Intraoperative portal vein stenting through umbilical vein approach: An innovative salvage procedure for portal vein thrombosis in pediatric liver transplant.

BACKGROUND: IPVS is considered a last resort or a salvage procedure in the event of recurrent PV thrombosis despite multiple attempts at redo PV anastomosis. We employed the opened umbilical vein approach to place the stent in the PV and deliver anticoagulation through a catheter. MATERIALS AND METHODS: From Jan 2017 to Feb 2022, 150 patients underwent pediatric transplantation at department of liver transplant and hepatobiliary surgery unit, Indraprastha Apollo hospitals, New Delhi. Age, weight, PELD Score, diagnosis, portal vein diameter on preoperative CT, Portal flow after stenting, decrease in spleen size after stenting in follow-up CT were collected from a prospectively maintained data base and reviewed. RESULTS: Eight patients underwent IPVS following LDLT (mean age-10.6 ± 2.2 months, mean weight 8.1 ± 1.6, mean PELD score 32.7 ± 7.3). The mean PV diameter on preoperative CT scan was 3.6 mm (range 2.7-5.6 mm). The mean portal flow following stenting was 718.75 cc/min. Percentage reduction in size of the spleen was 26.35% beyond 2nd post-operative week. No patient had recurrent PV thrombosis following IPVS and all maintained an adequate portal flow throughout the immediate postoperative period. Two patients had in-hospital mortality secondary to septic complications. CONCLUSION: Umbilical vein approach is technically feasible, easy to manipulate the stent and catheter placement after stenting helps to deliver anticoagulants locally.

Functional and Tableting Properties of Alkali-Isolated and Phosphorylated Barnyard Millet (Echinochloa esculenta) Starch.

The functional and tableting properties of barnyard millet starch (Echinochloa esculenta) were investigated in its native (alkali-treated) and chemically modified (phosphorylated) states. The grains were pulverized, soaked, and ground before filtration to separate starch and protein. Multiple NaOH treatments were performed. The starch was washed, neutralized, and dried. Sodium tripolyphosphate (STPP) and sodium sulfate were used to modify the starch, followed by maceration, washing, and drying to remove unreacted chemicals. The amylose content of alkali-treated barnyard millet starch increased by 19.96 ± 3.56% w/w. The amount of protein, the kind of starch used, and the size of the starch granules, all affected the ability of the starch granules to swell up. It was observed that alkali-extracted barnyard millet starch (AZS) has a swelling power of 194.3 ± 0.0064% w/w. The swelling capacity of treated starch was lesser as compared to the native alkali barnyard millet starch. Decrement in swelling power of phosphorylated starch was observed due to tightening of bonds in the molecular structure. The moisture content of the excipients may affect the overall stability of the formulation. The moisture content of the AZS was found to be 15.336 ± 1.012% w/w. Compared to AZS, cross-linked barnyard millet starch had a moisture content that was up to 20% lower than AZS. The Hausner ratio for phosphorylated starch was found to be 1.25, which indicates marked flow property. Similar morphologies could be seen in the alkali-isolated barnyard millet starch and the cross-linked/phosphorylated barnyard millet that was cross-linked using a mixture of sodium sulfate and sodium tripolyphosphate. The modest degree of substitution would have no effect on the surface morphology as shown by the scanning electron microscopic study. The crushing and compacting abilities of modified barnyard millet starch were also improved, but its friability and rate of disintegration were decreased. The whole study revealed that after cross-linking, barnyard millet had good tableting properties and it can be used as an excipient in drug delivery.

Transcatheter embolization of uterine arteriovenous malformation: report of 2 cases and review of literature.

Arteriovenous malformation (AVM) of the uterus is a rare cause of menorrhagia and may at times lead to life-threatening hemorrhage. The clinical findings may not always be reliable in the diagnosis of uterine AVM, and a high index of suspicion is important because, unlike many other causes of menorrhagia, curettage may paradoxically aggravate the bleeding. Herein are described the cases of 2 patients with uterine AVM with abnormal vaginal bleeding. Both had a history of abortion followed by dilation and curettage. In both patients, the diagnosis of uterine AVM was established at Doppler flow ultrasonography. Treatment using transcatheter embolization was successful, and both patients had normal menstrual cycles at follow-up. One patient delivered a healthy baby 2½ years after transcatheter embolization.

