Intrabiliary pressure in the pathophysiology of extra hepatic biliary obstruction.

Background and Aim: The aim of this study was to evaluate the role of intrabiliary pressure (IBP) in the pathophysiology of extrahepatic biliary obstruction (EHBO) during percutaneous transhepatic biliary drainage (PTBD). Materials and Methods: Adult patients with EHBO who underwent PTBD were prospectively enrolled. IBP was recorded during primary PTBD. The parameters of interest were age, gender, etiology of EHBO, baseline and post-PTBD liver function tests, duration for resolution of jaundice (decrease in total serum bilirubin ≥30% of baseline or <2 mg/dL), cholangitis, bile cultures, and serum albumin levels. The level of EHBO was divided into three types: Type 1 - secondary biliary confluence involved; Type 2 - primary biliary confluence involved; Type 3 - mid and distal common bile duct obstruction. Results: IBP was measured in 102 patients, and finally, 87 patients, including 52 (59.77%) females, were analyzed. The mean age of the patients was 56.1±11.6 years. The most common etiology of EHBO was carcinoma of the gallbladder in 44 (50.6%) patients. The mean IBP was 18.41±3.91 mmHg. IBP was significantly higher in Type 3 EHBO compared to Type 1 and 2 (p=0.012). A significant correlation was seen between IBP and baseline total serum bilirubin (p<0.01). There was a negative correlation between IBP and baseline serum albumin (p=0.017). In 56.3% of patients, resolution of jaundice was observed by day 3, but this was not significantly associated with IBP (p=0.19). There was no correlation between IBP and cholangitis (p=0.97) or bacterial cultures (p=0.21). Conclusion: IBP was significantly associated with the type of EHBO, baseline serum bilirubin, and albumin levels. IBP could not predict cholangitis or the resolution of jaundice after PTBD.

Utility and diagnostic accuracy of intraoperative frozen sections in hepato-pancreato-biliary surgical pathology.

BACKGROUND AND PURPOSE: Hepato-pancreato-biliary (HPB) surgeries are one of the most challenging and complex procedures. Intraoperative frozen section (IFS) diagnosis plays a pivotal role in management decisions. Comprehensive large cohort studies evaluating utility of IFS in HPB malignancies are lacking. This study aimed to evaluate the accuracy of frozen section analysis and to analyse discrepancies and impact of IFS on the surgical decisions. PATIENTS AND METHODS: This was a retrospective study of IFS received for the HPB specimens between years 2009 and 2021. The results were compared to the permanent sections to evaluate diagnostic accuracy, sensitivity and specificity. Indications, disagreements and impact on the surgical management were analysed. RESULTS: A total of 1008 specimens were evaluated: bile duct margin (279; 27.7%), gallbladder (203; 20.1%), liver lesions (125 cases; 12.4%), lymph nodes (147; 14.6%), pancreatic margin (120; 11.9%) and deposits (134; 13.3%). IFS were diagnosed as negative for malignancy (805; 79.9%), positive for dysplasia (8; 0.8%), suspicious for malignancy (6; 0.6%) and positive for malignancy (189; 18.8%). The overall diagnostic accuracy was 98.4%, and the discordant rate was 1.6%. The sensitivity, specificity, positive predictive value and negative predictive value were 94.7%, 99.4%, 97.5% and 98.6% respectively. The most important reason of discordant results was technical, followed by interpretational and sampling errors. CONCLUSION: The study demonstrates high diagnostic accuracy (98.4%) of IFS in a large dataset of HPB specimens. This comprehensive analysis apprises of the indications, errors and the impact of IFS diagnosis on subsequent HPB surgical management.

Imaging and Intervention in the Management of Vascular Complications Following Liver Transplantation.

