Impact of Functional Hepatic Venous Outflow Obstruction on Perioperative Outcome After Living-Donor Liver Transplant.

OBJECTIVES: An optimal initial graft function after living-donor liver transplant depends on optimal graft hemodynamics. Nonmechanical impediments to free hepatic venous outflow, due to elevated central venous pressure, may obstruct the "functional" hepatic venous outflow. Here, we evaluated whether central venous pressure affected early graft function and outcomes in adult living-donor liver transplant recipients. MATERIALS AND METHODS: This prospective observational study included 61 living-donor liver transplant recipients without technical complications who received transplants from August 2013 to November 2014. Hemodynamic variables were measured preoperatively, at anhepatic phase, 30 minutes postreperfusion, at end of surgery, and during postoperative days 1-5. RESULTS: Patients with high central venous pressure showed functional hepatic venous outflow obstruction, which caused delayed recovery of graft function. Although postoperative central venous pressure was the only identified independent risk factor for mortality, all 5 deaths in our study group occurred in those who had high central venous pressure at the anhepatic, postreperfusion, end of surgery, and postoperative phases. A postoperative central venous pressure value of ~11 mm Hg was determined to be the cutoff for high-risk mortality, with area under the curve of 0.859 (sensitivity of 80%, specificity of 68%). Increased central venous pressure was associated with increased portal venous pressure (increase of 45%, range, 28%-89%; P = .001). Central venous pressure at end of surgery (r = 0.45, P ≤ .001) and at posttransplant time points (r = 0.29, P = .02) correlated well with portal venous pressure at end of surgery. Other risk factors for early allograft dysfunction were Model for End-Stage Liver Disease and cardiac output posttransplant. CONCLUSIONS: High central venous pressure, modulating portal venous pressure, can result in functional hepatic venous outflow obstruction, causing delayed graft function recovery and increased risk of mortality. Maintaining a central venous pressure below 11 mm Hg is beneficial.

Explant portal vein for reconstructing middle hepatic vein in right lobe living donor liver transplantation-outcome analysis.

BACKGROUND: The aim of the study was to study the four week patency rates of the reconstructed neo middle hepatic vein specifically using the explant portal vein (PV) in right hemiliver live donor liver transplantation (LDLT). We hypothesized that short term patency of the neo-MHV should result in good graft and patient outcomes. METHODS: Pre, intra and post operative variables were prospectively collected for 88 consecutive patients undergoing right hemiliver LDLT from January 2014 to October 2015. RESULTS: Explant PV was used to reconstruct neo-MHV in 76 (86.4%, 76/88) patients. Neo MHV patency rate at 28 days with explant PV was 89.4% (59/66) and with other conduit (PTFE) was 90.9% (10/11). All occlusions were detected after 7 days. There was no impact of the patency of the neo-MHV on the incidence of early allograft dysfunction, sepsis, rejection, morbidity or mortality, despite the contribution of the anterior sector to the graft volume being more than 50% in close to two-thirds of patients. CONCLUSION: The reconstructed neo-MHV has excellent short term patency rates at 4 weeks. Perhaps due to the absence of early occlusions, there was no impact on graft or patient outcomes in the study population.

Antegrade Arterial and Portal Flushing Versus Portal Flushing Only for Right Lobe Live Donor Liver Transplantation-A Randomized Control Trial.

BACKGROUND: In live donor liver transplantation portal flush only of the graft is done on the bench. There are no data on antegrade arterial flush along with portal flush of the graft. METHODS: Consecutive patients undergoing elective right lobe live donor liver transplantation were block-randomized to receive either portal flush only or both portal and antegrade arterial flush. The primary objectives were safety, rate of early allograft dysfunction (EAD), and impact on vascular and biliary complications. RESULTS: After randomization, there were 40 patients in each group. Both groups had comparable preoperative, intraoperative, and donor variables. There were no adverse events related to arterial flushing. The portal and antegrade arterial flush group had significantly lower postoperative bilirubin on days 7, 14, and 21 (all P < 0.05), EAD (P = 0.005), intensive care unit/high dependency unit (P = 0.01), and hospital stay (P = 0.05). This group also had lower peak aspartate aminotransferase (P = 0.07), alanine aminotransferase (P = 0.06) and lower rates of sepsis (P = 0.08) trending toward statistical significance. Portal and antegrade arterial flush groups had lower ascitic fluid drainage and in-hospital mortality. Arterial and biliary complications were not statistically different in the 2 groups. Multivariate analysis of EAD showed portal with antegrade arterial flush was associated with lower rate (P = 0.007), whereas model for end-stage liver disease Na (P = 0.01) and donor age (P = 0.03) were associated with a higher rate of EAD. CONCLUSIONS: Portal with antegrade arterial flushing of right lobe live liver grafts is safe, significantly decreases postoperative cholestasis, EAD, intensive care unit/high dependency unit, and hospital stay and is associated with lower rates of sepsis, ascitic drainage and inhospital mortality in comparison to portal flush only.

