Pediatric living donor intestine transplant following an atypical complication of COVID-19: A unique case report from India.

Coronavirus disease-19 (COVID-19) infection causing severe gastrointestinal complications is rare. A 9-year-old child after recovering from mild COVID-19 infection developed small bowel gangrene due to superior mesenteric artery thrombosis. He required resection of entire necrotic small bowel along with caecum causing ultra-short bowel syndrome. Reverse transcriptase-polymerase chain reaction (RT-PCR) done on the resected specimen was positive for COVID-19. He was maintained on individualized parenteral nutrition for 3 months. A living donor intestinal transplant was performed using 200 cm of ileum donated by the patient's father. The graft function was satisfactory and was not complicated with thrombosis, infection, reactivation of latent COVID-19 or rejection. He could be weaned off completely from parenteral nutrition by postoperative day 21. The donor had an uneventful recovery. Six month follow-up was satisfactory with the child achieving complete enteral autonomy as well as target goal nutrition. Thrombotic phenomena associated with COVID-19 infection can affect larger vessel-like superior mesenteric artery leading to small bowel gangrene. Intestine transplant could be done safely after 3 months of recovery from COVID-19 without any adverse outcomes. Further studies are required to establish optimal timing and safety of small bowel transplant in this situation.

Lymphocyte depletion and risk of acute rejection in renal transplant recipients at increased risk for delayed graft function.

Delayed graft function (DGF) is a risk factor for acute rejection (AR) in renal transplant recipients, and KDIGO guidelines suggest use of lymphocyte-depletion induction when DGF is anticipated. We analyzed the United Network for Organ Sharing/Organ Procurement and Transplantation Network (UNOS/OPTN) database to assess the impact of induction immunosuppression on the risk of AR in deceased kidney recipients based on pretransplant risk of DGF using a validated model. Recipients were categorized into 4 groups based upon the induction immunosuppression: (1) Rabbit anti-thymocyte globulin (rATG); (2) Alemtuzumab (C1H); (3) IL2-receptor antagonists (IL2-RA; basiliximab or daclizumab), and (4) No antibody induction. The primary endpoint for analysis was a composite endpoint of treated AR or graft failure by 1-year posttransplantation. Compared to no antibody induction, rATG and C1H had consistently lower adjusted odds of the composite endpoint across all risk strata for DGF risk, whereas IL2-Ra was associated with increased adjusted odds of the composite endpoint with increasing DGF risk. When the induction agents were compared, rATG and C1H were associated with decreasing adjusted odds for the composite endpoint with increasing risk of DGF, especially at the higher risk spectrum of DGF. Consideration must be given to use of lymphocyte-depletion induction when the anticipated risk of DGF is increased.

Donor derived HSV hepatitis in a kidney transplant recipient leading to liver fibrosis and portal hypertension.

The unexpected transmission of donor-derived infection through organ transplantation is a rare event with current donor screening practices. In this case report we describe a probable donor-derived transmission of Herpes Simplex Virus (HSV)-2 via deceased donor kidney transplantation resulting in HSV hepatitis in the recipient. This manifested as acute liver failure which resolved with appropriate anti-viral therapy. Following recovery from the acute liver insult, the patient developed fibrotic liver morphology and portal hypertension, an unusual departure from the typical course.

Neuroendocrine carcinomas of the gallbladder: Lessons learnt from cases at opposite ends of the spectrum.

Neuroendocrine tumors are the rarest tumors of gallbladder. The most aggressive variant is neuroendocrine carcinoma which represents about 0.5% of all gallbladder carcinomas and 0.2% of all neuroendocrine tumors. It seems possible that survival rates can be improved by utilizing wide surgical resection combined with chemotherapy. We report on two cases of extreme presentation, including age, extend of disease and treatment modalities.

A study of events between the onset of symptoms and hospital admission in patients with acute abdomen.

