Day 2 :
Keynote Forum
M Amin El-Gohary
Burjeel Hospital, UAE
Keynote: Vomiting of surgical significance
Time : 09:00-09:40
Biography:
M Amin El-Gohary has completed his MBBCh in 1972 and his Diploma in General Surgery in 1975 at Cairo University, Egypt. He became the Chief and Head of the Department of Pediatric Surgery of a large government hospital. He also held post as the Clinical Dean of Gulf Medical College, Ajman for 3 years. He is well known
in Abu Dhabi for his extensive interest and involvement in scientific activities. He was the President of the Pediatric Surgical Association of UAE. He is a Member of several associations in Pediatric surgery: Executive Member of the International Society of Intersex and Hypospadias Disorder (ISHID), British Association of Pediatric Surgery, Egyptian Association of Pediatric Surgeons, Asian Association of Pediatric Surgeons, and Pan African Association of Pediatric Surgery. He is also the founder and member of the Arab Association of Pediatric Surgeons.
Abstract:
Vomiting is common symptoms among neonates, infants and children and the majority are managed by pediatrician or pediatric gastroenterologist. However there are types of vomiting that should be referred and managed by pediatric surgeons.
These include the following:
1. Bilious vomiting however small or intermittent
2. Projectile vomiting
3. Frothy neonates
The cardinal signs and symptoms of bowel obstruction are: vomiting, abdominal distension , abdominal pain and constipation. Of which bilious vomiting is considered the most important sign. Any Baby who vomits bile should be considered as having an underling intestinal obstruction until proved otherwise Mal-rotation in particular carries a high mortality rate if associated with volvulus , despite its minimal symptoms in the form of intermittent bilious vomiting. The presentation highlights the different pathological condition associated with vomiting, and their clinical, radiological and surgical management.
Keynote Forum
Yingbin Liu
Xinhua Hospital, China
Keynote: Total mesopancreas excision for pancreatic head cancer: analysis of 120 cases
Time : 09:40-10:20
Biography:
Yingbin Liu has his expertise in improving the prognosis of hepato-biliary-pancreatic diseases. He is Vice President of Xinhua Hospital, Dean of Institute of Biliary Tract Disease Research, and Chief of General Surgery Department, Xinhua Hospital, Shanghai Jiaotong University.
Abstract:
Objective: To evaluate the feasibility and safety of total mesopancreas excision (TMpE) in the treatment of pancreatic head cancer.
Methods: The clinical and pathological data of 120 patients with pancreatic head cancer who had undergone TMpE in our center from May 2010 to January 2014 were retrospectively analyzed.
Results: The mean operative time was 275.0±50.2 min and the average intra-operative blood loss was 390.0±160.5 mL. Postoperative complications were reported in 45 patients, while no peri-operative death was noted. The specimen margins were measured in three dimensions, and 86 patients (71.6%) achieved R0 resection.
Conclusions: TMpE is safe and feasible for pancreatic head cancer and is particularly helpful to increase the R0 resection rate.
Keynote Forum
Yuming Wang
Southwest Hospital, Third Military Medical University, China
Keynote: Renal involvement in patients with Hepatitis B
Time : 10:20-11:00
Biography:
Yuming Wang has obtained his MD degree and is a Professor and Chief Physician at Institute for Infectious Diseases, Southwest Hospital, Third Military Medical University, Chongqing. Currently, he serves as the Vice-President in Infectious Diseases Branch of Chinese Medical Doctor Association. His current research fields include severe hepatitis/liver failure, pathogenesis and treatment of viral hepatitis. He is the Chief Editor of 16 monographs, Associated Editor for 31 monographs and has published more than 400 papers, including Gastroenterology, Hepatology and CGH.