Percutaneous Transhepatic Biliary Drainage for Biliary Stricture After Endotherapy Failure in Living Donor Liver Transplantation: A Single-Centre Experience from India.

BACKGROUND: In the living donor liver transplant (LDLT) population, postoperative biliary stricture is a common problem. Endoscopic retrograde cholangiography (ERCP) and stenting failures usually occur because of odd angulation of the ducts, particularly in right lobe grafts. Percutaneous transhepatic biliary drainage (PTBD) is helpful in patients where endoscopic intervention is unsuccessful. We report our experience in this particular group of patients from India. METHODS: We analysed retrospective data of 932 patients who underwent LDLT at our centre. Data collected include basic demographics, technical and clinical success rate of PTBD, postprocedure complications and overall outcome. RESULTS: Of the 932 patients, 81 (8.7%) developed biliary stricture and required endoscopic or percutaneous interventions; out of whom, 75 patients underwent ERCP, and 6 patients had hepaticojejunostomy. Right posterior sector graft recipients had the highest incidence of biliary stricture (29.16%), followed by the right lobe grafts (8.57%), whereas stricture rate was less among left lobe and left lateral lobe graft recipients (3.77% and 3.7%, respectively). Failure of ERCP was common among the ductoplasty group (80%). The failure rate of ERCP did not differ significantly among patients who had single-duct, two-duct or three-duct anastomoses (44%, 36% and 50%, respectively, p > 0.05). PTBD was technically successful in 34 patients (87%) The mortality rate following PTBD was 2.5%, and morbidity was 15%. For the 5 patients in whom PTBD could not be performed, open hepaticojejunostomy was performed successfully. CONCLUSIONS: Right lobe liver grafts have high incidence of biliary stricture compared with left lobe grafts. The failure of ERCP was not dependent on the number of biliary anastomoses; however, the ductoplasty group had a higher failure rate. PTBD is technically successful in a majority of patients albeit with a morbidity of 15%. Open hepaticojejunostomy is a good therapeutic option following PTBD failure.

Comparative accuracy of CT, dual-echo MRI and MR spectroscopy for preoperative liver fat quantification in living related liver donors.

BACKGROUND: It is of significant importance to assess the extent of hepatic steatosis in living donor liver transplant (LDLT) surgery to ensure optimum graft regeneration as well as donor safety. AIM: To establish the accuracy of non-invasive imaging methods including computed tomography (CT), dual-echo in- and opposed-phase magnetic resonance imaging (MRI), and MR spectroscopy (MRS) for quantification of liver fat content (FC) in prospective LDLT donors with histopathology as reference standard. SETTINGS AND DESIGN: This retrospective study was conducted at our institution on LDLT donors being assessed for biliary and vascular anatomy depiction by Magnetic Resonance Cholangiopancreatography (MRCP) and CT scan, respectively, between July 2013 and October 2014. MATERIALS AND METHODS: Liver FC was measured in 73 donors by dual-echoT1 MRI and MRS. Of these, CT liver attenuation index (LAI) values were available in 62 patients. STATISTICAL ANALYSIS: CT and MRI FC were correlated with histopathological reference standard using Spearman correlation coefficient. Sensitivity, specificity, positive predictive value, negative predicative value, and positive and negative likelihood ratios with 95% confidence intervals were obtained. RESULTS: CT LAI, dual-echo MRI, and MRS correlated well with the histopathology results (r = 0.713, 0.871, and 0.882, respectively). An accuracy of 95% and 96% was obtained for dual-echo MRI and MRS in FC estimation with their sensitivity being 97% and 94%, respectively. False-positive rate, positive predictive value (PPV), and negative predicative value (NPV) were 0.08, 0.92, and 0.97, respectively, for dual-echo MRI and 0.03, 0.97, and 0.95, respectively, for MRS. CT LAI method of fat estimation has a sensitivity, specificity, PPV, and NPV of 73%, 77.7%, 70.4%, and 80%, respectively. CONCLUSION: Dual-echo MRI, MRS, and CT LAI are accurate measures to quantify the degree of hepatic steatosis in LDLT donors, thus reducing the need for invasive liver biopsy and its associated complications. Dual-echo MRI and MRS results correlate better with histological results in the study, as compared to CT LAI method for fat quantification.