BACKGROUND: Acute abdomen is a common surgical emergency. Prompt investigation and treatment, including surgical intervention, is critical in reducing morbidity and mortality. METHODS: We carried out a prospective observational study at a large urban secondary healthcare centre in India. Patients with surgical acute abdomen were consecutively enrolled in the study over a period of 2 years. Data were collected regarding the onset of symptoms, time of presentation to the hospital and events in the intervening period. RESULTS: Analysis showed that misdiagnosis by medical personnel was significantly associated with delay in admission to the hospital. Unfamiliarity with the medical facilities, ignorance, low education and illiteracy and public holiday were the contributing factors for delayed presentation. Even though we detected some trends, the delay was not significantly associated with age, sex, educational level or socioeconomic status of the patient. The delay resulted in an increased mortality and morbidity especially in patients who needed emergency operative management. CONCLUSION: Delayed presentation of acute abdomen is often not due to a single reason. The causes are distributed over various levels starting from the patient, family, medical personnel, administrative deficiencies, socioeconomic and sociocultural status of the country.

Why have we embraced minimally invasive surgery and ignored enhanced recovery after surgery?

There has been a lot of enthusiasm about minimally invasive surgery (MIS) in the surgical community in recent times. Some of the main reasons for this are an unmatched appeal to patients, doctors and healthcare systems alike. Push from the industry also serves as an important reason for its popularity. 'Enhanced recovery after surgery' (ERAS) is a programme of implementing multimodal interventions in the perioperative period to promote faster recovery. Even though MIS is an important component of ERAS protocols, the latter has not seen the reception the former has received. In this article, the authors present their personal viewpoint on the matter. The authors intend to highlight issues surrounding an increasing emphasis on MIS and to caution against the MIS operative technique superseding comprehensive perioperative care.

Fast-track surgery in India.

Fast-track surgery or 'enhanced recovery after surgery' or 'multimodal rehabilitation after surgery' is a form of protocol-based perioperative care programme. It is an amalgamation of evidence-based practices that have been proven to improve patient outcome independently and exert a synergistic effect when applied together. The philosophy is to treat the patient's pathology with minimal disturbance to the physiology. Several surgical subspecialties have now adopted such protocols with good results. The role of fast-track surgery in colorectal procedures has been well demonstrated. Its application to other major abdominal surgical procedures is not as well defined but there are encouraging results in the few studies conducted. There has been resistance to several aspects of this programme among gastrointestinal and general surgeons. There is little data from India in the available literature on the application of fast-tracking in gastrointestinal surgery. In a country such as India the existing healthcare structure stands to gain the most by widespread adoption of fast-track methods. Early discharge, early ambulation, earlier return to work and increased hospital efficiency are some of the benefits. The cost gains derived from this programme stand to benefit the patient, doctor and government as well. The practice and implementation of fast-track surgery involves a multidisciplinary team approach. It requires policy formation at an institutional level and interdepartmental coordination. More research is required in areas like implementation of such protocols across India to derive the maximum benefit from them.

Auxiliary Partial Orthotopic Liver Transplant as a Rescue Procedure for Acute Liver Failure with Extra-Small-for-Size Grafts: A Report of 2 Cases.