Abstract:
Chronic kidney disease (CKD) is defined as eGFR<60 mL/min-1.73m2 or a urinary albumin to creatinine ratio (ACR) >30mg/g is a global public health burden because of its increasing incidence and prevalence and progressive nature to end-stage renal disease (ESRD). The prevalence of adult CKD is over 10% and there are about 120 million adult CKD patients in China. Apart from major liver complications, clinical evidence suggests that chronic HBV infection exerts a negative impact on renal function, and can lead to glomerulonephritis, even in the absence of cirrhosis. In addition, nearly 15–30% of patients with chronic hepatitis B (CHB) have baseline renal dysfunction or comorbidities associated with CKD. Prevalence of CKD is likely to rise in patients with CHB because of increasing age, more advanced disease, comorbidities and nephrotoxic therapies. A CHB infection can cause renal dysfunction through immune complex mediated glomerular diseases, such as membranous nephropath and mesangiocapillary glomerulonephritis. In countries with endemic HBV infection, HBV-related glomerulopathies are an important cause of end-stage renal disease and renal replacement therapy. Currently, more and more attention is being paid to the safety issues for NUCs. Mitochondrial toxicity cannot explain the different adverse reactions, including nephrotoxicity, hyperlacticaemia, lactic acidosis, myopathy, peripheral neuritis, hepatic steatosis, etc. The currently approved oral antiviral agents are all primarily eliminated unchanged through the renal route. So, the core clinical issue is nephrotoxicity; other issues are either rare, related to a few special populations, or are easy to prevent. Consequently, current product labels recommend that in patients with renal insufficiency, dose reduction and/or increased dose intervals are recommended. Worsening of renal function during prolonged nucleotide therapy has primarily been reported with adefovir (ADV), but also with tenofovir (TDF). However, all current evidences indicate that among the NUCs, only telbivudine (LdT) therapy is associated with consistent increase in renal function (eGFR) across different CHB patient populations with decompensated and compensated disease. GLOBE study, a large scale clinical trial, has revealed that LdT significantly improved eGFR in CHB patients with compensated liver disease versus LAM/ETV. At the same time, most studies also revealed LdT can improve eGFR in patients with CHB versus ADV/TDF. But the mechanism of the beneficial effect of LdT therapy on renal function remains to be determined. These results may be important for clinicians to best assess the choice of antiviral therapy in those patients most vulnerable for renal dysfunction, including the elderly and those with baseline renal insufficiency, severe liver fibrosis, or decompensated liver disease. In summary, the number of patients with CHB with renal dysfunction is increasing. The key clinical safety issue for NUCs is nephrotoxicity. According to current evidence, patients with CHB receiving long-term NUC antiviral therapy should have renal function monitored. Renal function in patients with CHB improves steadily during long-term LdT monotherapy, while LdT+ADV/TDF combination therapy could improve eGFR as well. In addition, early prevention or protection of renal involvement is emphasized in clinical practice.
- Hepatitis C | Pancreatitis | Liver Diseases | Liver Transplantation and Surgery
Chair
M Amin El-Gohary
Burjeel Hospital, UAE
Co-Chair
Yingbin Liu
Xinhua Hospital, China
Session Introduction
Abdulaziz Shaher
Assir Central Hospital, Saudi Arabia
Title: The Surgeon vs the Gastroenterologist in the management of Acute Biliary Pancreatitis, Where Does the Intensivist stand?
Biography:
Abdulaziz Shaher is a Board Certified General Surgeon and Intensive Care Fellow. He is an Associate Fellow of the American College of Surgeons, Active Member in the Saudi and the American Critical Care Societies with a specific interest in acute care surgery, resuscitation and trauma.
Abstract:
The high prevalence of gallstones within the Saudi Arabian population is the leading cause of Acute Pancreatitis (AP), the disease notorious for its range of severity and challenging management options. AP is a medical disease that is commonly managed by surgeons in most of the institutions within Saudi Arabia. AP is a wait and sees disease an area that is well mastered by the physicians, where the surgeons lack a huge deal of experience in this field, and indeed they feel incapacitated exactly as if you take the rifle from a sniper and you tell him to wait and see. Surgeons choose surgery because they are doers and physicians chose medicine because they are thinkers and nothing wrong with either choice, but things get missy when you through a medical ball such as AP in the field of surgeons, they suddenly want to kick it while in fact it’s an oracle crystal ball. At the same time Gastroenterologists maximum input would be to do and ERCP, while it can be difficult sometimes, but still a 1 hour challenge would melt in front of daily continuous care. Here comes the choreographer; the designer of the initial aggressive resuscitation, the follow up and the de-resuscitation phase to take back all the excess fluids that have been given. The aim of this presentation is to discuss in brief the resuscitation principles and endpoints of the Systemic Inflammatory disease as a result of AP and rule played by the Intensivist through the whole phases of challenging cases of AP. The integration of the echocardiographic target goals of resuscitation, the dry resuscitation principles, the abdominal compartment syndrome,vacuum management in open abdomen and the de-resusciation towards the recovery phase. In this article I’m trying to capture the whole aspect of the complicated pancreatitis management within the ICU setting, from the eye of a surgeon/Intensivist.