Liver transplantation is the treatment of choice in majority of the patients with end stage liver disease. Vascular complication following liver transplantation is seen in around 7-13% of the patients and is associated with graft dysfunction and high morbidity and mortality. Early diagnosis and prompt treatment are crucial in management of these patients. Advances in interventional radiology have significantly improved the management of vascular complications using minimally invasive percutaneous approach. Endovascular management is preferred in patients with late hepatic artery thrombosis, or stenosis, whereas retransplantation, surgical revision, or endovascular management can be considered in patients with early hepatic artery thrombosis or stenosis. Hepatic artery pseudoaneurysm, arterioportal fistula, and splenic artery steal syndrome are often treated by endovascular means. Endovascular management is also preferred in patients with symptomatic portal vein stenosis, early portal vein thrombosis, and symptomatic late portal vein thrombosis, whereas surgical revision or retransplantation is preferred in patients with perioperative portal vein thrombosis occurring within 3 days of transplantation. Venoplasty with or without stent placement can be considered in patients with hepatic venous outflow tract or inferior vena cava obstruction. Transjugular intrahepatic portosystemic shunt (TIPS) may be required in transplant recipients who develop cirrhosis, often, secondary to disease recurrence, or chronic rejection. Indications for TIPS remain same in the transplant patients; however, major difference is altered vascular anatomy, for which adjunct techniques may be required to create TIPS.

Early Allograft Dysfunction After Live Donor Liver Transplantation: It's Time to Redefine?

BACKGROUND: An ideal definition of early allograft dysfunction (EAD) after live donor liver transplantation (LDLT) remains elusive. The aim of the present study was to compare the diagnostic accuracies of existing EAD definitions, identify the predictors of early graft loss due to EAD, and formulate a new definition, estimating EAD-related mortality in LDLT recipients. METHODS: Consecutive adult patients undergoing elective LDLT were analyzed. Patients with technical (vascular, biliary) complications and biopsy-proven rejections were excluded. RESULTS: There were 19 deaths due to EAD of a total of 304 patients. On applying the existing definitions of EAD, we revealed their limitations of being either too broad with low specificity or too restrictive with low sensitivity in patients with LDLT. A new definition of EAD-LDLT (total bilirubin >10 mg/dL, international normalized ratio [INR] > 1.6 and serum urea >100 mg/dL, for five consecutive days after day 7) was derived after doing a multivariate analysis. In receiver operator characteristics analysis, an AUC for EAD-LDLT was 0.86. The calibration and internal cross-validation of the new model confirmed its predictability. CONCLUSION: The new model of EAD-LDLT, based on total bilirubin >10 mg/dL, INR >1.6 and serum urea >100 mg/dL, for five consecutive days after day 7, has a better predictive value for mortality due to EAD in LDLT recipients.

Strategic approach to minimally invasive necrosectomy for necrotizing pancreatitis: technique, complications and predictors of outcome.

BACKGROUND: Minimally invasive retroperitoneal necrosectomy has been an integral component of 'step-up' approach for infected pancreatic necrosis. Even though the clinical outcome of nephroscopic necrosectomy has been studied earlier, its predictor and morbidities following surgery have not been extensively evaluated. We aimed to evaluate the clinical outcome and early and late complications after percutaneous nephroscopic necrosectomy (PCNN). METHODS: The pre- and intra-operative as well as post-operative and follow-up data of severe pancreatitis patients undergoing PCNN were collected prospectively. RESULTS: Out of 115 patients requiring intervention, 40 patients (34.78%) improved with percutaneous drain alone and another 40 proceeded for PCNN. After exclusion, 37 patients successfully underwent 48 sessions of PCNN. Median number of PCNN session was 1 (1-4). Early complications were seen in 21 (56.75%) patients and mortality was experienced in eight (21.62%) patients. On median follow-up of 36 months, 12 (32.43%) patients experienced late complications. Persistent post-operative pancreatic fistula was observed in six (16.21%) patients. Of these, three developed late-onset pseudocyst, whereas one patient had disconnected duct syndrome. Seven patients experienced new-onset diabetes. Age, severity of pancreatitis, preoperative organ failure and multiorgan failure were significant predictors of mortality on univariate analysis (P ≤ 0.05 for each). The logistic regression analysis revealed presence of multiorgan failure before surgery as the sole predictor (P = 0.007; odds ratio 10.417; 95% confidence interval 1.759-61.672). CONCLUSION: Preoperative multiorgan failure was the most important predictor of mortality following PCNN. Late complications were seen in nearly one-third of patients emphasizing the need for long-term follow-up.

Laparoscopic cholecystectomy in patients with portal cavernoma without portal vein decompression.