Auxiliary partial orthotopic liver transplant is a complex technique whereby a partial liver graft is transplanted in the orthotopic position, leaving behind a portion of the native liver. In acute liver failure, auxiliary partial orthotopic liver transplant serves as a rescue therapy and bridge for the native liver to regenerate. Auxiliary partial orthotopic liver transplant was initially considered a technically challenging procedure with inferior results versus orthotopic liver transplant. However, advancements in surgical techniques have led to improved results with auxiliary partial orthotopic liver transplant. Auxiliary partial orthotopic liver transplant is now increasingly accepted as a valid treatment option for acute liver failure. We present 2 cases of acute liver failure treated with auxiliary partial orthotopic liver transplant using an extra-small-for-size graft. The first case was a 12-year-old female patient who presented with druginduced acute liver failure and required an auxiliary partial orthotopic liver transplant with an extra-small left lobe graft (graft-to-recipient weight ratio of 0.45). The second case was a 23-year-old male patient with acute liver failure of unknown etiology who underwent an auxiliary partial orthotopic liver transplant with a small right lobe graft (graft-torecipient weight ratio of 0.5). In both cases, computed tomography liver volumetry was performed to determine the appropriate graft size for the recipient. Both patients underwent successful auxiliary partial orthotopic liver transplants, with good postoperative recovery. Follow-up examinations showed satisfactory liver function without evidence of graft failure or rejection. Auxiliary partial orthotopic liver transplant using extra-small grafts can be an effective treatment option for acute liver failure when no other suitable option exists, including as a rescue procedure for small grafts. However, careful patient selection and surgical planning are essential to ensure successful outcomes.

Laparoscopic Transgastric Resection of a Large Gastric GIST: A Case Report and Review of Literature.

Introduction Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal (GI) tract. Their primary treatment is surgical. Case Report Here we report a case of a 36-year-old male patient who was being evaluated for weakness, anemia, and melena. Upper GI endoscopy showed a mass projecting into the lumen and an abdominal computed tomography (CT) confirmed a well-defined mass close to the lesser curvature on the posterior wall. An endoscopic ultrasound-guided fine needle aspiration suggested a diagnosis of GIST. After optimization, the patient was taken up for a laparoscopic transgastric resection of the GIST. The resected specimen measured 9.5 × 8.5 × 7.5 cm. Postoperatively, the patient recovered well and was discharged by the fifth postoperative day. Discussion While traditionally, open surgery has been advocated for GISTs, for fear of spillage and peritoneal seeding, the role of minimal access surgery has been growing in recent years. The use of a transgastric approach avoids the potential complication of luminal stenosis following a wedge resection of a tumor close to the cardia. Because lymphadenectomies are rarely required and local invasion is uncommon, a wide local resection is usually curative. Thus, a laparoscopic approach can be considered as the first line in uncomplicated GISTs, irrespective of tumor size.

Monosegment Liver Allografts for Liver Transplantation in Infants Weighing Less Than 6 kg: An Initial Indian Experience.

BACKGROUND: Living donor liver transplantation in small infants is a significant challenge. Liver allografts from adults may be large in size. This is accompanied by problems of graft perfusion, dysfunction, and the inability to achieve primary closure of the abdomen. Monosegment grafts are a way to address these issues. METHODS: Two recipients in our cohort weighed less then 6 kg. The prospective left lateral segments from their donors were large for size. Therefore, monosegment 2 liver grafts were harvested. Data regarding the preoperative, intraoperative, and postoperative events in the donor and the recipient were recorded. RESULTS: We were able to achieve significant reduction in the sizes of the grafts harvested. The donors underwent surgery and hospital stay uneventfully. The recipients had normal graft perfusion and no graft dysfunction, and we could achieve primary abdominal closure. One recipient had self-limiting bile leak postoperatively. CONCLUSIONS: Monosegment 2 liver allografts are safe and effective for use in living donor liver transplantation in small infants weighing less than 6 kg.

Castleman's disease in carcinoma gall bladder.

Castleman's disease (CD) also known as angiofollicular lymph node hyperplasia represents a group of uncommon non-clonal lymphoproliferation. We herein report a case of CD associated with carcinoma of the gall bladder. To the best of our knowledge, it is the first of its kind and has not been reported in the past. The hypothesis regarding the aetiopathogenesis of CD is that it is associated with interleukin-6 surges. This may be explained by the overproduction of IL-6 by tumour cells or IL-6 production due to a long-standing/smouldering localised inflammatory response. An important question raised by this observation is whether the finding of CD has any effect on the outcome of this patient of carcinoma of the gall bladder. Further research is required in this matter.

Factors Impacting Mortality in the Pre-Hospital Period After Road Traffic Accidents in Urban India.