Deceased donor liver transplant: Experience from a public sector hospital in India.

BACKGROUND: Deceased donor liver transplant (DDLT) is an uncommon procedure in India. We present our experience of DDLT from a public sector teaching hospital. METHODS: A retrospective analysis of all DDLT was performed from April 2012 till September 2016. Demographics, intraoperative, donor factors, morbidity, and outcome were analyzed. RESULTS: During the study period, 305 liver transplants were performed, of which 36 were DDLT (adult 32, pediatric 4; 35 grafts; 1 split). The median age was 42.5 (1-62) years; 78% were men. The median donor age was 28 (1-77) years; 72.2% were men. About 45% of organs were procured from outside of Delhi and 67% of all grafts used were marginal. Three of 38 liver grafts (7.8%) were rejected due to gross steatosis. Commonest indication was cryptogenic cirrhosis (19.4%). The median model for end-stage liver disease sodium and pediatric end-stage liver disease scores were 23.5 (9-40) and 14.5 (9-22), respectively. Median warm and cold ischemia times were 40 (23-56) and 396 (111-750) min, respectively. Major morbidity of grade III and above occurred in 63.8%. In hospital (90 days), mortality was 16.7% and there were two late deaths because of chronic rejection and biliary sepsis. The overall survival was 77.8% at median follow up of 8.6 (1-54) months. CONCLUSIONS: DDLT can be performed with increasing frequency and safety in a public sector hospital. The perioperative and long-term outcomes are acceptable despite the fact that most organs were extended criteria grafts.

Portal Inflow in Extensive Portomesenteric Thrombosis: Using the Pericholedochal Varix in Living Donor Liver Transplantation.

Extensive portomesenteric thrombosis presents a technical challenge in liver transplantation. Establishing portal inflow in living donor liver transplantation (LDLT) is indispensable to ensure regeneration of the graft. The use of a pericholedochal varix for inflow has been described only in a few case reports. Described herein is one such instance in the setting of LDLT, highlighting the nuances of this procedure in the light of available literature.

Association of thrombocytopenia with outcome following adult living donor liver transplantation.

This study aimed to evaluate the association of postoperative thrombocytopenia with outcome following adult living donor liver transplantation (LDLT) for end-stage liver disease (ESLD). It was a prospective study of 120 consecutive adult LDLT from September 2012 to May 2015. Preoperative platelet counts (PLTs) and postoperative PLTs were recorded at regular intervals till 3 months after LDLT. Univariate and multivariate analyses were performed. The median pretransplant PLT was 61 × 10(9) /l. The lowest median PLT after LDLT was observed on POD 3. Patients were stratified into low platelet group (n = 83) with PLT <30 × 10(9) /l and high platelet group (n = 37) with PLT ≥30 × 10(9) /l. Patients with PLT <30 × 10(9) /l had statistically significant higher grade III/IV complication (P = 0.001), early graft dysfunction (P = 0.01), sepsis (P = 0.001), and prolonged ascites drainage (P = 0.002). On multivariate analysis, PLT<30 × 10(9) /l was identified as an independent risk factor for grade III/IV complications (P = 0.005). Overall, patients survival was significantly different between two groups (P = 0.04), but this predictive value was lost in patients who survived more than 90 days (P = 0.37). Postoperative PLT of <30 × 10(9) /l was a strong predictor of major postoperative complications and is associated with early graft dysfunction, prolonged ascites drainage, and sepsis. The perioperative mortality rate was high in the thrombocytopenia group.

Biliary complications after living donor hepatectomy: A first report from India.

Biliary complications after donor hepatectomy can result in significant morbidity. We herein present our experience of donor hepatectomy, highlighting surgical techniques that prevent complications. Data were reviewed from a prospectively maintained database of all donors who underwent hepatectomy from April 2011 to April 2015. Standard operative technique as described was followed in all patients. Biliary complications and morbidity were recorded and stratified as per Clavien-Dindo classification. Results were compared with published literature. During the study period, 160 donors underwent hepatectomy. The majority of the graft types were right hemiliver without the middle hepatic vein (71.9%). Major complications (grade III and above) occurred in 5.6% of the donors. There was no donor mortality. Only 1 out of the 160 donors (0.6%) has had a grade III biliary complication requiring endoscopic retrograde cholangiography and papillotomy. There were 3 grade II biliary complications, all occurring after left lateral sectionectomy, necessitating prolonged retention of the intra-abdominal drain. The median duration of hospital stay was 11 days (range, 5-67 days), and the duration of follow-up was 16 months (range, 3-52 months). There was no loss to follow-up, and no donor required readmission or outpatient procedures for any biliary complication. In conclusion, with careful donor selection and a standardized surgical technique, biliary complications can be minimized. Liver Transplantation 22 607-614 2016 AASLD.