Abdel Rahman Abdulla Al Manasra
Jordan University of Science and Technology, Jordan
Title: Prevalence and patterns of Non-alcoholic fatty liver disease among morbidly obese patients undergoing sleeve gastrectomy
Biography:
Abdel Rahman Abdulla Al Manasra, MD, has completed his graduation in 2005 from Jordan University of Science and Technology, Irbid, Jordan with Bachelor’s in Medicine and Surgery. Later, he obtained a higher specialization degree in General Surgery from same university after 5 years of residency training at King Abdullah University Hospital. In 2013, he graduated from the Medical University of South Carolina and became an American Society of Transplant Surgeons’ (ASTS) Certified Abdominal Multi Organ Transplant Surgeon. This was followed by a one year of specialized fellowship training in pediatric abdominal transplant surgery. Since 2014, he has been working as a Consultant Abdominal Transplant and Hepatobiliary Surgeon at King Abdullah University Hospital, as well as an Assistant Professor of Surgery at Faculty of Medicine, Jordan University of Science and Technology.
Abstract:
Background & Aim: Obesity related non-alcoholic fatty liver disease (NAFLD) is increasingly recognized worldwide. Multiple predictive and risk factors have been proposed for NAFLD. We aim to describe the prevalence, histologic patterns, and risk factors for this disease in morbidly obese patients undergoing sleeve gastrectomy.
Methods: This is a prospective study, which included a cohort of 49 obese patients undergoing sleeve gastrectomy with concomitant true cut liver biopsy. Patients were excluded when they have history of alcohol intake, liver disease, or hepatotoxic agents’ intake. Clinical, biochemical, and histological features were evaluated. Histological patterns were classified based on the NIH-sponsored NASH Clinical Research Network NAFLD Activity Score (NAS).
Results: Most patients were females (73%), with mean age of 34 (range 17-58). Mean BMI was 43 (35-52). 45 patients (91.8%) showed NAFLD, 19 (39%) showed non-alcoholic steatohepatitis (NASH) and 5 (10%) showed fibrosis. Only 4 biopsies (8%) were reported as normal. Significant correlation was found between low-density lipoprotein (LDL) vs. NASH (P=0.005), LDL vs. steatosis grade (P=0.023), aspartate aminotransferase (AST) vs. NAS (P=0.005), AST vs. steatosis grade (P=0.009), glucose vs. steatosis (P=0.006), sex vs. NAFLD (P=0.02), and sex vs. hepatocyte ballooning (P=0.005). There was no morbidity or mortality in this study.
Conclusion: NAFLD has a very high prevalence among morbidly obese patients. Significant correlation is evident between biochemical markers and histological components of liver assessment. Intraoperative liver biopsy is safe in morbidly obese patients undergoing sleeve gastrectomy for the diagnosis of NAFLD.
