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.

HPi: A Novel Parameter to Predict Graft-related Outcome in Adult Living Donor Liver Transplant.

BACKGROUND: Portal hyperperfusion is frequently associated with early allograft dysfunction (EAD). It is imperative to identify patients who would require portal inflow modulation. We aimed to identify factors associated with hyperperfusion-related graft injury and develop a predictive index for the same. METHODS: Prospectively maintained database was queried to identify 135 adult living donor liver transplant recipients between September 2016 and July 2020. According to the calculated sample size, 96 patients were randomly selected for "test cohort". The remaining 39 patients made the "validation cohort." EAD was defined according to the A2ALL study. "Hyperperfusion index (HPi)," defined as posttransplant portal pressure gradient (ΔPpost)/graft-to-recipient splenic volume ratio (GRSVR), was devised on the basis of laws of flow dynamics and regression analysis. RESULTS: Overall, 40 patients (29.6%) had EAD, six 90-d mortalities (4.4%) were attributable to EAD. In the test cohort, EAD patients (n = 29, 30.2%) had lower GRSVR (1.00 versus 2.22, P < 0.001), higher ΔPpost (14.8 versus 11.9, P = 0.004), and HPi (20.89 versus 8.67, P < 0.001). Multivariate analysis revealed GRSVR, ΔPpost, and HPi as significant factors to predict EAD. Receiver operating characteristic determined cutoff of HPi ≥9.97 could predict EAD with sensitivity of 90% and specificity of 73% (F-score = 0.712). HPi ≥16.25 predicted 90-d mortality with sensitivity of 100% and specificity of 78.9%. Patients with higher HPi had delayed graft-related recovery. Non-EAD patients had a higher 1-y (96% versus 79%) and 2-y (88% versus 79%) survival. The cutoff of HPi was validated well in the validation cohort (F-score = 0.645) (Hosmer-Lemeshow test, P = 0.89). CONCLUSIONS: While predicted GRSVR may help identify at-risk patients preoperatively, intraoperatively calculated HPi is more accurate in identifying patients who would require portal inflow modulation. Achieving an HPi below target cutoff significantly decreases the risk of EAD even in low-GRSVR patients.

Expression of scavenger receptor A in rat's liver tissue during acute obstructive cholangitis and its significance.

OBJECTIVE: Acute obstructive cholangitis (AOC) is a severe disease that leads to sepsis, shock and multiple organ dysfunction syndrome. Liver is the largest and the major organ for the defense mechanisms during the sepsis. Our aim was to investigate the expression of scavenger receptor A (SRA) in rat's liver tissue during AOC and its relation with the inflammatory mediators and hepatic injury caused by endotoxins. METHODS: Ninety Wistar rats were randomly divided into three equal groups. In group one, the choledochus were ligagted and Escherichia coli O111B4 injected into it to produce AOC model. Group two had choledochus ligated and group three had sham surgery. Six animals from each group were sacrificed at 0, 3, 6, 12 and 24 h for comparative analysis of endotoxins, tumor necrosis factor-alpha, interleukin-6 in plasma and expression of SRA protein and SRA mRNA in liver tissue. The P < 0.05 was considered significant. Ethical approval was obtained. RESULTS: The plasma endotoxins, tumor necrosis factor-alpha and interleukin-6 levels in AOC rats increased progressively with time. The SRA protein and SRA mRNA expression decreased with time. The differences among groups were significant (P < 0.01). Liver histopathology showed gradually aggravated hepatic injury with neutrophil infiltration, degeneration and necrosis of hepatocytes. CONCLUSION: In AOC, the expression of SRA in liver gradually decreased with progressive increase in level of plasma endotoxins and hepatic injury suggesting its importance in the defense mechanism.

Role of high-mobility group box 1 in patients with acute obstructive suppurative cholangitis-induced sepsis.