The role of non-operative strategies in the management of severe acute pancreatitis.

CONTEXT: Non-operative strategies are gaining preference in the management of patients with severe acute pancreatitis. OBJECTIVE: The present study was undertaken to evaluate the efficacy of a non-operative approach, including percutaneous drainage, in the management of severe acute pancreatitis. DESIGN: Prospective study. SETTING: Tertiary care centre in India. PATIENTS: Fifty consecutive patients with severe acute pancreatitis were managed in an intensive care unit. INTERVENTIONS: The patients were initially managed conservatively. Those with 5 cm, or more, of fluid collection having fever, leukocytosis or organ failure underwent percutaneous catheter drainage using a 10 Fr catheter. Those not responding underwent a necrosectomy. Depending on the outcome of their supportive care, the patients were divided into three groups: those responding to intensive care, those needing percutaneous catheter drainage and those requiring surgical intervention. Twelve patients were managed conservatively (Group 1) while 24 underwent percutaneous catheter drainage (Group 2), 9 of whom were not operated (Group 2a) and 15 of whom underwent necrosectomy (Group 2b). Fourteen patients were operated on directly (Group 3). MAIN OUTCOME MEASURES: Hospital stay, intensive care unit stay, and mortality. RESULTS: Among patients requiring surgery, the patients in Group 2b had a shorter intensive care unit stay (22.1±11.1 days) as compared to the patients in Group 3 (25.0±15.6 days) and a longer interval to surgery, 30.7±8.9 days versus 25.4±8.5 days. However, these differences did not reach statistical significance (P=0.705 and P=0.133, respectively). The two groups did not differ in terms of mortality (5/15 versus 3/14; P=0.682). CONCLUSION: The use of percutaneous catheter drainage helped avoid or delay surgery in two-fifths of the patients with severe acute pancreatitis.

Pancreas preserving total duodenectomy for complex duodenal injury.

CONTEXT: To assess the feasibility and safety of a pancreas-preserving total duodenectomy in the management of severe duodenal injury caused by abdominal trauma. CASE REPORT: Two patients with both extensive injury of the duodenum and diffuse peritonitis underwent pancreas preserving total duodenectomy at our tertiary care centre. These two young male patients (age 20 and 22 years) presented 2 days and 6 hours respectively following blunt abdominal trauma. The duodenum was almost completely separated from the pancreas. Ampulla was seen as a button on the pancreas. Following total duodenectomy, reconstruction was performed by suturing the jejunum to the head of the pancreas anteriorly and posteriorly away from the ampulla (invagination of the pancreas into the jejunum). There were no complications attributable to the procedure. Both patients are well on follow up. CONCLUSION: A Pancreas-preserving total duodenectomy offers a safe alternative to the Whipple procedure in managing complex duodenal injury. This procedure avoids unnecessary resection of the adjacent pancreas and anastomosis to undilated hepatic and pancreatic ducts.

Correlates of organ failure in severe acute pancreatitis.

CONTEXT: The clinical course of severe acute pancreatitis may be complicated by organ failure. OBJECTIVE: We studied the incidence of organ failure and the correlation of the extent of necrosis and infective necrosis with organ failure. METHODS: The medical records of 161 patients with severe acute pancreatitis and persistent organ failure over a 4-year period were studied. MAIN OUTCOME MEASURES: Pancreatic necrosis on CT was graded as <30%, 30-50% and >50% necrosis. Infected necrosis was diagnosed on the basis of a positive culture of fine needle aspiration or of a surgical specimen. Organ failure was defined according to the Atlanta criteria. Patient demographics, extent of pancreatic necrosis and presence of infection were correlated with organ failure. INTERVENTION: All patients were managed by a predefined treatment protocol. RESULTS: Of the 161 patients (124 males, 37 females, mean age 41.5+/-15.0 years), 52.2% had organ failure. In patients with organ failure, 48.8% had one, 33.3% two and 17.8% had multiple organ failure. Pulmonary failure was the most common organ dysfunction (76.2%). A more advanced age of patients and a higher APACHE II score were significant risk factors for the development of organ failure. Pancreatic necrosis on CT scan in patients with one, two and three organ failures was 48.8%, 51.8% and 83.3%, respectively while, in patients without organ failure, only 28.6% had more than 50% necrosis (P<0.001). No correlation was found between infected necrosis and organ failure. Overall mortality was 47.8% and mortality increased with an increasing number of organ failures. CONCLUSION: Persistent organ failure occurred in 52.2% of our patients with severe acute pancreatitis. The advanced age of the patients, a higher APACHE II score and the extent of necrosis, but not infected necrosis, emerged as significant correlates of organ failure.

