First Experience of Using Two-stage Resection of the Liver (Split in situ) in Patients with Metastatic Colorectal Cancer

( Zhanat Spatayev ),( Asan Zhexembayev ),( Adilbek Mukazhanov ),( Baurzhan Ibrayev ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: To present the first in Kazakhstan performed split in situ surgical procedure in a patient with sT4aN2bMOG2 colorectal cancer at National Oncology & Transplant Center. Introduction: Two-stage liver surgery with preliminary right portal vein occlusion procedure (ligation or embolisation) became standard in clinical practice and allows liver resections in 60-82% of initially inoperable patients. Right portal vein ligation with concomitant liver partition in situ (in situ splitting, ISS) is innovatory and promising approach. This case report of a 67 y.o. male with three colon meta- stasis in right liver lobe. Methods: A case report of the patient``s two-stage surgical procedure and results Results: Right portal vein ligation and in situ splitting was performed in 67 years old male with three colon metastases in right liver lobe (figure-1) and insufficient volume of future liver remnant (FLR/SLV = 550/1294=29%). After completion of dissection of liver parenchyma and portal vein ligation subsequent hepatico-jejunoanostomosis was performed as shown in figure-2. The early post-first operative period went without complications. CT angiography on 11th postoperative day showed left liver lobe hypertrophy rate of 58% (FLR/SLV = 750/1294) and left liver lobe volume increase from 29 to 58%. During surgery the left liver hypertrophy was seen (as shown in figure-3), there was no visible parenchymal injury in observation during laparotomy. Right hemihepatectomy was performed on day 13 after the first stage. There were no signs of postoperative liver failure. According to the dynamical transaminases (shown in the figure-2) in situ split procedure doesn’t induce liver injury. Conclusions: New two-stage surgery approach (ISS) can decrease number of patients who were inoperable because of insufficient volume of future liver remnant and high risk of postoperative liver failure.

HSV after LDLT

( Abylaikhan Sharmenov ),( Gani Kuttymuratov ),( Tokan Sultnaliyev ),( Mukazhanov Adilbek ),( Zheksembayev Asan ),( Yermakhan Assylkhanuly ),( Mels Asykbayev ),( Said Abdugafarov ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: Viral infection such as HSV, after Living donor liver transplantation (LDLT) is a major cause of morbidity and mortality that result in injury to allograft rejection and opportunistic superinfection. Most patients undergoing liver transplantation are seropositive for HSV. Without antiviral treatments, reactivated HSV infection develops in as many as 40% of these patients. Anogenital lesions are the second most common presentation of HSV disease in LDLT recipients, and are usually due to reactivation of latent HSV-2 in the sacral ganglia. Methods: In our clinical experience, i present a case of a 57-year-old female with hepatocellular carcinoma in the outcome of chronic viral hepatitis C who underwent surgery LDLT. ELISA viral panel before surgery: EBV IgG - positive, IgM - negative, HSV IgG- positive, IgM negative. Her immunosuppressive regimen included - MMF, Tacrolimus, and Prednisone. On the 15th day after the LDLT operation the patient in the pubic region appeared herpes lesion. The level of transaminases in dynamics has increased significantly. Biochemical analysis of blood: ALT - 364 U/l, AST - 98 U/l. GGTP - 159.66 U/l. CRP - 64 ng/ml. Then taken polymerase chain reactions (PCR) analysis for viral infection. PCR for viral panel: HSV DNA 1.2 - detected. CMV DNA - negative. EBV DNA - negative. Given the presence of herpes and PCR data scheduled antiviral therapy - per oral Famvir Famcyklovir) 1500 mg per day and local Acyklovir ointment. Results: After the 2 days on the background of anti-viral therapy transaminase levels started to decline over time. Biochemical analysis of blood: AST - 52.80 U/l, ALT - 204.20 U/l, CRP - 11.04 ng/ml. Post operative day (POD) №22, taken PCR for viral panel: HSV DNA 1.2 - negative. CMV DNA - negative. EBV DNA - negative. Antiviral therapy is continued, the dose of Famvir is reduced to 1000 mg per day. On the background of anti-viral therapy marked regression of herpes lesion, transaminase levels declined. Biochemical analysis of blood: AST - 32.80 U/l, ALT - 104.20 U/l. CRP - 3.96 ng/ml. Conclusions: These Results could help define reasonable indications for transplantation in an era with a shortage of liver grafts related to presented case. Prophylaxis for common infections (HSV and other) in high risk patients improves outcomes in the first year after LDLT. HSV can lead to liver failure after liver transplantation. Antiviral therapy such as Acyclovir, Famcyclavir active against HSV in vitro, and these substances must be used in the treatment of HSV infection after LDLT.

