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    Are Ki-67 and Procalcitonin Expression Levels Useful in Predicting the Biological Behavior of Hepatocellular Carcinoma After Liver Transplantation?
    (Mdpi, 2025) Karabulut, Ertugrul; Akbulut, Sami; Samdanci, Emine Turkmen; Akatli, Ayse Nur; Elsarawy, Ahmed; Kucukakcali, Zeynep; Ogut, Zeki
    Background: Examinations of procalcitonin (PCT) and Ki-67 expression levels in hepatocellular carcinoma (HCC) patients who have undergone liver transplantation (LT) through immunohistochemical analyses of tumor tissue may reveal the biological characteristics of the tumor, thus informing the selection of HCC patients for LT. Methods: Hepatectomy specimens from 86 HCC patients who underwent LT were obtained and analyzed immunohistochemically for the expression of PCT and Ki-67. The percentage and intensity of PCT staining, as well as the percentage of Ki-67 expression, were assessed for each patient. The impacts of PCT and Ki-67 expression on disease-free survival, overall survival, and the recurrence rate were studied, as well as their correlations with other clinicopathological features. Results: The recurrent HCC group showed a higher Ki-67 level (p < 0.001), larger maximum dominant tumor diameter (p < 0.001), and higher rate of vascular invasion (p = 0.001). The pre-transplant AFP (p = 0.001), maximum dominant tumor diameter (p < 0.001), number of tumor nodules (p < 0.001), rate of vascular invasion (p = 0.001), and Ki-67 level (p = 0.044) were higher in patients beyond the Milan criteria. Similarly, the pre-transplant AFP (p < 0.001); maximum dominant tumor diameter (p < 0.001); number of tumor nodules (p < 0.001); rates of portal vein tumor thrombus (p = 0.002), poor differentiation (p = 0.021), and vascular invasion (p < 0.001); and Ki-67 level (p = 0.010) were higher in patients beyond the expanded Malatya criteria. The maximum dominant tumor diameter (p = 0.006); Ki-67 level (p = 0.003); rates of vascular invasion (p < 0.001), cases beyond the Milan criteria (p = 0.042) and the expanded Malatya criteria (p = 0.027), and portal vein tumor thrombus (p = 0.020); and presence of recurrence (p < 0.001) were higher in HCC patients with mortality. The Kaplan-Meier estimates indicated that Ki-67 levels exceeding 5% significantly affected DFS and OS. Although the Kaplan-Meier estimates indicated that a PCT staining percentage of >= 25% did not have a statistically significant effect on DFS or OS, the outcomes may be considered clinically significant. Conclusions: This study demonstrated that the Ki-67 proliferation index can be used as a predictive biomarker of the biological behavior of HCC. Furthermore, we claim that PCT expression over a particular threshold might impact recurrence and survival, and we believe that further multicenter prospective studies focused on standardized PCT antibody staining are crucial in order to determine its potential as a biomarker for HCC.
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    Clinical Features of Hydatid Disease
    (Springer Science+Business Media, 2025) Hargura, Abdirahman Sakulen; Elsarawy, Ahmed; Akbulut, Sami
    Echinococcal infestation is an important health problem that needs vigilant screening and stepwise approach for diagnosis, treatment, and follow up as dictated by the World Health Organization (WHO). The most common forms are cystic echinococcosis caused by Echinococcus granulosus and alveolar echinococcosis caused by Echinococcus multilocularis. Liver hydatid disease is increasingly encountered worldwide with the rise in health awareness and availability of medical diagnostics, in addition to the active immigration across the globe. Although hydatid disease (especially cystic echinococcosis) is most commonly seen in the liver and lungs, it can affect many tissues and organs in the body. In hydatid cyst involvement of almost all organs, patients remain asymptomatic for varying periods and diagnosed with an incidental radiological finding done on routine examination. In this study, we will summarize the clinical sign and symptoms of hydatid disease, which involves both hepatic and extrahepatic involvement such as lungs, spleen, heart, pancreas, central nervous system, musculoskeletal and soft tissues, kidney and retroperitoneum, subcutaneous tissue, orbital and ocular space, head, neck, thyroid and parotid glands. © 2025 The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG.