Rehan Saif
Aster DM Healthcare Group, India
Title: Evolving role of Minimally Invasive (Laparoscopic and Robotic) Donor Hepatectomy
Biography:
Rehan Saif is a Consultant in HPB Surgery and Abdominal Multi-Organ Transplantation. He is associated with the Integrated Liver Care Team at Aster DM Healthcare Group in India running multi-organ transplant centers at Aster Medcity, Kochi and Aster CMI Hospital, Bangalore. He completed his Post-graduate General Surgical training in India following which he spent 12 years gaining further specialist higher surgical training in the United Kingdom. He obtained his MRCS and FRCS (HPB and Transplantation) from The Royal College of Surgeons of Edinburgh leading on to CCT (UK). He also completed the European Diploma in Transplantation (European Society for Organ Transplantation) and is accredited by the UEMS (European Board of Surgery) where he obtained his FEBS (HPB Surgery). This was followed by a period of further fellowships and training in the field of Liver Transplantation first at the Institute of Transplantation, Newcastle upon Tyne, UK (Post CCT Senior Fellowship) and then an International Travelling Fellowship in Living Donor Liver Transplantation at the Kaohsiung Chang Gung Memorial Hospital, Taiwan (RCSEd Ethicon Travelling Fellowship). He is also trained in the Field of Robotic Minimally Invasive HPB Surgery in the UK, Europe and has done an International Fellowship in Robotic HPB Surgery at UIC Medical Center, Chicago (USA). He is an expert in highly advanced procedures including liver
transplantation (live donor and cadaveric), pancreas transplant, kidney transplant, complex HPB surgery and minimally invasive robotic HPB surgery.
Abstract:
Liver transplantation has become an established modality of treatment for patients with end stage liver disease. The shortage of deceased donor organs has led to living donor liver transplantation (LDLT) becoming a valid alternative in selected transplant centers, and its safety and feasibility have been well determined. Minimally invasive surgery mainly laparoscopic surgery has been adopted in various surgical fields over the last two decades with well validated advantages such as reduced blood loss, reduced postoperative morbidity, shorter hospital stay and excellent cosmetic outcome in comparison to conventional open surgery. However, despite inception over 15 years ago laparoscopic liver resection has remained mainly in the domain of selected centers and enthusiasts. The delay in the wide application of minimally invasive liver surgery can probably be explained by the requirement of extensive open liver resection experience, in-depth understanding of anatomy, and potential for massive bleeding, need for considerable laparoscopic technical expertise and a protracted learning curve. Given that a liver resection is ideally suited for a minimally invasive approach as there is no anastomosis and a very large incision is required in the open approach, there has been an increasing interest in this technique worldwide. However the actual experience is limited to a few selected centers and guidelines remain inadequate. Furthermore, the application of minimally invasive liver surgery to liver graft procurement in LDLT have been delayed significantly due to concerns about donor safety, graft outcome and the requirement of expertise both in laparoscopic liver surgery and LDLT. Some experienced centers now routinely employ laparoscopic left lateral segmentectomy as standard of care in adult-to-pediatric LDLT. There has been a recent shift in the application of minimally invasive approach towards the procurement of left lobe and right lobe grafts in adult-to-adult LDLT. However the number of cases is too small and restricted to very few centers. The use of newer technology such as the robotic platform offers certain distinct advantages over traditional laparoscopy such as a stable magnified field with 3-D vision and enhanced instrument articulation, enhanced ability for suture ligation and an additional fourth robotic arm. This facilitates and improves the possibility of minimally invasive liver resection even in challenging major liver resection such as liver graft procurement in LDLT. Minimally invasive live donor hepatectomy is technically feasible with outcomes comparable to conventional open surgery. However careful validation of larger sample sizes is necessary to achieve standardization and wider application. The most important concern remains donor safety.
Sonal Asthana
Aster CMI Hospital, India
Title: A Novel Bio-Printed 3D Liver Tissue Platform: Tool for Medical Research
Biography:
Sonal Asthana is a trained Hepatobiliary and Transplant Surgeon with work experience in leading centers in North America, UK and India. He has completed an American Society of Transplant Surgeons-Accredited Fellowship at the University of Alberta Hospital, Edmonton, Canada. The management of a transplant team requires a strong multidisciplinary approach to patient care, which is fairly different from the traditional hierarchical method still common in most surgical practice. Managing teams of highly skilled individuals working towards common goals will be a key skill for managers in modern medicine. He has authored more than 35 peer-reviewed papers, and has won international awards for basic and clinical research. His research has been supported by competitive grant funding from government and industry.
