTH) cut-off threshold predictive of hypocalcemia after total thyroidectomy for safe and effective postoperative management.MethodsThis prospective single center study was done in 2 phases. In phase I, predictors of symptomatic hypocalcemia were analyzed and the receiver operating characteristic curve was used to define the optimal iPTH cut-off threshold predictive of hypocalcemia. Phase II studied giving prompt prophylactic supplemental calcium and vitamin D to all patients who had iPTH levels below the calculated threshold, while phase I patients were given prompt selective supplementation if they had postoperative hypocalcemia or symptoms.ResultsUnivariate analysis of patients in phase I showed that postoperative iPTH was the only significant variable that can predict symptomatic hypocalcemia. Using receiver operating characteristic curve and Youden index, the confirmed optimal cut-off threshold predictive of hypocalcemia was iPTH 19.95 pg/mL, with area under the curve of 0.903, 100% sensitivity, negative predictive value, and highest Youden index, while iPTH 15 pg/mL and iPTH 10 pg/mL were less optimal. Symptomatic hypocalcemia occurred in 30% of the phase I cohort who received selective supplementation versus 3% of those in the phase II cohort who received prophylactic supplementation. Return to emergency department and need for intravenous calcium were also significantly better in phase II.ConclusioniPTH cut-off for post-thyroidectomy hypocalcemia was 19.95 pg/mL. Low-risk patients were discharged with no supplementation while all high-risk patients received prompt calcium and vitamin D supplementation, which led to effective hypocalcemia management and safe 24-hour discharge.

OBJECTIVES Budd-Chiari syndrome is an infrequent, but potentially fatal, hepatic condition with the clinical manifestation of obstructed venous drainage. This may lead to progressive hepatic congestion, portal hypertension, and, ultimately, liver failure. If medical, interventional, and surgical approaches are not effective, liver transplant offers a rescue modality. The primary objective of this study was to report the perioperative and, above all, the vascular challenges associated with living donor liver transplant in patients with Budd-Chiari syndrome. MATERIALS AND METHODS We retrospectively reviewed demographic and clinical characteristics of 6 patients with Budd-Chiari syndrome who underwent living donor liver transplant at our transplant center from April 2004 to July 2020. We also evaluated all data regarding perioperative course, surgical outcome, and the postoperative follow-up period. RESULTS All patients displayed advanced liver disease with a Child-Pugh score C. The mean calculated Model for End-Stage Liver Disease score was 32. The causes of Budd-Chiari syndrome were factor V Leiden thrombophilia in 1 patient, myeloproliferative disorder in 3 patients, antiphospholipid antibody syndrome in 1 patient, and a protein C deficiency in 1 patient. The mean age of patients was 40 years. One of the 6 patients was female. All patients had living donor liver transplant from immediate kin according to Jordanian allocation rules. The mean graft-to-recipient weight ratio was 0.9, and the median follow-up period was 89 months. Cumulative 1-, 3-, and 5-year-survival rates were 84%, 67%, and 67%, respectively. CONCLUSIONS Good survival rates are achievable with living donor liver transplant for patients with advanced Budd-Chiari syndrome, particularly by means of posterior cavoplasty for enlargement of the cava orifice. Therefore, in countries with insufficient deceased donor programs, such as Jordan, living donor liver transplant may be a lifesaving therapeutic possibility.

Background: Obesity presents one of the leading causes of many chronic liver disorders and injuries. Nowadays, non-alcoholic steatohepatitis (NASH) demonstrates a challenging issue for the global health system. NASH can progress to life-threatening conditions such as cirrhosis and hepatocellular or cholangio carcinoma. Currently, NASH cirrhosis is a major indication for liver transplant (LT). Case presentation: We present the case of a 37 year-old male who has lost 74 kg after undergoing successful laparoscopic sleeve gastrectomy (SG) four years ago. Recently, he underwent right hepatectomy in the course of living-donor liver transplantation for his sick father in our clinic. Before the SG was conducted four years ago, his weight was at 157 kg and his Body Mass Index (BMI) at 49 kg/m(2). At that time, Ultrasound examination showed severe fatty liver changes and intraoperative inspection of the liver was consistent with that observation. At the time of surgery, he weighed 83 kg and his BMI was at 27 kg/m(2). An effective weight reduction after bariatric surgery might protect NASH patients from further deterioration of their medical condition. Conclusion: To our knowledge, we report the first successful case of a right lobe living-donor hepatectomy in a patient who previously underwent successful laparoscopic sleeve gastrectomy (LSG).

