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.

Type Va Duplication of the Common Bile Duct With Type IIIa Intrahepatic Bile Duct Anatomy: A Rare Combination of Dual Biliary Ductal Anomaly With Difficulty to Extract Common Bile Duct Stone.

Extrahepatic duplication of the common bile duct (CBD) is an extremely rare anatomic variation seen in the biliary tract. It represents failure of regression of the primitive duplicated biliary ductal system, resulting in five different subtypes of the duplicated CBD as described by Choi et al. To date, only few such cases have been reported in the literature. Associated variation in branching of intrahepatic bile ducts presenting as combined dual ductal anomaly is even rarer phenomena to be seen. We report a case of a 67-year-old man with chronic kidney disease and obstructive jaundice resulting from choledocholithiasis. Evaluation revealed type IIIa branching of intrahepatic bile ducts with type Va duplication of the CBD.

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.

Renal transplant evaluation: multimodality imaging of post-transplant complications.

With advancements in surgical techniques and immuno-suppression, renal transplantation is established as the most effective treatment option in patients with end-stage renal disease. Early detection of renal allograft complications is important for long-term graft survival. Late clinical presentation often causes diagnostic delays till the time allograft failure is advanced and irreversible. Imaging plays a key role in routine surveillance and in management of acute or chronic transplant dysfunction. Multimodality imaging approach is important with ultrasound-Doppler as the first-line imaging study in immediate, early and late post-transplant periods. Additional imaging studies are often required depending on clinical settings and initial ultrasound. Renal functional MRI is a rapidly growing field that has huge potential for early diagnosis of transplant dysfunction. Multiparametric MRI may be integrated in clinical practice as a noninvasive and comprehensive "one-stop" modality for early diagnosis and longitudinal monitoring of renal allograft dysfunctions, which is essential for guiding appropriate interventions to delay or prevent irreversible renal damage. With rapidly increasing numbers of renal transplantation along with improved patient survival, it is necessary for radiologists in all practice settings to be familiar with the normal appearances and imaging spectrum of anatomical and functional complications in a transplant kidney. Radiologist"s role as an integral part of multidisciplinary transplantation team continues to grow with increasing numbers of successful renal transplantation programs across the globe.

Economic Perspectives on Setting up and Running Telepsychiatry Services in India.

BACKGROUND: Telemedicine Practice Guidelines, 2020 and Telepsychiatry Operational Guidelines, 2020 can be potential game changers in the practice of medicine in India. They provide legal grounds for the practice of telemedicine. The economics of setting up and running telepsychiatry services vis-à-vis in-person services in India is discussed in this paper to aid the practitioners in understanding the costs involved in each of these modalities. METHODS: Costs for various hardware, software, real estate, and human resources are collated from various sources. Telepsychiatry vs. in-person setup is compared for the costs involved. RESULTS: Telepsychiatry consultation will cost much lesser to that of in-person consultation. CONCLUSIONS: Telepsychiatry is an economically viable option. There are many benefits and hurdles in telepsychiatry practice. It is a step towards providing psychiatric services at the doorstep in compliance with the Mental Healthcare Act 2017, upholding the rights of persons with mental illness. It will benefit the practitioner, the patient, and the society.

Measuring reliability and validity of "Stressometer®": A computer-based mass screening and assessment tool for evaluation of stress level and sources of stressors.

INTRODUCTION: It is essential to develop tools that can identify stress manifestation, source of stressors, and suffering in an effort to bridge the treatment gap and enhance behavioral health in the developing world. To that aim, the Stressometer® (SOM) was developed as a comprehensive scale of stress and behavioral health for use around the world. MATERIALS AND METHODS: A validation study of the Stressometer® (SOM) was undertaken with a sample in India that included a nonclinical group and a group of patients at a clinic in New Delhi. For validation purposes, participants were also administered three currently validated scales, including Perceived Stress Scale, Stress Overload Scale (SOS), and Depression Anxiety Stress Scale (DASS). RESULTS: The Stressometer® (SOM) was found to be reliable and had high correlations with established scales. CONCLUSION: Stressometer® (SOM) is a valid and reliable, computer based mass screening tool for evaluation of stress level and sources of stress. Overall, Stressometer® (SOM) creates a robust measurement of stress and behavioral health that is likely culturally neutral and thus has universal applicability. A scale such as this one is ideal for use in the developing world to help bridge the treatment gap created and enhance behavioral health, especially in those suffering.

Simultaneous Courvoisier's and double duct signs.

Presence of Courvoisier's or double duct signs in a jaundiced patient is suggestive of malignant obstruction of the pancreaticobiliary ductal system. The oncologic impact of the simultaneous occurrence of these signs on the survival of patients with periampullary cancer is unknown. We report a case of obstructive jaundice secondary to an ampullary cancer demonstrating the Courvoisier's sign on clinical examination and a double duct sign on imaging. The patient underwent a pancreaticoduodenectomy which confirmed an ampullary adenocarcinoma.

Eosinophilic ascites: A diagnostic and therapeutic challenge.

