Biliary complications among live donors following live donor liver transplantation.

INTRODUCTION: In live donor liver transplantation (LDLT), bile duct division is a critical step in donor hepatectomy. Biliary complications hence are a feared sequelae even among donors. Long term data on biliary complications in donors from India are sparse. METHODS: Prospective evaluation of 452 live donors over 10 years was performed to ascertain the incidence & risk factors of clinically significant biliary complications. RESULTS: Of the 452 donor hepatectomies (M: F = 114:338, median age = 38), 66.2% (299) were extended right lobe grafts, 24.1% (109) modified right lobe and 9.7% (44) were left lobe grafts. Portal vein anatomy was Type-I in 85% (386), Type-II in 7.5% (34) and Type-III in 7.1% (32). Following donor hepatectomy, a single bile duct opening occurred only in 46.5% (210) of the grafts. Of the remaining 53.5% grafts, 2 ductal openings were noted in 217 (48%) and three ductal openings in 25 (5.5%). Incidence of multiple openings in the duct were more commonly noted in Type II (70.6%) and III (75%) portal vein anatomy than in grafts with Type I (50.4%) portal anatomy (P = 0.001) Bile leak was noted in 15 (3.3%) donors which included one broncho-biliary fistula and bilio-pleural fistula. Analysis revealed no association between post-operative biliary complications and type of graft, portal vein anatomy or biliary anatomy. There was a single mortality in this series secondary to biliary sepsis. On long term follow, there were no biliary strictures in any of the patients. CONCLUSIONS: Biliary complications although rare (3.3%), present significant peri-operative morbidity to the donors.

Perioperative prostaglandin e1 infusion in living donor liver transplantation: A double-blind, placebo-controlled randomized trial.

The role of prostaglandin E1 (PGE1) infusion in improving early graft function has not been well defined, especially in the scenario of living donor liver transplantation (LDLT). We designed a randomized, double-blind, placebo-controlled trial to evaluate the role of perioperative PGE1 infusion in LDLT. Patients in the study arm received PGE1 (alprostadil) at the rate of 0.25 µg/kg/hour, starting at 1 hour after portal venous reperfusion, and continued for 96 hours. The primary endpoint was early allograft dysfunction (EAD). We analyzed multiple secondary endpoints including postoperative liver function and renal function parameters, acute kidney injury (AKI), hepatic artery thrombosis (HAT), postoperative bleeding, overall mortality, and posttransplant hospital stay. The incidence of EAD was lower in the PGE1 arm, although the difference did not reach statistical significance (22.4% versus 36%; P = 0.21). Among the secondary endpoints, the incidence of AKI was significantly lower in the PGE1 arm (8.2% versus 28%; P = 0.02), as were the peak and mean postoperative creatinine levels. The need for renal replacement therapy was similar between the 2 groups. Among the postoperative graft function parameters, postoperative alanine aminotransferase level was significantly lower in the PGE1 arm (P = 0.04), whereas the remaining parameters including serum bilirubin, aspartate aminotransferase, and international normalized ratio were similar between the 2 arms. There was no difference in the incidence of HAT and postoperative bleeding, in-hospital mortality, and posttransplant hospital stay between the 2 arms. Perioperative PGE1 infusion reduces the incidence of posttransplant renal dysfunction in patients undergoing LDLT. Liver Transplantation 22 1067-1074 2016 AASLD.

Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group's practical consensus statements for surgical management of localized and locally advanced rectal cancer.

Introduction: There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings. Methods: Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement. Results: Using the results of the review of the literature and experts' opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as "strong or weak", based on the GRADE framework. Conclusion: The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons' community in India.

Live donor liver transplantation for antitubercular drug-induced acute liver failure.