INTRODUCTION: Laparoscopic cholecystectomy (LC) in patients with extrahepatic portal vein obstruction causing portal cavernoma (PC) is considered high risk because of portosystemic collateral veins in the hepatocystic triangle. The literature is limited to isolated case reports. We describe our experience of LC in patients with PC. PATIENTS AND METHODS: Data of patients with PC who underwent LC for symptomatic gallstones or related complications was reviewed. Patients with simultaneous cholecystectomy with splenorenal shunt and open cholecystectomy were excluded. Pre-operative evaluation consisted of complete blood count, international normalisation ratio and liver function tests, ultrasound of the abdomen with Doppler, contrast-enhanced computerised tomography, magnetic resonance cholangiopancreatography and esophagogastroscopy as indicated. A standard four-port LC was performed. The technical principles followed were to avoid injury to the collateral veins, liberal use of energy sources and division of dominant collateral veins between clips. RESULTS: Seven adult patients including three females underwent LC. Three patients had thrombosis of previous surgical shunt with persistent PC. The remaining four patients did not have any indication for shunt surgery. Successful LC was performed in six patients. The median duration of surgery was 170 (130-250 min). Blood transfusion was not required. All the patients had uneventful post-operative recovery. The histopathology of gall bladder consists of acute cholecystitis in three patients and chronic cholecystitis in four. CONCLUSION: LC is feasible in patients with PC at a centre with experience in both laparoscopic and portal hypertension surgeries. Excellent outcome with low rate of conversion to open surgery can be achieved.

Single Orifice Outflow Reconstruction: Refining the Venous Outflow in Modified Right Lobe Live Donor Liver Transplantation.

BACKGROUND: MHV reconstruction is essential to avoid anterior sector congestion in adult live donor liver transplantation (LDLT) using a modified right lobe graft. AIMS: The objective of this study is to evaluate the graft and patient outcomes with single orifice outflow reconstruction technique (SORT) (RHV + neo-MHV combined reconstruction on IVC) vs. dual outflow reconstruction technique (DORT) (RHV and neo-MHV separately reconstructed on IVC) in a modified right lobe LDLT. METHODS: Prospectively collected data of consecutive patients undergoing LDLT from June 2011 to August 2018 were analyzed. The patients were divided into two groups: SORT (n = 207) and DORT (n = 108). The perioperative morbidity and mortality were compared between two groups. RESULTS: The two groups were comparable in baseline preoperative characteristics. Intraoperatively, warm ischemia time (27 vs. 45 min, p < 0.001), anhepatic phase (132 vs. 159 min, p < 0.001), and operative time (680 vs. 840 min, p < 0.001) were significantly shorter in SORT group. SORT group also had significantly lower GRWR (0.92 vs. 1.06, p < 0.001) and higher portal flow (2.4 vs. 2.7 L/min, p = 0.02). Postoperatively, SORT group had lower peak AST (177 vs. 209 IU/L, p < 0.001), ALT (163 vs. 189 IU/L, p = 0.004), creatinine levels (0.98 vs. 1.10, p = 0.01), rate of severe sepsis (13.7% vs. 22.9%, p = 0.03), major morbidity (50.7% vs. 62.6%, p = 0.03), shorter ICU (9 vs. 14 days, p < 0.001), and hospital stay (21 vs. 26 days, p = 0.03). Overall survival rates were comparable. CONCLUSION: A SORT leads to improved early graft function and perioperative morbidity in modified right lobe LDLT in spite of having lower GRWR and higher portal flow.

Biliary Reconstruction in Adult Living Donor Liver Transplantation: The All-Knots-Outside Technique.