BACKGROUND Acute-on-chronic liver failure was first defined within the last 10 years as acute decompensation of chronic liver disease accompanied by multiorgan failure and poor outcome. Budd-Chiari syndrome is a rare and potentially deadly hepatic condition. To the best of our knowledge, this is the first case report of a live liver donor recipient with antiphospholipid antibody syndrome. CASE REPORT A 47-year-old woman from Sudan with acute-on-chronic liver failure and subacute Budd-Chiari syndrome triggered by active pneumonia was evacuated to Amman, Jordan. In Amman, she was transferred to our hospital for liver transplant evaluation. She presented with progressive liver failure, acute kidney failure, acute respiratory failure, and encephalopathy stage IV. Multidisciplinary therapy was initiated with IV anti-infective drugs and optimizing mechanical ventilation. Clinically, we stopped her progressive deterioration after 48 h and she improved slightly in our ICU. Accelerated work-up for donors and recipient was completed and her daughter was selected as a medically appropriate donor despite the fact that she was found to have heterozygote factor V Leiden mutation and antiphospholipid antibody syndrome, similar to her mother. A lifesaving live-donor liver transplantation was carried out after 72 h. Donor and recipient were discharged in good condition with normal liver function and both were discharged on anticoagulant Rivaroxaban 20 mg. CONCLUSIONS We present the first case of a patient with acute-on-chronic liver failure with subacute Budd-Chiari syndrome, which was triggered by bacterial pneumonia and was successfully treated by live-donor liver transplantation from a donor with antiphospholipid antibody syndrome.

Severe acute alcoholic liver disease (SAAH) unresponsive to medical therapy shows one-year-mortality rates of up to 90%. Most transplant centers request six months of alcohol abstinence prior to transplantation, the so-called "6-month rule." This regulation is not based on strong evidence, repeatedly making it a topic of controversial debates. The majority of patients with SAAH will die before fulfilling the 6-month rule. Therefore, liver transplantation (LT) protocols are becoming more flexible towards the rigid abstinence regulation, especially concerning SAAH patients. We conducted a literature review regarding LT in SAAH and its outcomes, including post-transplant mortality and recidivism. We studied available data on PubMed from 2011 and onwards whilst including articles dealing with genetic components, medical therapy and historic snapshots of alcoholism. Emerging studies recommend LT in SAAH not responding to medical therapies even without realizing the required abstinence period, since the majority of these patients would die within 6 months. SAAH without response to medical therapy has one-year-mortality rates of up to 90%. The 6-month rule is not based on strong evidence and is repeatedly a topic of controversial debates. There is genetic linkage to alcoholism and medical therapy is not as effective as estimated, yet. The 6-months-regulation has not shown to evidently decrease the risk of recidivism post-LT, which is a lifesaving treatment in SAAH patients. Insisting on rigid sobriety rules results in excluding patients with a low risk of recidivism from being transplanted. Moreover, the genetic linkage of alcoholism must be recognized.

[b]BACKGROUND[/b] Liver surgery is considered as a beneficial approach to increase survival rates in patients with colon cancer hepatic metastases. A hepatobiliary multidisciplinary board must evaluate patients with synchronic CRLM, because early multimodal management of patients with potentially resectable CRLM is fundamental for overall survival. [b]CASE REPORT[/b] Here, we demonstrate the case of a young man with very advanced sigmoid carcinoma and widespread hepatic metastases affecting the whole liver. He underwent extended right hepatectomy with partial right diaphragm resection and standard left hemicolectomy. Margins of a resected specimen were all tumor-free. Some of the dissected lymph nodes from the left hemicolectomy were tumor-positive. At the end of the operation, the remnant liver still contained about 10 lesions of various diameters. The surgical course was ordinary. After the extensive surgery, postoperative systemic chemotherapy was given. The multidisciplinary team approved this approach. The remaining lesions disappeared and 3 calcifications became visible after 6 courses of chemotherapy. CEA decreased from 1800 µg/l (preoperative) to a normal value below 3.5 µg/l. [b]CONCLUSIONS[/b] This individualized and personalized multidisciplinary approach could be advantageous and efficacious in highly selected young patients. Further studies are essential.