Antitubercular therapy (ATT)-induced hepatotoxicity is often over looked and active tuberculosis is considered a contraindication for liver transplantation, however it might be the only lifesaving option to certain patients of acute liver failure (ALF) due to ATT. We have assessed the outcome of live donor liver transplantation in ATT-induced ALF. A retrospective analysis of all the cases of ALF that underwent liver transplantation from 2006 to 2014 at the Amrita Institute of Medical Sciences was done. A total of seven (7.7%) patients with ATT-induced ALF who had underwent live donor liver transplantation were included in the study. Out of seven patients, three (42.8%) had established diagnosis of tuberculosis and the remaining (58.2%) patients were started on ATT empirically. The median duration of ATT intake was 2 months. All the patients underwent live donor liver transplant as they met King's College criteria, and their model for end-stage liver disease score was above 35 on admission, receiving graft from first degree relatives. Histopathology of explant liver showed pan acinar necrosis. Restarting of ATT after transplant was individualized. It was restarted only in two (28%) patients with prior sputum-positive pulmonary tuberculosis after a median time of 27 days after transplant. ATT was not restarted in rest of the (72%) patients. Postoperative mortality was seen in two (28%) patients due to conditions that masquerade the ATT-induced acute liver failure. The overall survival rate was 71.4% with a median follow up of 22 months. Live donor-related transplantation is feasible option in ATT-induced acute liver failure. Restarting of ATT post liver transplant is feasible and should be individualized along with frequent monitoring of immunosuppressant levels; however, if the primary diagnosis of tuberculosis was empirical, reintroduction of ATT can be omitted.

Acute liver failure due to zinc phosphide containing rodenticide poisoning: Clinical features and prognostic indicators of need for liver transplantation.

Zinc phosphide (ZnP) containing rodenticide poisoning is a recognized cause of acute liver failure (ALF) in India. When standard conservative measures fail, the sole option is liver transplantation. Records of 41 patients admitted to a single centre with ZnP-induced ALF were reviewed to identify prognostic indicators for requirement of liver transplantation. Patients were analyzed in two groups: group I (n = 22) consisted of patients who either underwent a liver transplant (n = 14) or died without a transplant (n = 8); group II (n = 19) comprised those who survived without liver transplantation. International normalized ratio (INR) in group I was 9 compared to 3 in group II (p < 0.001). Encephalopathy occurred only in group I. Model for End-Stage Liver Disease (MELD) score in group I was 41 compared to 24 in group II (p < 0.001). MELD score of 36 (sensitivity of 86.7 %, specificity of 90 %) or a combination of INR of 6 and encephalopathy (sensitivity of 100 %, specificity of 83 %) were the best indicators of mortality. Such patients should undergo urgent liver transplantation.

Incidental detection of tubular esophageal duplication in gastric cardia malignancy.

Congenital esophageal duplications represent about 15% of digestive tract duplications. We report a 38-year-old man who presented with longstanding heartburn and recent dysphagia. Endoscopy showed communicating tubular duplication of lower esophagus with ulceroproliferative growth at the gastric cardia extending into the lower esophagus. Histology of radical esophagogastrectomy specimen showed poorly differentiated adenocarcinoma of gastric cardia without evidence of Barrett's esophagus.

Gastrointestinal intramural hematoma--analysis of clinical and radiological features for early differentiation from mesenteric ischemia.

INTRODUCTION: Long-term anticoagulation is associated with hemorrhage at various sites. Gastrointestinal intramural bleeds and hematomas (IMH) often mimic mesenteric ischemia (MI) due to similar clinical settings and imaging features, making early differentiation difficult. AIM: To compare the demography, clinical features and imaging characteristics of patients presenting with IMH with those of MI, so as to help in evolving clinical and imaging guidelines to differentiate both early in the course of the disease. METHODS: All radiologically (contrast-enhanced computed tomogram [CT]) diagnosed cases of gastrointestinal IMH from the hospital database during the period between 2006 and 2012 were retrospectively analyzed. This data was compared with the clinical and imaging features of a group of surgically confirmed MI during the same period. Patients not on anticoagulation therapy at the time of presentation and those with incomplete clinical or radiological data were excluded from the study. RESULTS: There were 16 patients in IMH group and 54 patients in MI group. Clinical features like overt rectal bleeding or melena, and prolonged prothrombin time-international normalized ratio (PT-INR) more than three, and CT features like proximal location in the bowel, increased bowel wall thickness, hyperdensity on plain scan (>40 Hounsfield units (HU)), and short segment bowel involvement were significantly associated with IMH. Visualization of embolus and absent mesenteric vasculature to a segment of intestine in CT was significantly associated with MI. CONCLUSION: Attention to clinical features and early CT scan can aid in early differentiation of IMH from MI, facilitating appropriate intervention early in the course of disease.