Biliary complications (BCs) following living donor liver transplantation (LDLT) can lead to significant morbidity and occasional mortality. The present study describes our experience of the all-knots-outside technique (AKOT) of biliary reconstruction (BR) and its impact on BCs. A retrospective analysis was performed using prospectively collected data of 330 consecutive adult patients undergoing LDLT from July 2011 to February 2018 with a minimal follow-up of 24 months. Only 2.8% required hepaticojejunostomy and were excluded. In an initial 122 patients, BR was performed with the standard technique (ST), and AKOT was performed in the subsequent 208 patients. In the AKOT group, a single anastomosis was attempted even for multiple ducts whenever feasible. A major BC was defined as requiring endoscopic, percutaneous, or surgical interventions. In the AKOT group, significantly more patients received a left lobe graft (5.7% versus 18.3%; P = 0.001), had shorter warm ischemia time (44.6 versus 27 minutes; P < 0.001), and had a left hepatic artery (LHA) in the right lobe that was used for arterial reconstruction (48 [39.3%] versus 122 [58.6%]; P = 0.003). The incidence of BCs in the entire cohort was 47 (14.2%). For the ST versus AKOT groups, the overall BCs (27/122 [22.1%] versus 20/208 [9.6%]; P = 0.003) and major BCs (20.5% versus 6.7%; P < 0.001) decreased significantly. In the multivariate analysis, the number of bile ducts (hazard ratio [HR], 4.18; 95% confidence interval [CI], 1.62-10.78; P = 0.003), number of anastomoses (HR, 2.03; 95% CI, 1.03-4.02; P = 0.04), and technique of anastomosis (HR, 0.36; 95% CI, 0.19-0.68; P = 0.002) predicted BCs. In conclusion, in adult LDLT, with standardization of the donor and recipient surgery, preferential use of LHA for right lobe arterial reconstruction, reduction in the number of anastomoses, and AKOT for BR significantly decreased the incidence of BCs.

Three-Dimensional Volumetric Assessment of Graft Volume in Living Donor Liver Transplantation: Does It Minimise Errors of Estimation?

BACKGROUND: Accurate volumetric assessment of graft and remnant liver is essential in living donor liver transplantation (LDLT) for optimal clinical outcome in both donors and recipients. Recently, three-dimensional (3D) volumetry is proposed over conventional computed tomography (CT) volumetry to minimise errors. The aim of this study is to assess the correlation of estimated graft volume (EGV) by both the methods with actual graft weight (AGW). METHODS: One hundred fifty-four consecutive donors were enrolled prospectively. Conventional CT volumetry (semiautomatic) and 3D volumetry were performed using Myrian software. Total liver volume (TLV), EGV, and remnant liver volume (RLV) were assessed using both methods and correlated with intraoperatively measured AGW as the reference standard. Error of estimation was calculated accordingly. RESULTS: One hundred eighteen donors underwent right hepatectomy excluding middle hepatic vein (MHV), twenty-nine donors had left hepatectomy including MHV and six donors underwent left lateral sectionectomy. The median EGV on CT and 3D volumetry was 628.5 ml (140-1300) and 634.5 ml (156-1349), respectively. The median AGW was 647 gm (200-1004). Both CT and 3D volumetry showed strong correlation with AGW (correlation coefficients: 0.834 and 0.856, respectively). Linear correlation is as follows: (a) AGW = 99.75 + 0.818 × EGV (CT) and (b) AGW = 96.03 + 0.835 × EGV (3D). The mean percentage error for CT and 3D volumetry was 14.2 ± 12.5% and 12.2 ± 11.8%, respectively. The overall accuracy of estimation of EGV improved using 3D software (P=0.015). For the subgroup of types of graft, the difference did not reach statistical significance (P=0.062, 0.214 and 0.463 for right, left and left lateral grafts, respectively). CONCLUSION: Both conventional CT and 3D volumetric methods strongly correlate with AGW in donors of LDLT, whereas overall accuracy of estimation of graft weight improved marginally by 3D volumetry.

Preoperative Alanine Aminotransferase and Remnant Liver Volume Predict Liver Regeneration After Live Donor Hepatectomy.

BACKGROUND: Regeneration of the remnant liver in early postoperative period determines the outcome in live liver donors (LLDs). The aim of the current study is to evaluate the factors that influence liver regeneration following live donor hepatectomy. METHODS: Total liver volume (TLV), estimated graft volume (EGV), and remnant liver volume (RLV) were calculated preoperatively in a prospective study of 154 LLDs. Absolute and percentage growth of remnant liver (regeneration index) in donor was estimated at 7th postoperative day (POD) by computed tomography (CT) volumetric analysis. RESULTS: One hundred eighteen donors underwent right hepatectomy (RH), 29 underwent left hepatectomy (LH), 6 donors had left lateral sectionectomy (LLS), and one had right posterior sectionectomy. The median percentage growth of remnant liver at the end of the first week was 46.14% (51.74%, 35.32%, and 17.38% for RH, LH, and LLS, respectively). On univariate analysis, female donors (p = 0.051), RH graft (p = 0.001), no steatosis on ultrasonography (p = 0.042), lower TLV (p = 0.029), RLV (p = < 0.001), RLV-to-body weight ratio (RLVBWR) (p = < 0.001), preoperative alanine aminotransferase (ALT) level (p = 0.017), aspartate aminotransferase (AST) (p = 0.035) and higher POD 7 alkaline phosphatase (ALP) (p = 0.033), and POD 7 gamma-glutamyl transferase GGT (p = 0.006) were found to be predictors of greater liver regeneration. Among them, lower RLV (P = 0.008), RLVBWR (p = 0.011), and preoperative ALT level (p = 0.021) were most significant factors predictive of liver regeneration on logistic regression analysis with backward elimination. CONCLUSION: The liver regenerates rapidly in LLDs following hepatectomy. Low RLV, RLVBWR, and preoperative ALT levels were predictors of liver regeneration in the first week following donor hepatectomy.