Eosinophilic gastroenteritis (EGE) is a rare condition characterized by eosinophilic infiltration of the gastrointestinal tract. Depending on the dominant layer of infiltration it is classified into three types namely, mucosal, muscularis and subserosal. The most uncommon variant is the subserosal type characterized by primarily subserosal disease, eosinophilic ascites and peripheral hypereosinophilia. The clinical features are non-specific with history of atopic predisposition and allergy. Endoscopic biopsy is frequently non-diagnostic due to an uninvolved gastrointestinal mucosa rendering its diagnosis a challenge. The mainstay of diagnosis is peripheral hypereosinophilia and eosinophil-rich ascitic fluid on diagnostic paracentesis. Oral steroid therapy is usually the first line of treatment with dramatic response. Due to a propensity for relapse, steroid-sparing therapy should be considered for relapses of EGE. We report a case of subserosal EGE with diagnostic clinical features and treatment response and review the current strategy in the management of eosinophilic ascites.

18F-fluorodeoxyglucose positron emission tomography-computed tomography finding of left gonadal vein thrombosis in a case of renal cell carcinoma.

Tumor thrombus from renal cell carcinoma is commonly reported in renal vein and inferior vena cava with a few reports of gonadal vein involvement. Here, we report a case of an elderly female who underwent fluorodeoxyglucose (FDG) positron emission tomography-computed tomography scan for initial staging of left renal cell carcinoma. Along with an FDG avid left renal mass lesion, scan also revealed FDG avid tumor thrombus in the entire length of the left gonadal vein.

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.

Safety and effectiveness of divalproex sodium extended release containing regimen in Indian patients with bipolar I disorder in continuation phase: Results of EASED registry.

The study was conducted to evaluate the safety and effectiveness of divalproex sodium XR containing regimen in patients with bipolar disorder (BPD) who are in continuation phase. It was an open-label, prospective, observational study conducted from July 2010 to December 2011 at 48 sites across India. Adult patients with bipolar I disorder of manic or mixed type fulfilling the DSM-IV criteria and who were in the continuation phase were included. Safety (primary outcome) was assessed by incidence of treatment emergent adverse events (AEs). Effectiveness (secondary outcome), was evaluated by proportion of patients who did not have a relapse, change in Clinical Global Impression Score-BP version-Severity of Illness (CGI-BP) and Young's Mania Rating Scale (YMRS) score. Data was recorded at three visits: visit-1 (baseline), visit-2 (end of 2 months ± 7 days) and visit-3 (end of 4 months ± 14 days), and summarised using descriptive statistics. p<0.05 was considered statistically significant. A total of 489 and 468 patients were included in the safety and effectiveness analyses, respectively. Of the 66 AEs reported, 57 (89.0%) were mild and 7 (10.9%) were moderate (data missing for 2 events). In total, 75.0% (48/64) of the AEs were related to the study drug. No serious AEs reported (N=64). No relapse observed in 93.3% of patients. There was a significant (p<0.0001) reduction in the YMRS and CGI-BP scores from baseline to visit-3. Our study confirms the results of earlier studies in terms of good tolerability and effectiveness of divalproex sodium XR containing regimen in this study population.

Does situs inversus totalis preclude liver donation in living donor liver transplantation? A series of 3 cases from single institution.

INTRODUCTION: Liver transplantation (LT) is the gold standard for decompensated Chronic Liver Disease (CLD) in individuals satisfying the selection criteria. Organ scarcity is the rate limiting step in liver transplantation across the globe. Expanding the donor pool is practiced by transplant surgeons across the globe in view of perennial donor organ scarcity and ever increasing organ demand. PRESENTATION OF CASE: We have presented series of 3 cases of liver transplantation (LT) with modified left lobe (conventional right) graft from a situs inversus donor and implanting it as a conventional right lobe with a modified technique. The grafts had Type 1, Type 2 and Type 3 biliary anatomies. One graft had inferior hepatic veins also. All three patients had uneventful recoveries. The follow up period range is 4 years to 8 months. DISCUSSION: There are multiple case reports in the literature involving situs inversus donors in liver transplantation. Various techniques have also been described. We describe simple and effective technique which has proved successful to our patients. CONCLUSION: SIT donors can be safely accepted for living donor liver transplantation. It is a technically challenging procedure both for donor liver harvesting and implantation in recipient. This is the first case series of LT using modified left lobe graft (conventional right) from a SIT donor with 2 different techniques. Biliary anastomosis is the tricky part of the operation.

Preoperative CT evaluation of potential donors in living donor liver transplantation.

Living donor liver transplantation is an effective, life sustaining surgical treatment in patients with end-stage liver disease and a successful liver transplant requires a close working relationship between the radiologist and the transplant surgeon. There is extreme variability in hepatic vascular anatomy; therefore, preoperative imaging of potential liver donors is crucial not only in donor selection but also helps the surgeons in planning their surgical approach. In this article, we elaborate important aspects in evaluation of potential liver donors on multi-detector computed tomography (MDCT) and the utility of MDCT in presurgical assessment of the hepatic parenchyma, relevant hepatic vascular anatomy and segmental liver volumes.