Background: Inappropriate use of antimicrobials results in rapid emergence of resistance, selection pressure on resistant microorganisms, adverse reactions, and treatment failures. An effective approach to improving antimicrobial use in healthcare settings is a structured antimicrobial management program known as antimicrobial stewardship (AMS). Education and training is considered a backbone element of AMS program .This study aimed to evaluate the impact of educational program on the knowledge, attitude, and practice (KAP) of healthcare providers (HCPs) towards antimicrobial stewardship before and after the educational program at the surgery department and surgical ICU, National Liver Institute hospital (NLI), Egypt.Results: Among the 69 invited HCPs, 48 attended the educational program sessions with attendance response rate about 70%. Regarding pre-educational KAP score of the respondents' physicians and pharmacists, 39.3% of them had good knowledge score, 85.7% of them had positive attitude, &and 31.8% of physicians had good practice score; however, 100% of the pharmacists had poor practice. Regarding the respondents' nurse, the pre-education mean score of knowledge was 13.3/20, attitude 14.8/16, and practice 9.3/14. Following educational program, there was a significant improvement in knowledge, attitude, and practice of the respondents' health care providers (P < 0.001); on the contrary, there was no significant improvement in the practice of pharmacists (P > 0.05). Conclusion:The implemented educational program was successful in improving the knowledge, attitude, and practice of HCPs; therefore, continuous efforts are needed to implement more educational programs to increase awareness towards AMS among HCPs.

The aim of this work is to study the different factors that affect the outcome of living donor liver transplantation for patients with hepatocellular carcinoma (HCC). Between April 2003 to November 2014, 62 patients with liver cirrhosis and HCC underwent living donor liver transplantation (LDLT) in the National Liver Institute, Menoufia University, Egypt. The preoperative, operative, and postoperative data were analyzed. After studying the pathology of explanted liver; 44 (71 %) patients were within the Milan criteria, and 18 (29 %) patients were beyond Milan; 13 (21.7 %) of patients beyond the Milan criteria were also beyond the University of California San Francisco criteria (UCSF) criteria. Preoperative ablative therapy for HCC was done in 22 patients (35.5 %), four patients had complete ablation with no residual tumor tissues. Microvascular invasion was present in ten patients (16 %) in histopathological study. Seven (11.3 %) patients had recurrent HCC post transplantation. The 1, 3, 5 years total survival was 88.7, 77.9, 67.2 %, respectively, while the tumor-free survival was 87.3, 82.5, 77.6 %, respectively. Expansion of selection criteria beyond Milan and UCSF had no increased risk effect on recurrence of HCC but had less survival rate than patients within the Milan criteria. Microvascular invasion was an independent risk factor for tumor recurrence.

Background and Aim: latrogenic biliary injuries are among the most serious complications of biliary surgery. Reparative surgery is challenging, especially in recurrent patients. The aim of this study was to evaluate the success of high hepaticojejunostomy in the management of various types of iatrogenic injuries, both as primary repair and after previous failed attempts at surgical repair. Patients and Methods: Twenty-two patients (13 females, 9 males) with a mean age of 44.7 years were included and injury had occurred during: open cholecystectomy in 19 patients; laparoscopic cholecystectomy in 2 patients, and repair of an incisional hernia in 1 patient. Eight patients had had previous repair attempts with bilioenteric anastomosis in 6 and primary repair over a T tube in 2 patients. The last previous surgery was 1 week to 6 years earlier. The level of injury was diagnosed by endoscopic retrograde cholangiopancreaticography in 15 patients, and by percutaneous transhepatic cholangiography in 7 patients. The patients underwent Roux-en-Y hepaticojejunostomy at the confluence in 15 (68%) and just below the confluence in 7 (32%). The mean follow-up period was 25 ± 15 months. Results: Eighteen patients (82%) had an uneventful recovery and good outcome during follow-up, whereas 4 patients (18%) had moderate or poor outcome. There was no correlation between the duration of biliary injury or previous repair attempts and the outcome of surgery. Conclusion: High hepaticojejunostomy offers good results in the management of complicated iatrogenic biliary injuries. Failed previous attempts at repair do not alter the success of reparative surgery.

Granular cell tumor is a rare cause of hepatic dysfunction. We report here on a patient who underwent liver transplantation for this ailment. In our literature review, the common bile duct was most commonly involved (56%). A wide variety of therapies were advanced for this type of lesion, spanning three decades of care. Twenty-eight patients (49%) had no follow-up reported, and another 2 (3%) were found at autopsy. Sixteen patients (28%) were followed more than 1 year, with 72% followed less than 1 year if at all. We present the first case of a granular cell tumor being treated with liver transplantation. Although adequate early excisional surgery should obviate the need for transplantation in these cases, widely disparate therapy and poor follow-up may mask generally inadequate therapy for this lesion. The authors recommend thorough excision and long-term follow-up for patients with this entity to avoid secondary biliary cirrhosis and to eliminate the preventable need for transplantation.

Background: Acute mesenteric venous thrombosis (MVT) is a dreadful complication of liver cirrhosis that requires prompt diagnosis and aggressive management for better outcome. The aim of this work was to study the diagnostic tools and the optimal management of acute MVT in patients with liver cirrhosis.Methods: It was a retrospective study including 40 patients with liver cirrhosis who were admitted to the surgical emergency and were eventually diagnosed as acute MVT between May 2011 to September 2016. The preoperative clinicopathological data, operative data and postoperative follow up were recorded.Results: Forty patients had acute MVT. Twenty five patients (62.5%) had prolonged prothrombin time, 18 patients (45%) had thrombocytopenia and 22 patients (55%) had low protein C. triphasic CT scan was the main diagnostic image in 28 patients, with sensitivity 100% and accuracy 96.9% in detection of intestinal infarction. Ten patients (25%) underwent conservative treatment with anticoagulant, while 30 patients (75%) were surgically explored and 28 patients of them had gangrenous bowel loops and underwent primary resection and anastomosis. Three patients underwent second look operation. Three patients had recurrent symptoms after 1 month of the first presentation. The overall 30- and 90-day mortality was 27.5% and 37.5% respectively.Conclusions: Cirrhotic patients may have hypercoagulable state and the usual laboratory tests don’t accurately assess the coagulation status in these patient. Acute MVT in cirrhotic patients has a high early morbidity and mortality that needs early diagnosis and urgent management with selective surgical intervention and proper anticoagulant.