BACKGROUND: High-mobility group box 1 (HMGB1) is a proinflammatory cytokine that plays an active role during the pathogenesis of inflammatory processes. The primary aim of this study was to detect whether HMGB1 is involved in the pathogenesis of acute obstructive suppurative cholangitis (AOSC). METHODS: We collected peripheral blood samples from 23 patients with AOSC and 23 healthy volunteers who served as normal controls. All participants were tested for HMGB1 mRNA level, HMGB1 protein, tumor necrosis factor alpha (TNF-alpha), and interleukin 10 (IL-10). HMGB1 mRNA levels were tested using real-time polymerase chain reaction. HMGB1 protein expression was measured using Western blot. TNF-alpha and IL-10 were tested using enzyme-linked immunosorbent assay. RESULTS: The expression of HMGB1 mRNA and HMGB1 protein was higher in the AOSC group than in the normal controls (P<0.01), and the levels gradually decreased to normal after treatment of the disease (P<0.01). The content of TNF-alpha and IL-10 in peripheral blood of patients with AOSC was significantly higher than that of normal controls (P<0.01) but decreased to normal levels after the necessary treatment (P<0.01). CONCLUSION: The levels of HMGB1 mRNA and HMGB1 protein were elevated in patients with AOSC, which may play an important role in the inflammation of the bile duct and appears to be associated with the development of sepsis. This suggests the importance of monitoring HMGB1 levels in the management of AOSC-induced sepsis.

Parenteral nutrition combined with enteral nutrition for severe acute pancreatitis.

Background and Aims. Nutritional support in severe acute pancreatitis (SAP) is controversial concerning the merits of enteral or parenteral nutrition in the management of patients with severe acute pancreatitis. Here, we assess the therapeutic efficacy of gradually combined treatment of parenteral nutrition (PN) with enteral nutrition (EN) for SAP. Methods. The clinical data of 130 cases of SAP were analyzed retrospectively. Of them, 59 cases were treated by general method of nutritional support (Group I) and the other 71 cases were treated by PN gradually combined with EN (Group II). Results. The APACHE II score and the level of IL-6 in Group II were significantly lower than Group I (P < 0.05). Complications, mortality, mean hospital stay, and the cost of hospitalization in Group II were 39.4 percent, 12.7 percent, 32 ± 9 days, and 30869.4 ± 12794.6 Chinese Yuan, respectively, which were significantly lower than those in Group I. The cure rate of Group II was 81.7 percent which is obviously higher than that of 59.3% in Group I (P < 0.05). Conclusions. This study indicates that the combination of PN with EN not only can improve the natural history of pancreatitis but also can reduce the incidence of complication and mortality.

Diagnosis and cure experience of hepatolithiasis-associated intrahepatic cholangiocarcinoma in 66 patients.

BACKGROUND: The management of hepatolithiasis combined with intrahepatic cholangicarcinoma (IHHCC) remains a challenge due to poor prognosis. The aim of this study was to summarize our diagnosis and cure experience of IHHCC over the recent 10 years. METHODS: From January 1996 to January 2006, 66 patients with IHHCC were reviewed retrospectively. RESULTS: Of the 66 patients, 52 underwent surgical resection (radical resection in 38 and palliative in 14) and 8 patients abdominal exploration, while the other 6 cases received endoscopic retrograde biliary internal drainage and stent implantation. In this series, correct diagnosis of advanced stage was made during operation in 8 cases (8/60, 13.3%) and all of them (underwent unnecessary abdominal exploration, among them the positive rate of CA19-9 was 100%, and the positive rate of CEA was 87.6% (7/8), incidence rate of ascites was 100% and short-term significant weight loss was 100%, with median overall survival of only 4 months. CONCLUSION: Radical resection is mandatory for IHHCC patient to achieve long-term survival, the CT and MR imaging features of IHHCC being concentric enhancement. Patients with IHHCC have significant higher CA199 and significant higher CEA and short-term significant weight loss and ascites should be considered with advanced stage of IHHCC and unnecessary non-therapeutic laparotomies should be avoided.