Cost and efficacy of immunosuppression using generic products following living donor liver transplantation in India.

BACKGROUND: Cost of post liver transplant immunosuppression is a major financial burden to patients in developing countries. In India, generic varieties of various immunosuppressants are often used without any definite evidence to their efficacy. This study was aimed at studying the dosage, side effect profile and cost of post-liver transplant immunosuppression using generic products in Indian population following living donor liver transplantation (LDLT). METHODS: Data on dose, cost, and toxicity of immunosuppression were retrieved retrospectively from case records of 59 patients who had undergone LDLT at our center. RESULTS: Adequate immunosuppression was obtained by tacrolimus (Pangraf(®)-Panacea) of 0.04 to 0.05 mg/Kg, and mycophenolate (Mycept(®)-Panacea) of 500 to 1,000 mg; the acute rejection rate was 15% during the first month. Serum tacrolimus levels were 5.4 to 7.3 ng/mL. The cost of immunosuppression varied from Rs. 28,705 in the first month to Rs. 8,820 per month at the end of first year, amounting to an average monthly cost of Rs. 17,250. Approximately 23% and 51% of cost was for mycophenolate and for drug level measurement of tacrolimus, respectively. CONCLUSION: Average cost of immunosuppression after LDLT in India is much lower than that reported elsewhere in the world, since lower drug doses are needed and cheaper generic drugs are available. This can be reduced further by decreasing the frequency of tacrolimus drug level measurement.

Completeness of low anterior resection pathology report: a hospital-based audit with recommendations on improving reporting.

AIMS: To audit the information content of the pathology report on Low Anterior Resection (LAR) specimens and to provide recommendations in order to improve the existing standard of reporting. MATERIALS AND METHODS: All the reports of LAR specimens during 2004 - 2005 were collected from the Hospital Information System (HIS). Individual items of information were compared with the minimum data sets provided by the Royal College of Pathologists (RCP). RESULTS: Fifty-nine reports were audited. Nineteen percent of the reports were classified as satisfactory. Although many items were well reported, only 30.5% (18/59) of the reports contained a statement on the completeness of excision at the circumferential resected margin and only 25.4% of all reports mentioned the relation of tumors to the peritoneal reflection. CONCLUSION: The information content of the reports on colorectal cancer resection specimens is inadequate. The use of the standard proforma (template) for reporting rectal cancer is therefore recommended, along with improved education, review of laboratory practices in the light of current knowledge, and further motivation of pathologists through their involvement in multidisciplinary cancer management.

Revisiting the double-barreled wet colostomy for simultaneous urinary and fecal diversion--an Indian experience.

Pelvic exenteration in advanced malignancies is usually a curative procedure aimed at improving quality of life. We analyzed the perioperative data and outcomes in 12 patients who underwent simultaneous urinary and fecal diversion with a double-barreled wet colostomy after total pelvic exenteration. Eight males and four females aged between 25 and 73 years underwent the procedure with mean operative duration of 350 min and mean postoperative stay of 15 days. Three patients developed early complications while four developed late complications. During follow up ranging from 6 to 64 months, four patients died of disease progression while four died of unrelated causes. One lady was lost to follow up, the remaining had a mean survival of 32.9 months. None had deterioration in renal function or peristomal dermatitis and all were well accustomed to managing one stoma. Our results show that double-barreled wet colostomy is technically simple and reduces surgical morbidity while providing satisfactory outcomes and patient comfort.