Since more than 30 years ago, it is well understood that the survival of patients with a severe stage of hepatic damage due to alcohol, is no longer influenced by abstinence. Often, liver transplantation is the only way for these patients to survive. The arbitrary exclusion of these critically ill patients from an adequate therapy, in itself, is a substantial violation of the human rights of the patients and the national constitutional law in several countries. Not transplanting patients with alcoholic hepatitis simply because they failed to demonstrate long-term abstinence appears to be very hard to defend and preserve, particularly in view of the high fatality risk without LT. SAAH patients deserve to be included in the life saving organ donation system and deserve to be treated equally. The outcome of patients transplanted for severe acute alcoholic hepatitis is at least as good as patients transplanted for other diagnoses. Summary Emerging studies have verified the excellent survival advantage of LT in carefully selected patients with severe alcoholic hepatitis who failed medical therapy. Conclusion Patients with severe acute alcoholic hepatitis should have legitimate equal access to LT compared to other LT candidates.

BACKGROUND Hepatitis C virus (HCV) genotype 4 (GT-4) is widespread in the Middle East, where it is responsible for the majority of HCV infections. It shows moderate treatment response rates when compared to other genotypes in the current era of interferon-based regimens. However, in the era of direct acting antiviral (DAA) drugs, its response is at least as good as observed for HCV genotypes 1-3. CASE REPORT We present a case of a 44-year-old patient with HCV cirrhosis. Since 2007, he has been treated for HCV infection with multiple ineffective regimens of interferon (INF) and ribavirin. A liver biopsy in 2010 revealed stage 5-6/6 indicating cirrhosis, which was later complicated by the occurrence of portal vein thrombosis and a large hepatocellular carcinoma (HCC) (maximum diameter 9 cm). The patient was successfully treated with sorafenib, transcatheter arterial chemoembolization (TACE), and radiofrequency ablation. After four TACE procedures, the patient's AFP (alpha-fetoprotein) decreased remarkably and almost normalized. The HCC disappeared radiologically as shown by triple phase CT, MRI with contrast, and PET-CT. He successfully underwent a living donor liver transplantation. Four weeks post liver transplantation he started treatment with sorafenib, and switched from tacrolimus to Rapamune (sirolimus) as immunosuppressant therapy. Ten weeks after liver transplantation, HCV treatment was introduced along with ledipasvir and sofosbuvir due to his increasing liver enzyme levels. A rapid viral response was achieved after 14 days. In total, the patient received 12 weeks of this treatment. CONCLUSIONS This case study might be of significance in informing early management and personalized treatment of patients with recurrent HCV GT-4 infections after liver transplantation, even in complex clinical surroundings.

BACKGROUND:The treatment of hepatitis C virus (HCV) infection is evolving rapidly. Many studies have been completed during the last 2 years, with more studies still in progress. The management of recurring HCV infection following liver organ transplantation remains very challenging, especially for HCV genotype 4 (GT-4). More research is needed in this area.CASE REPORT:We report on a patient with a recurring HCV infection and fibrosing cholestatic hepatitis following liver retransplantation, who was successfully treated with a combination therapy of simeprevir and sofosbuvir without interferon/ribavirin. As far as we know, this is the first reported case of this kind.CONCLUSIONS:This information may be of importance and inform future management of patients with recurrent HCV infections following liver transplantation.

BACKGROUND Associated Liver Partition and Portal vein ligation with Staged hepatectomy (ALPPS) leads to rapid hepatic hypertrophy and decreases incidence of post-hepatectomy liver failure in patients with a marginal future liver remnant. Various procedural ALPPS modifications were previously described. Here, we present the first case of a new ALPPS modification, carrying out a left hepatic trisectionectomy with segment 1. CASE REPORT We present the case of a 36-year-old woman with locally advanced sigmoid adeno-carcinoma and extensive left liver metastases extending to segment V and VIII, who received state-of-the-art systemic conversion chemotherapy. Preoperative CT volumetric scan demonstrated a FLR/TLV (Future Liver Remnant/Total Liver Volume) of 22%. A left hepatic trisectionectomy procedure was conducted using our new ALPPS modification. Sufficient hepatic hypertrophy of FLR was reached with a volume increase of 100%. The period between the 2 stages was 7 days. The patient underwent left trisectionectomy and left colectomy with tumor-free margins. All dissected lymph nodes were tumor-negative. The surgical intra- and postoperative course was uneventful. Medically, the patient acquired an Acinetobacter infection, with severe sepsis and acute renal injury. After 3 dialysis sessions, the renal function recovered completely. Afterwards, the patient recovered slowly, and reintroduction ambulation and oral feeding was prolonged. Later on, the patient received Xeloda 1500 mg twice daily as adjuvant chemotherapy. CONCLUSIONS The new ALPPS modification leads to a sufficient hypertrophy of FRL within 1 week, allowing left hepatic trisectionectomy with tumor-free FRL. Despite the challenging complications, the new ALPPS modification might represent an alternative procedure for use when the classic ALPPS procedure is not applicable. Further studies are required.