Enteral nutrition in severe acute pancreatitis.

CONTEXT: There is controversy concerning the merits of enteral and parenteral nutrition in the management of patients with severe acute pancreatitis. OBJECTIVE: This study was undertaken to evaluate the effect of enteral nutrition versus parenteral nutrition on serum markers of inflammation and outcome in patients with severe acute pancreatitis. SETTING: Tertiary care centre in North India. DESIGN: A prospective clinical trial. METHODS: Fifty consecutive patients with severe acute pancreatitis were randomized in a prospective trial to receive total enteral nutrition (n=25) or total parenteral nutrition (n=25). Enteral nutrition was delivered distal to the ligament of Treitz. Serum C-reactive protein, transferrin levels, albumin, surgical intervention, infections, duration of hospital stay and mortality were compared in the two groups. RESULTS: The mean age in the enteral nutrition group was 38.4+/-13.8 years and in the total parenteral nutrition group 41.1+/-11.3 years. The etiological factors were alcohol (n=19), gallstones (n=23), idiopathic (n=7) and drug-induced (n=1). There was a significant decrease in serum C-reactive protein values in both the enteral nutrition group and the total parenteral nutrition group at one week and two weeks (P<0.001 for both). Serum albumin rose from a prenutritional value of 2.82+/-0.51 g/dL to 3.34+/-0.45 g/dL on day 14 of nutritional support in the enteral nutrition group (P=0.003); in the total parenteral nutrition group, the level rose from 3.10+/-0.59 g/dL to 3.21+/-0.30 g/dL (P=0.638). A significant rise in transferrin value was observed from day 0 to day 14 in enteral nutrition group (169+/-30 to 196+/-36 mg/dL; P<0.001) whereas, in the total parenteral nutrition group, a less significant difference (191+/-41 to 201+/-29 mg/dL; P=0.044) was observed. There was no significant difference in surgical intervention (56.0% versus 60.0%; P=1.000), infective complications (64.0% versus 60.0%; P=1.000), hospital stay (42 days, 15-108 days, versus 36 days, 20-77 days; median, range; P=0.755), or mortality (20.0% versus 16.0%; P=1.000) in enteral nutrition versus total parenteral nutrition, respectively. CONCLUSION: Enteral nutrition and total parenteral nutrition are comparable in the management of severe acute pancreatitis in terms of hospital stay, need for surgical intervention, infections and mortality.

Emphysematous pancreatitis. Radiological curiosity or a cause for concern?

CONTEXT: Emphysematous pancreatitis is a rare, potentially fatal variant of severe acute pancreatitis with gas in the pancreatic bed. There are isolated case reports describing this condition. OBJECTIVE: This report summarizes our experience with the management of this condition in order to compare its clinical characteristics, microbiological and radiological features, surgical management and the outcome of patients with emphysematous pancreatitis and non-emphysematous infected pancreatic necrosis. SETTING: The hospital records of the patients who underwent necrosectomy for infected pancreatic necrosis between 2002 and 2006 were reviewed. PATIENTS: Fifty-seven patients were identified: 11 of them (19.3%) had gas in and around the pancreas on computed tomography and 46 (80.7%) had non-emphysematous infected pancreatic necrosis. MAIN OUTCOME MEASURES: The clinical characteristics and the hospital course of the two groups of patients were compared. RESULTS: The mean age of 11 patients with emphysematous pancreatitis was 34.0+/-11.5 years and alcohol was the most common etiology (54.5%). The median computed tomography severity index was 10. All 11 patients with emphysematous pancreatitis had growth of organisms on culture of fine needle aspiration or pancreatic tissue obtained at surgery, with Escherichia coli in all of them. Polymicrobial infection was seen in 5 (45.5%) of them. In comparing patients having emphysematous pancreatitis with those having non-emphysematous infected necrosis, there was no significant difference in the severity of the disease (P=0.319), time to surgical intervention (P=0.553), incidence of organ failure (P=0.297), hospital stay (P=0.580) or mortality rate (P=0.739). The total number of locoregional complications was significantly higher in patients with emphysematous pancreatitis (P=0.049). However, when compared separately, the incidence of enteric fistula, bleeding, intra-abdominal collections and wound complications were similar in the two groups (P>0.250). CONCLUSION: Emphysematous pancreatitis is easily diagnosed on computed tomography and all patients require surgical intervention. The clinical course and prognosis is not different from that of infected pancreatic necrosis.