Splenic Artery Steal Syndrome after Orthotopic Liver Transplantation

( Saitkarim Abdugafarov ),( Gani Kuttymuratov ),( Tokan Sultnaliyev ),( Mukazhanov Adilbek ),( Zheksembayev Asan ),( Kakharman Yesmembetov ),( Yermakhan Assylkhanuly ),( Aiymkul Ashimkhanova ),( Baizh 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: To present successful treatment of post liver transplant non occlusive hepatic artery hypoperfusion syndrome presented by splenic steal syndrome (SASS) cases managed by splenic artery embolization. SASS is one of possible arterial complications after living donor liver transplantation. Material includes personal experience in diagnostics and treatment of this syndrome. In each case complication was suspected based on laboratory and ultrasound data and proved by angiography. Successful treatment was performed using splenic artery embolization. Methods: From 2014 there are total of 13 liver transplantations were performed and we had 2 cases of SASS. All donor livers undergo biopsy and those biopsy tissues with no more than 10% steatosis could be eligible for transplantation. Results: One of the most threatening complications of liver transplantation from a living donor is hepatic artery thrombosis. There are many possible causes of thrombosis including technical, and coagulation dysfunctions that will lead to the different level of graft disorders. However, in some circumstances other possible factors may induce arterial dysfunction due to functional features of visceral blood flow under established portal hypertension. SASS develops in 1-4% of post-transplant cases at early period after surgery from 2-5 days, and is characterized by re-distribution of blood supply from celiac trunk predominantly to splenic or gastro-duodenal artery. As a result of this phenomenon the linear and volumetric blood flow rates in the hepatic artery decreases leading to arterial ischemia of liver graft and might even lead to thrombosis. During this process the level of transaminases and bilirubin increases along with the Doppler ultrasound changes and CT-angiography data. The most dangerous consequence of SASS is the development of hepatic artery thrombosis (HAT) with the possible loss of transplant. The main reason of SASS development is hyper perfusion of the transplant. The timely diagnosis of the formidable pathologic syndrome is very crucial in order to avoid the loss of the graft. Conclusions: It appears that patients with decompensated cirrhosis with long-time established portal hypertension should be carefully monitored early post-operative time after transplantation for any unexplained liver dysfunction confirmed with Doppler ultrasound, CT-angiography and coagulation abnormalities suggestive of SASS.