Abstract:
Background: Bio-engineered in vitro 3D human liver tissues, that are structurally and functionally accurate, provide an opportunity to reconstruct biological processes, both physiological and pathological. Normal cell physiology and function strongly depend on cell-cell and cell-extracellular matrix (ECM) interactions in the 3D tissue environment. Cells grown in 2D do not exhibit in vivo cell polarization and cellular interactions, and are generally non-viable after confluency within 3-5 days. The utility of co-culture of different cell types is limited by overgrowth of some cell types, especially fibroblasts using current two dimensional (2D) monolayer culture.
Methods: Hepatocytes and fibroblasts were encapsulated in an ECM-mimetic hydrogel, and 3D bio-printed as micro patterns with low aspect ratios. Typically 50,000 cells in 25 μl of hydrogel were extruded to about 5 mm in x and y directions, and 1 mm in the z direction. The hydrogel was then thermally cross linked to achieve the desired shape. These cell based tissue constructs were then cultured under standard conditions. Viability, histology, bio chemistry, gene and protein expression were observed at timely intervals.
Results: 3D bio-printed tissues express various critical liver functions such as production of albumin, cholesterol, fibrinogen, transferrin, urea, and inducible cytochrome P450 enzymatic activities (CYP1A2 and CYP3A4). Histology shows in vivo like cellular morphology. Viability and functionality of the 3D tissues could be maintained for 8 weeks, as compared to 5-7 days for conventional 2D cell culture. Hepatocytes and fibroblasts could be co-cultured in distinct hydrogel micro compartments, without fibroblast overgrowth and hepatocyte suppression. We present a novel 3D liver tissue platform that can be manufactured reproducibly, harbor multiple cell types in micro architectures, express functionality over an extended period of time, and thus can be used as a tool for translational medical research.
Biography:
Rehan Saif is a Consultant in HPB Surgery and Abdominal Multi-Organ Transplantation. He is associated with the Integrated Liver Care Team at Aster DM Healthcare Group in India running multi-organ transplant centers at Aster Medcity, Kochi and Aster CMI Hospital, Bangalore. He completed his Post-graduate general surgical training in India following which he spent 12 years gaining further specialist higher surgical training in the United Kingdom. He obtained his MRCS and FRCS (HPB and Transplantation) from The Royal College of Surgeons of Edinburgh leading on to CCT (UK). He also completed the European Diploma in Transplantation (European Society for Organ Transplantation) and is accredited by the UEMS (European Board of Surgery) where he obtained his FEBS (HPB Surgery). This was followed by a period of further fellowships and training in the field of Liver Transplantation first at the Institute of Transplantation, Newcastle upon Tyne, UK (Post CCT Senior Fellowship) and then an International Travelling Fellowship in Living Donor Liver Transplantation at the Kaohsiung Chang Gung Memorial Hospital, Taiwan (RCSEd Ethicon Travelling Fellowship). He is also trained in the field of Robotic Minimally Invasive HPB Surgery in the UK, Europe and has done an International Fellowship in Robotic HPB Surgery at UIC Medical Center, Chicago (USA). He is an expert in highly advanced procedures including liver transplantation (live donor and cadaveric), pancreas transplant,kidney transplant, complex HPB surgery and minimally invasive robotic HPB surgery.
Abstract:
Liver surgery has advanced more than any other type of surgery since the early 1980s. This is partly due to advances in technology and surgical instrumentation, as well as in anesthetic management of patients. In fact, indications for extended liver surgery interventions being performed today were thought of as unthinkable practice just a few decades ago. The open approach continues as the predominant one in liver surgery, despite great enthusiasm following the development and growth of laparoscopy since the early 1990s. In some high-volume centers with skilled surgeons, laparoscopy is now the method of choice when performing left lateral segmentectomy or when lesions are located in anterior segments. However, major resection (removal of three or more segments) is typically performed using the open approach. In our experience, the robot-assisted approach is distinctly different from laparoscopy for this type of surgery. Major liver resection using the robot is not only feasible but also advantageous, creating the ideal gateway for minimally invasive surgery of the liver of all liver resections, right hepatectomy is the most commonly performed worldwide, and its technique is well standardized. In this video, we describe the surgical steps of this technique using the robot-assisted approach. Robotic right hepatectomy is feasible, safe and offers a new
technical option for minimally invasive major liver resection.