Upfront pancreaticoduodenectomy in severely jaundiced patients: is it safe?

AIM: The aim of this study was to evaluate the outcomes following upfront pancreaticoduodenectomy (PD) in severely jaundiced (serum bilirubin level ≥15 mg/dl) patients with malignant distal common bile duct (CBD) obstruction. BACKGROUND: Recent studies have failed to show the benefits of preoperative biliary drainage (PBD) before PD. In addition, there is limited data on the impact of upfront PD on perioperative outcomes in severely jaundiced patients. METHODS: We reviewed the prospectively collected data of 177 patients who had undergone PD for the malignant distal CBD obstruction from May 2009 to May 2018. Study subjects were divided into Group A (severely jaundiced patients with upfront PD; n = 20), Group B (patients with serum bilirubin <15 mg/dl and no PBD; n = 88) and Group C (PBD prior to PD; n = 69). Overall morbidity, in-hospital mortality, and postoperative hospital stay were compared. RESULTS: No significant differences were noted between the three groups regarding sex, tumor size and stage, comorbidities, and surgical technique. The intra-operative blood loss was more in severely jaundiced patients as compared to Groups B and C (605 vs. 300 vs. 350 ml, P = 0.0001), but similar operative times, blood transfusions, and rates of post-pancreatectomy leak and hemorrhage. The infective complications were significantly less with upfront surgery. The overall morbidity, in-hospital mortality, and hospital stay were comparable between the three groups. Multiple logistic regression analysis failed to identify both the presence of preoperative jaundice and hyperbilirubinemia ≥15 mg/dl as independent risk factors for post-PD major morbidity. CONCLUSION: Upfront PD can be performed safely in the selected severely jaundiced patients and is associated with significantly lower infective complications.

Living Donor Liver Transplantation for Acute Liver Failure: Donor Safety and Recipient Outcome.

In countries where deceased organ donation is sparse, emergency living donor liver transplantation (LDLT) is the only lifesaving option in select patients with acute liver failure (ALF). The aim of the current study is living liver donor safety and recipient outcomes following LDLT for ALF. A total of 410 patients underwent LDLT between March 2011 and February 2018, out of which 61 (14.9%) were for ALF. All satisfied the King's College criteria (KCC). Median admission to transplant time was 48 hours (range, 24-80.5 hours), and median living donor evaluation time was 18 hours (14-20 hours). Median Model for End-Stage Liver Disease score was 37 (32-40) with more than two-thirds having grade 3 or 4 encephalopathy and 70% being on mechanical ventilation. The most common etiology was viral (37%). Median jaundice-to-encephalopathy time was 15 (9-29) days. Preoperative culture was positive in 47.5%. There was no difference in the complication rate among emergency and elective living liver donors (13.1% versus 21.2%; P = 0.19). There was no donor mortality. For patients who met the KCC but did not undergo LT, survival was 22.8% (29/127). The 5-year post-LT actuarial survival was 65.57% with a median follow-up of 35 months. On multivariate analysis, postoperative worsening of cerebral edema (CE; hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.01-6.31), systemic inflammatory response syndrome (SIRS; HR, 16.7; 95% CI, 2.05-136.7), preoperative culture positivity (HR, 6.54; 95% CI, 2.24-19.07), and a longer anhepatic phase duration (HR, 1.01; 95% CI, 1.00-1.02) predicted poor outcomes. In conclusion, emergency LDLT is lifesaving in selected patients with ALF. Outcomes of emergency living liver donation were comparable to that of elective donors. Postoperative worsening of CE, preoperative SIRS, and sepsis predicted outcome after LDLT for ALF.