BACKGROUND: India currently has the dubious distinction of experiencing the highest number of road traffic accidents in the world. OBJECTIVES: We believe that this study on road traffic accidents may help to identify factors in the pre-hospital setting that may influence mortality rates. PATIENTS AND METHODS: A prospective observational study was carried out in a metro area in India over a period of one year. The study included consecutive patients admitted to the trauma service after road traffic accidents. Demographic information, time and place of accident, and details regarding the vehicle and the events leading up to the hospital admission were recorded. Injury severity, management in the hospital, and final outcomes in terms of mortality were noted. The data were analyzed with SPSS software. RESULTS: A total of 773 patients were enrolled. Of these, there were 197 deaths and 576 survivors. The majority of patients were aged 15 - 40 years (67%) and were male (87.84%). More accidents occurred at night (58.2%) than during the day (41.8%). Mortality was not significantly associated with age, sex, or time of accident. City roads (38.9%) saw more accidents than highways (26.13%), but highway accidents were more likely to be fatal. Two-wheeler riders (37.65%) and pedestrians (35.75%) formed the majority of our study population. Mortality was significantly associated with crossing the road on foot (P = 0.004). Pillion riders on two-wheeler vehicles were more likely to experience poor outcomes (relative risk [RR] = 1.9, P = 0.001). Front-seat occupants in four-wheeler vehicles were at an increased risk of not surviving the accident (61.98%; RR=2.56, P = 0.01). Lack of safety gear, such as helmets, seat belts, and airbags, was significantly associated with mortality (P = 0.05). Delays in transfers of patients to the hospital and a lack of pre-hospital emergency services was significantly associated with increased mortality (P = 0.000). CONCLUSIONS: A lack of respect for the law, weak legislation and law enforcement, disregard for personal safety, and driving vehicles under adverse conditions are some of the leading causes of road traffic accidents. There should be an emphasis on emergency trauma care in the pre-hospital setting.

Fast Track Surgery in the Elderly: Avoid or Proceed with Caution?

The feasibility of applying fast track surgery in its current form in the elderly still remains to be proven. It is important to identify the reasons for failure and carve out programs suited to the impaired physiology in this patient population. There needs to be a consensus among practitioner regarding the definitions of failure and flexibility of fast track programs at institutional as well as regional levels.

Fast-Tracking Colostomy Closures.

There have been very few studies on applying fast-track principles to colostomy closures. We believe that outcome may be significantly improved with multimodal interventions in the peri-operative care of patients undergoing this procedure. A retrospective study was carried out comparing patients who had undergone colostomy closures by the fast-track and traditional care protocols at our centre. We intended to analyse peri-operative period and recovery in colostomy closures to confirm that fast-track surgery principles improved outcomes. Twenty-six patients in the fast-track arm and 24 patients in the traditional care arm had undergone colostomy closures. Both groups were comparable in terms of their baseline parameters. Patients in the fast-track group were ambulatory and accepted oral feeding earlier. There was a significant reduction in the duration of stay (4.73 ± 1.43 days vs. 7.21 ± 1.38 days, p = 0.0000). We did not observe a rise in complications or 30-day re-admissions. Fast-track surgery can safely be applied to colostomy closures. It shows earlier ambulation and reduction in length of hospital stay.

Liver Transplantation in India: At the Crossroads.

As the liver transplant journey in India reaches substantial numbers and suggests quality technical expertise, it is time to dispassionately look at the big picture, identify problems, and consider corrective measures for the future. Several features characterize the current scenario. Although the proportion of deceased donor liver transplants is increasing, besides major regional imbalances, the activity is heavily loaded in favor of the private sector and live donor transplants. The high costs of the procedure, the poor participation of public hospitals, the lack of a national registry, and outcomes reporting are issues of concern. Organ sharing protocols currently based on chronology or institutional rotation need to move to a more justiciable severity-based system. Several measures can expand the deceased donor pool. The safety of the living donor continues to need close scrutiny and focus. Multiple medical challenges unique to the Indian situation are also being thrown up. Although many of the deficits demand state intervention and policy changes the transplant community needs to take notice and highlight them. The future of liver transplantation in India should move toward a more accountable, equitable, and accessible form. We owe this to our citizens who have shown tremendous faith in us by volunteering to be living donors as well as consenting for deceased donation.