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    Effect of Complex Venous Outflow Drainage Reconstruction on Postoperative Graft Function in Right-Lobe Living Donor Liver Transplantation
    (Mdpi, 2025) Kilercik, Hakan; Akbulut, Sami; Elsarawy, Ahmed; Aktas, Sema; Alkara, Utku; Sevmis, Sinasi
    Background: Living donor liver transplantation (LDLT) is the predominant transplantation technique in regions with low rates of deceased donation. Right-lobe grafting is adopted in most clinical and radiological donor/recipient scenarios. Due to the considerable variations in right-lobe hepatic venous anatomy, many techniques have been used over the years for the purpose of appropriate venous outflow reconstruction during the recipient procedure. In this paper, we present the technical details and consequences of a complex venous outflow reconstruction model (CORM) based on experience, and the long-term patency results obtained using the model. Methods: Data of patients with end-stage liver disease who underwent LDLT between 21 December 2017 and 29 November 2022 were prospectively collected and retrospectively reviewed. The nomenclature of CORM was assigned when three or more hepatic vein anastomoses were performed. Patients with CORM (CORM group; n = 69) were compared with non-CORM patients (non-CORM group; n = 130) in terms of demographic, pre- and postoperative clinical, and follow-up features. Results: Sixty-nine recipients had three or more separate outflow reconstructions (RHV, RIHV, and one or more anterior sectoral veins); these constituted the CORM group. The estimated graft volume of the CORM group was significantly lower than that of the non-CORM group (833 vs. 898; p = 0.022), and the mean GRWR was also significantly lower (1.1 vs. 1.2; p = 0.004). CORM cases showed longer anhepatic phases, as well as longer times for cold and warm ischemia, than non-CORM cases (63 vs. 51 min, 46 vs. 38 min, and 48 vs. 33 min, p < 0.001), though no difference was found with respect to total operative duration. There were no statistical differences between the two groups with respect to rates of in-hospital re-exploration, length of ICU stay, or length of total hospital stay. Graft survival rates at 1 year, 3 years, and 5 years were 88.1%, 83.3%, and 83.3%, respectively, in the CORM group, and 82.9%, 80.2%, and 70.6%, respectively, in the non-CORM group (p = 0.167). Conclusions: Performing three or more CORMs in right-lobe LDLT is not associated with inferior outcomes, either with regard to perioperative variables or to patient and graft outcomes. Right-lobe graft with complex venous anatomy from a living donor should not be a determinant factor for donor exclusion.
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    Factors Affecting Intraoperative Blood Transfusion Requirements during Living Donor Liver Transplantation
    (Mdpi, 2024) Kilercik, Hakan; Akbulut, Sami; Elsarawy, Ahmed; Aktas, Sema; Alkara, Utku; Sevmis, Sinasi
    Background: Intraoperative blood transfusion (IOBT) during liver transplantation (LT) has negative outcomes, and it has been shown that an increasing number of these procedures may no longer require IOBT. Regarding living donor liver transplantation (LDLT), the literature on the pre-transplant predictors of IOBT is quite heterogeneous and deficient. In this study, we reviewed our experience of IOBT among a homogenous cohort of adult right-lobe LDLTs. Methods: We conducted a retrospective analysis of prospectively collected data on adult LDLT recipients between January 2018 and October 2023. Two groups were constructed (No-IOBT vs. IOBT) for the exploration of pre- and intraoperative predictors of IOBT using univariate and multivariate analyses. An ROC curve analysis was applied to identify possible cut-offs. The one-year post-LDLT overall survival was compared using the Kaplan-Meier method. A p-value < 0.05 was considered statistically significant. Results: A total of 219 adult LDLT recipients were enrolled. The No-IOBT (n = 56) patients were mostly males (p = 0.016), with higher preoperative levels of HGB (p < 0.001), fibrinogen (p = 0.005), and albumin (p = 0.007) and a lower incidence of pre-transplant upper abdominal surgery (p = 0.017), portal vein thrombosis (p = 0.04), hepatorenal syndrome (p = 0.015), and ascites (p = 0.02) than the IOBT group (n = 163). The No-IOBT group had a shorter anhepatic phase (p = 0.002) and received fewer intravenous crystalloids (p = 0.001). In the multivariate analysis, the pre-transplant HGB (p < 0.001), fibrinogen (p < 0.001), and albumin (p = 0.04) levels were independent predictors of IOBT, showing the following cut-offs in the ROC curve analysis: HGB <= 11.5 (AUC: 0.800, p < 0.001), fibrinogen <= 125 (AUC: 0.638, p = 0.0024), and albumin <= 3.6 (AUC: 0.663, p = 0.0002). These were significantly associated with the No-IOBT group. The one-year overall survival of the No-IOBT and IOBT groups was 100% and 83%, respectively (p = 0.007). Conclusions: IOBT during LDLT is associated with inferior outcomes. The increased need of IOBT during LT can be predicted by evaluating serum levels of hemoglobin, albumin and fibrinogen before liver transplantation.
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    Terminology Used for Hydatid Disease: Parasitological and Surgical Aspects
    (Springer Science+Business Media, 2025) Elsarawy, Ahmed; Akbulut, Sami; Hargura, Abdirahman Sakulen
    Echinococcosis is a parasitic disease caused by the Echinococcus species parasite and results in a spectrum of human diseases. Though known to be an endemic disease in some regions in the world, it is steadily diagnosed and managed in almost all healthcare levels worldwide. The characterization of the clinical diseases resulting from human infestation by the Echinococcus species is quiet variable owing to different and heterogenous nomenclature used in the relevant literature. In the last decade, there has been increasing local and international efforts to standardize the parasitic nomenclature used in this domain so as to unify and augment the research topics as regards to Echinococcosis, especially in this well-appreciated era of increasing disease burden worldwide. The liver is the most commonly affected organ by this parasite, and hence hepatic Echinococcosis literature showed a major part of this heterogenous terminology, either in the description of the clinical entity or the management approach. Moreover, the liver itself from a surgical anatomical standpoint has witnessed an evolution of its surgical description, and resectional approaches. So, hepatic Echinococcosis as a stand-alone surgical entity has become an interesting and clinically relevant area of research and insight. Most recently, the revolution of minimally invasive hepatic surgery has enriched the management of all hepatic diseases, including hepatic Echinococcosis. In this chapter, we focus on and merge together the most recent parasitic terminology and clinical/surgical nomenclature as regards hepatic Echinococcosis, aiming at guiding clinicians and surgeons to better manage their patients and pursuing research with standard outlines. © 2025 The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG.