BACKGROUND Most patients with hydatid cysts are asymptomatic, and they are diagnosed incidentally during radiological evaluations performed for other reasons. However, some patients develop symptoms and complications due to cyst size, location, and the relationship between the cyst and adjacent structures. The most serious complications that can occur are rupture of the cysts into the biliary tract, vascular structures, hollow viscus, and peritoneal cavity. We aimed to describe the management of four cases of intraperitoneal rupture of hydatid cysts. CASE SUMMARIES Four patients aged between 27 and 44 years (two men and two women) were admitted to our clinic with sudden abdominal pain ( n = 4), hypotension ( n = 3), and anaphylaxis ( n = 2). Three of the perforated cysts were located in the liver, and one was located in the spleen. Two patients developed cyst rupture after minor trauma, and the other two developed spontaneous rupture. Enzyme-linked immunosorbent assay IgG results were positive for two patients and negative for the other two. All patients received albendazole treatment after surgical intervention (range: 2-6 mo). Two patients developed hepatic abscesses requiring drainage; one of these patients also developed hydatid cyst recurrence during postoperative follow-up (range: 25-80 mo). CONCLUSION Intraperitoneal rupture is a life-threatening complication of hydatid cysts. It is important to manage patients with surgical intervention as soon as possible with aggressive medical treatment for anaphylactic reactions.

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In this study, we evaluated the diagnosis, epidemiology, risk factors, and treatment of chylous ascites developing after liver transplantation (LT). Between 2002 and 2011, LT was performed 693 times in 631 patients at our clinic. One-hundred fifteen of these patients were excluded for reasons such as retransplantation, early postoperative mortality, and insufficient data. Chylous ascites developed after LT (mean 6 SD ¼ 8.0 6 3.2 days, range ¼ 5-17 days) in 24 of the 516 patients included in this study. Using univariate and multivariate analyses, we examined whether the following were risk factors for developing chylous ascites: age, sex, body mass index, graft-to-recipient weight ratio, Model for End-Stage Liver Disease score, vena cava cross-clamping time, total operation time, Child-Pugh classification, sodium level, portal vein thrombosis or ascites before transplantation, donor type, albumin level, and perihepatic dissection technique [LigaSure vessel sealing system (LVSS) versus conventional suture ligation]. According to a univariate analysis, a low albumin level (P ¼ 0.04), the presence of ascites before transplantation (P ¼ 0.03), and the use of LVSS for perihepatic dissection (P < 0.01) were risk factors for developing chylous ascites. According to a multivariate Cox proportional hazards model, the presence of pretransplant ascites [P ¼ 0.04, hazard ratio (HR) ¼ 2.8, 95% confidence interval (CI) ¼ 1.1-13.5] and the use of LVSS for perihepatic dissection (P ¼ 0.01, HR ¼ 5.4, 95% CI ¼ 1.5-34.4) were independent risk factors. In conclusion, the presence of preoperative ascites and the use of LVSS for perihepatic dissection are independent risk factors for the formation of chylous ascites. To our knowledge, this study is the most extensive examination of the development of chylous ascites. Nevertheless, our results should be supported by new prospective trials.

Echinococcus alveolaris (EA) causes a hepatic zoonotic infection and behaves like a malignant tumor during invasion. Liver transplantation (LT) is the only curative treatment option for this unresectable disease. Here, we share our experience with living donor liver transplantation (LDLT) due to EA from the time between March 2002 and November 2014 at the Liver Transplantation Institute of _ In€ on€ u University. Ten patients (mean age, 38.6 years) undergoing LDLT because of unresectable EA were evaluated preoperatively, and the operative and follow-up data were analyzed retrospectively. The mean time interval between diagnosis and LT was 27 months. The mean operation time and mean intraoperative blood requirement were 613 minutes and 4 units of packed red blood cells, respectively. Diaphragmatic resections were performed in 3 patients, and vena cava replacement was performed in 2 patients because of difficulties in removing the extended disease. The local recurrence and distant metastasis rates were 10% and 20%, respectively. The mean survival time was 19.5 months (range, 0-54 months), and the mortality rate was 30%. Unresectable hepatic alveolar echinococcosis is a rare indication for LT and presents some technical difficulties during surgery because diaphragmatic resection, vascular reconstruction, or multiple blood transfusions may be needed. LDLT can be performed successfully in patients with this rare infectious disease, with careful follow-up for potential recurrence and metastasis and administration of low-dose immunosuppressive agents. Liver

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Reconstruction of anomalous portal vein branching (APVB) during right lobe living donor liver transplantation (LDLT) can be challenging. The goal of this article is to describe our surgical technique, named the Malatya Approach, in case of APVB during right lobe LDLT. The technique unifies the APVB and obtains a funnel-shaped common extension with a circumferential fence by a saphenous vein conduit. In total, 126 (10.6%) of 1192 right lobe grafts had APVB that were divided into 2 groups according to the adopted surgical techniques: the Malatya Approach group (n = 91) and the previously defined other techniques group (n = 35). Both groups were compared regarding portal vein thrombosis (PVT), postoperative 90-day mortality and survival. PVT developed in 3 patients (3.3%) in the Malatya Approach group and developed in 10 (28.6%) patients for the other group (P < 0.001). There were 8 (8.8%) 90-day mortalities in the Malatya Approach group (1 PVT related) and 15 patients (9 PVT related) died in the other techniques group (P < 0.001). Mean follow-up time for both groups was similar (999.1 days for the Malatya Approach group versus 1024.7 days for the other group; P = 0.47), but longterm survival in the Malatya Approach group was better than in the other group (84.6% versus 40%; P < 0.001). Multivariate analysis revealed that the Malatya Approach group showed less PVT development and longer survival (P < 0.001). This technique is promising to avoid PVT and mortalities in cases of APVB during right lobe LDLT. Liver Transplantation 23 751-761 2017 AASLD.