Retroperitoneal perforation of the appendix presenting as a right thigh abscess.

A rare case of a retroperitoneal rupture of the appendix is being reported here. A 53-year-old male presented to us with a right sided thigh abscess. There were not any abdominal complaints at presentation. There was continuous discharge after incision and drainage from the thigh. Isolation, in culture, of an enteric bacterium from the pus prompted an evaluation of the gastrointestinal tract as a possible source. An MRI scan revealed fluid tracking from the right paracolic gutter over the psoas sheath and paraspinal muscle into the thigh. A CT scan revealed the perforation at the base of the appendix into the retroperitoneum. At laparotomy the above findings were confirmed. A segmental ileocaecal resection was done. The patient made an uneventful recovery. The absence of abdominal symptoms at presentation leads to delay in diagnosis in such cases. Nonresolving thigh and groin abscesses should lead to the evaluation of the gastrointestinal tract as origin. Diagnostic clues may also be provided by culture reports what as happened in this case.

A comparative study of 'fast-track' versus traditional peri-operative care protocols in gastrointestinal surgeries.

INTRODUCTION: A 'fast-track protocol' in surgery suggests the application of evidence-based practices to expedite patient recovery. It has shown to reduce hospital stay, hasten recovery as well as facilitate earlier return to work. It has a considerable impact in reducing healthcare costs. The basic tenet is to treat the patient's disease by minimal disturbance of their physiology. The protocol encompasses pre-operative, intra-operative and post-operative interventions which when carried out together would show maximal benefits. The surgeon is usually the leader of the team managing the patient, but it cannot be over-emphasised that this is a multi-disciplinary team approach. MATERIALS AND METHODS: We conducted a prospective interventional study to investigate whether 'fast-track' surgery protocols improve patient outcome when compared to traditional peri-operative care followed at our institute. By doing so, we observed that the patients who underwent 'fast tracking' required lesser analgesia, had earlier ambulation, earlier return of intestinal motility, were free from tubes, catheters and drains earlier and lastly were discharged earlier. This was achieved without a rise in complications or re-admissions. RESULTS/CONCLUSION: The results have proved that implementing the fast-track protocol for gastrointestinal surgeries is not only safe and effective, but also improves patient outcome.

Fast-track surgery: Toward comprehensive peri-operative care.

Fast-track surgery is a multimodal approach to patient care using a combination of several evidence-based peri-operative interventions to expedite recovery after surgery. It is an extension of the critical pathway that integrates modalities in surgery, anesthesia, and nutrition, enforces early mobilization and feeding, and emphasizes reduction of the surgical stress response. It entails a great partnership between a surgeon and an anesthesiologist with several other specialists to form a multi-disciplinary team, which may then engage in patient care. The practice of fast-track surgery has yielded excellent results and there has been a significant reduction in hospital stay without a rise in complications or re-admissions. The effective implementation begins with the formulation of a protocol, carrying out each intervention and gathering outcome data. The care of a patient is divided into three phases: Before, during, and after surgery. Each stage needs active participation of few or all the members of the multi-disciplinary team. Other than surgical technique, anesthetic drugs, and techniques form the cornerstone in the ability of the surgeon to carry out a fast-track surgery safely. It is also the role of this team to keep abreast with the latest development in fast-track methodology and make appropriate changes to policy. In the Indian healthcare system, there is a huge benefit that may be achieved by the successful implementation of a fast-track surgery program at an institutional level. The lack of awareness regarding this concept, fear and apprehension regarding its implementation are the main barriers that need to be overcome.