JC Virus-Related Progressive Multifocal Leukoencephalopathy After Living-Donor Liver Transplant: A Rare Case.

Progressive multifocal leukoencephalopathy caused by polyoma JC virus is a rare and severe demyelinating disease of the central nervous system. It occurs in immunocompromised patients and is scarcely reported in liver transplant recipients. Brain biopsy demonstrating demyelination with presence of foamy macrophages, relative preservation of axons, astrogliosis, and typical polyomavirus inclusions in the enlarged oligodendroglial nuclei is essential for diagnosis. Here, we report a case of JC virus-associated progressive multifocal leukoencephalopathy in a living-donor liver transplant recipient who was transplanted for hepatitis C virus-related decompensated cirrhosis. Brain biopsy with immunohistochemistry confirmed the diagnosis of progressive multifocal leukoencephalopathy secondary to JC virus. JC virus related-progressive multifocal leukoencephalopathy is associated with extremely poor prognosis. Awareness and consideration of this entity in liver transplant recipients who present with sudden progressive neurologic manifestations can help in prompt diagnosis and timely treatment.

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.

"No go" donor hepatectomy in living-donor liver transplantation.

BACKGROUND: Selection of appropriate donors after rigorous evaluation is of paramount importance in living-donor liver transplantation. Despite this, donor surgery may not proceed due to unforeseen reasons. The aim of this paper is to study reasons for "no go" donor hepatectomy in living liver donors. PATIENTS AND METHODS: Donor operations stopped after surgical start, directly due to donor safety-related reasons, qualified for inclusion as "no go" donor hepatectomy. Living-donor evaluation was performed as per standard protocol. Data for consecutive living liver donors operated between April 2012 and November 2016 were analyzed to evaluate reasons for "no go" donor hepatectomy in a liver transplantation unit at a tertiary care teaching hospital. RESULTS: In 307 donors, the operation was aborted in 7 (2.3 %). One patient had unexpected biliary pathology with fibrosis found intraoperatively. Operations in five donors were abandoned in view of liver parenchymal abnormalities (fibrosis/steatohepatitis). One donor had hemodynamically significant bradycardia after handling the round ligament. All these donors recovered uneventfully and remained well on follow-up. CONCLUSIONS: "No go" donor hepatectomy remains a real possibility despite rigorous assessment. Although thresholds for on-table rejection of the donor after complete evaluation vary, "no go" hepatectomy is a calculated risk-avoidance approach.

Major Liver Resection for Large and Locally Advanced Hepatocellular Carcinoma.

Optimal management of large and locally advanced hepatocellular carcinoma (HCC) remains a clinical challenge especially in patients with chronic liver disease (CLD). We present our experience of major liver resection for large and locally advanced HCC. Prospectively collected data of patients with large and locally advanced HCC who underwent major liver resection between March 2011 and May 2015. The outcome measures of interest were the characteristics of tumor, surgical outcome, and overall as well as disease-free survival. Eighteen patients (14 male) with median age of 59 years (20 to 73 years) with good performance status underwent resection. Fifteen patients were in Child Pugh class A and three in class B. On contrast-enhanced computed tomography (CECT) scan, four patients had lobar/segmental portal vein involvement, two patients had bilobar disease, and one had biliary obstruction. Seven patients underwent extended resection (>5 segments), five right hepatectomy, two modified right hepatectomy, one modified right hepatectomy with wedge resection of segment six, two left hepatectomy, and one left lateral sectionectomy. On histopathology, 12 were solitary and six were multiple, the median tumor diameter was 9 cm (5-18 cm). All 18 patients had R0 resection. Eight patients had cirrhosis, six had fibrosis, and four had chronic hepatitis. Vascular invasion was noticed in 12 and out of these, six had large-vessel embolization. Morbidity according to Clavien-Dindo class was grades 1-11, grades 2-5, grade 3B-1, and grades 5-1. After a median follow-up of 32 months (6-54 months), the overall survival at 1 and 3 years was 83 and 54 %, respectively. The disease-free survival at 1 and 3 years was 75 and 54 % respectively. In carefully selected patients with large and locally advanced HCC, acceptable perioperative and medium term outcomes can be achieved with major liver resection.

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.