Surgical Treatment of Liver Alveococcosis

( Dzhussubaliev Yerbol ),( Gani Kuttymuratov ),( Tokan Sultnaliyev ),( Mukazhanov Adilbek ),( Zheksembayev Asan ),( Yermakhan Assylkhanuly ),( Mels Asykbayev ),( Sharmenov Abylaikhan ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: Alveococcosis - a parasitic disease caused by echinococcus multilocularis larvae and proceeding with the formation of the primary liver tumor. Alveococcosis complications may include festering parasitic tumor, a rupture in the formation of peritoneal or pleural cavity, jaundice, portal hypertension, alveococcus metastasis into brain and lungs. In terms of surgical tactics at liver alveococcosis, the most difficult issues are the choice of the optimal variant of surgical intervention and liver resection volume. Methods: Experience of observation over 36 patients with alveococcosis within 2 years is the basis for this presentation. Radical liver resection is performed on 30 patients, the other 6 patients had the unresectable alveococcosis volume. After radical liver resection alveococcosis relapse was observed on 1 patient. At the impossibility to execute radical surgery, resection - bone removal and palliative interventions remain the only surgery options. Results: During intrasurgical audit, mainly right lobe impairment has been revealed on 28 (93,3%) patients, 5 (17,8%) of them had parasitic knots crossed to segments of the left lobe of a liver. 2 (6,7%) patients had tumor generally localized separately in the left lobe of a liver without spreading to the adjacent organs. Germination in the adjacent organs was observed at 2 (7,1%) patients in the 1st group (to a diaphragm). In the same group one patient had lymph nodes of colon impaired, and 2 (7,1%) patients had the remote metastasises of abdominal cavity settled down in retroperitoneum (in the lower hollow vein and a tail of a pancreas). Often, parasitic impairment of an alveococcosis is massive which in some observations demands non-standard approach to treatment of such patients. Separate attention should be given to some clinical observations. Two-stage surgical treatment carried out for 25 years old patient. First, right-sided hemihepatectomia was performed (first phase), then, 12 months later atypical resection of segments II and III was performed (the second phase). In order to achieve a radical intervention for a 42 year-old patient, the resection of the V-VI liver segments, an atypical resection of the VII segment and a bisegmentectomy of the II-III segments were augmented with a radio-frequency ablation of two small (diameter to 1 cm) centers in the VII liver segment. During 2 years of treatment she had been receiving chemotherapy with albendazole, in 2 years after surgery CT of an abdominal cavity in the VII segment will reveal postablation lesions; no signs of disease recurrence present. Conclusions: Thus, alveococcosis remains surgicai- dependent disease. Radical resection during alveococcosis is abie to heal completely majoriti of patients and brings good results in the further perspective. I wonder alveococcosis liver surgery because I was ill alveococcosis liver and underwent surgical treatment. Now I``m alive and well.

PE-102: Treatment of End-stage Liver Disease in the JSC National Scientific Center for Oncology and Transplantology, Astana, Kazakhstan: Views and Perspectives

( Kulpash Kaliaskarova ),( Yuriy Prokopenko ),( Zhansaya Muratova ),( Sergey Borovskiy ),( Tokan Sultanaliyev ),( Adilbek Mukazhanov ),( Bakhyt Zharkimbekov ),( Assan Zhexembayev ),( Gani Kuttymuratov 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: End-stage liver disease represents a major healthcare problem worldwide and in Kazakhstan, carrying a high risk for mortality. Around 1000 patients with end-stage liver disease need liver transplantation in Kazakhstan, more than 50 of them dying yearly without being transplanted. The aim of this paper was review treatment methods for end-stage liver cirrhosis in our center. Methods: Results of various treatment options for end-stage liver disease patients, treated in JSC National Scientific Center for oncology and transplantology since June 2013 so far, were reviewed. Results: Total of 18 liver transplantations, including 6 from cadaveric and 12 from live donors, were performed in our clinic since June 2013, so far. Etiology of liver disease was as follows: HCC (due to nonalcoholic steatohepatitis in 2, hepatitis B in 1) 3 patients, liver cirrhosis (due to alcoholic liver disease in 3, hepatitis C in 2, hepatitis B+D in 6, autoimmune hepatitis in 1, primary biliary cirrhosis in 2 and autoimmune hepatitis and hepatitis B in 1) 14 patients, remaining was 7-year old pediatric patient with biliary atresia. Out of 18 transplanted patients, 2 have succumbed in the early post-operative period due to hemorrhage, remaining 16 are followed-up, counting up to 32 months of disease and rejection-free survival. Since the establishment of hepatology beds at department of general therapy in June 2015, total of 122 patients with liver cirrhosis and hepatocellular carcinoma were treated so far up to February 2016. Methods of treatment of hepatocellular carcinoma included transarterial chemoembolisation used 10 times in 6 patients, 1 patient has succumbed after 3 months of being diagnosed. Treatment options for portal hypertension in 113 liver cirrhosis patients included: esophageal varices ligation and sclerotherapy in 45 patients, splenic artery and esophageal varices embolisation in 22 patients with no complications dated and treatment with beta blockers in the rest of the patients. Out of 113 patients, 1 has succumbed due to the disease progression since start of follow-up in June 2015. Conclusions: Liver transplantation is the only viable option for end-stage liver disease patients. Portal hypertension treatment options using endoscopic and endovascular methods may provide sufficient short-term effect with good safety profile while being waitlisted, thus making liver transplantation available for more patients.