Day 1 :
Vrije University, Belgium
Time : 9:20 - 10:00
H Reynaert, MD, PhD is a Professor of Physiology and Pathophysiology at the Vrije Universiteit Brussel. He is Head of the Hepatology unit at the University Hospital Brussels (UZ Brussel) and Senior Researcher in the Liver Cell Biology lab at the Vrije Universiteit Brussel. He is the past President of the Belgian Association for Study of the Liver (BASL) and current President of the Flemish Society of Gastroenterology (VVGE). He is the member of many national and international societies, including AASLD, EASL, and AGA. He is interested in many aspects of liver disease, including cirrhosis and its complications, viral hepatitis and Non-Alcoholic Liver Disease (NAFLD).
Non-Alcoholic Fatty Liver Disease (NAFLD) is defined by the presence of steatosis in >5% of hepatocytes. It comprises the spectrum of simple steatosis (Non-Alcoholic Fatty Liver or NAFL), and a progressive form, Non-Alcoholic Steatohepatitis (NASH), in which steatosis is accompanied by inflammation, fibrosis or even cirrhosis and hepatocellular carcinoma. NAFLD is associated with insulin resistance and its prevalence is increasing rapidly, paralleling the prevalence of metabolic syndrome. It is estimated that in some countries 30% of the population has NAFLD, but the prevalence in patients with diabetes mellitus type 2 (DMT2) is much higher. Moreover, in DMT2 patients, NASH is more prevalent. Therefore, it is imperative to screen patients with DMT2. In recent years, non-invasive methods to identify patients at risk have been developed. These include imaging techniques and several scoring systems consisting of clinical and biological data. In high risk patients, liver biopsy, which remains the gold standard for diagnosing and grading disease severity, should be performed. Patients at risk should be treated and strict follow-up to detect complications early is essential. We suggest an algorithm as depicted in Figure 1. Treatment of NASH is difficult and unsatisfactory. Weight loss by diet and life style changes (exercise) remains the cornerstone of treatment. It has been shown that ≥7% weight loss resulted in histological improvement. Weight loss is however problematic in this patient group: bariatric surgery improves all histological lesions in NASH including fibrosis. Up to now, no drug treatment has been shown to unequivocally improve NASH. PPAR-gamma agonists, vitamin E, FXR agonists, GLP-1 agonists and PPAR-alpha/delta agonists have shown favorable effects, but large phase 3 trials are lacking. A multitude of new drugs, targeting different metabolic pathways are being developed and tested. Hopefully, we will be able to treat patients with NASH more optimally in the near future.
CGMH Kaohsiung, Taiwan
Keynote: Microscopic hepatico biliary anastomosis in staged adult living liver transplant is a safe and accessible choice
Time : 10:00-10:40
Ali Ghannam has analyzed and studied surgical technique by microscope in liver transplant surgery. He did special comparison between microscopic duct to duct and enteric hepatico biliary anastomosis of the different cases of adult split liver transplant. He has experience as Hapatico Biliary Pancreatic Laparoscopic Surgeon from Al Bashir Hospital in Amman, Jordan. He joined Liver Transplant Center, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, Kaohsiung, Taiwan as a Researcher and Clinical Fellow in Liver Surgery and Liver Transplant for one year. He established and organized the data for future study in the Field of Microscopic Biliary Drainage Split Liver Transplant. This analysis made the surgical practice in split liver transplant updated and evidenced by clinical based medicine.
Statement of Problem: Staged liver transplant is a solving problem for cases of transplant associated with portal hypertension and massive bleeding from the raw surfaces due to previous liver resection and retransplant. Usually biliary reconstruction is postponed 24-48 hours till coagulopathy and circulatory stability improved. There is a known complication of biliary drainage including stricture and leak which is not only a serious morbidity but also associated with increased mortality.
Purpose: The purpose of the study is to focus on hepatico biliary anastomosis and biliary drainage as a choice in staged liver transplant, defined in the previous study. In our experience, we preferred to do enteric drainage and we find it accessible by microscopic surgery.
Methodology & Theoretical Orientation: Long term study of the whole cases of liver transplant in our center has been studied. Total number of 40 cases of staged adult living liver transplant has been grouped in to two groups. Group A of staged biliary duct to duct (12 cases) and group B enteric hepaticobiliary (28) anastomosis has been compared in our study.
Findings: Microscopic technique in staged split liver living adult transplant enteric biliary drainage is a choice practiced in our center with acceptable complication.
Conclusion & Significance: The operative plan for staged living liver transplant can include enteric drainage of biliary system. Era of microscopic surgery in hepatico biliary drainage can be applied in challenging cases of portal hypertension, high child’s grade and intraoperative massive blood loss.
Recommendation & Treatment: Microscopic surgery is applied in vascular surgery and now it is also applied for biliary drainage procedure. Complicated cases of living split liver adult transplant biliary drainage by duct to duct anastomosis and classic Roux-en-Y hepatic jejunal anastomosis is carrying the same results.
Hirslanden Hospital, Switzerland Group Photo 11:
Praxis Dr. Hani Oweira is a Partner of the Surgical Center Zurich. He was affiliated doctor at the Andreas Clinic Cham train
Liver resections are performed to manage Benign and Malignant focal lesions in the liver, and the post-operative outcome was improved over time due to improvement of surgical techniques which get benefit from understanding the liver anatomy and segmentation with improvement of hemostasis techniques. Anatomy wise liver is divided to 2 lobes (Right and left) ant into 8 segments classified by Couinaud based on vascular inflow and outflow. There are many techniques for liver parenchymal transection started with clamp –crush technique and developed to ultrasonic vibration (harmonic shear), Cavitron Ultrasound Surgical Aspirator CUSA), hydro jet, radiofrequency dissector and recently staplers. There are numerous types of resection could be divided to major (>2 segments) and minor (<2 segments) and could be divided into anatomical (right and left hepatectomy, right anterior and posterior sectionectomy and left lateral sectionectomy), non-anatomical resection and individual segmentectomy. There are many other interventional procedures can be done during surgery for hepatic focal lesions rather than surgery as radiofrequency ablation (RFA), cryoablation or irreversible electroporation (IRE) which usually kept as combined intervention with surgery in deep parenchymal lesions which difficult to be removed without injuring or scarifying a major hepatic structure. Also one of the elegant technique in management of hepatic focal lesions especially Malignant one is adjuvant or pre operatiove angio-embolization or chemo/ radio embolization which deprive the lesion from its blood supply and supplying it with chemo or radiotherapy which may decrease the size of lesion and make it easier and accessible to be removed. In addition to that, systemic chemotherapy could have benefit in malignant lesions as it may decrease the size of the lesions and minimize the liver parenchyma needed to be resected to remove the whole lesion, and sometimes it
changes non resectable liver lesions to resectable one.