Abdominal packing for surgically uncontrollable haemorrhage.

Background: Using abdominal packs is often a life-saving technique for uncontrollable bleeding during operations. It prevents worsening of the hypothermia, coagulopathy and acidosis which usually accompanies massive bleeding till they may be corrected and the packs removed later. However, packing may be associated with a mortality of 56 to 82 % due to continued bleeding, intra-abdominal abscesses and the compartment syndrome. We follow a policy of early abdominal packing (considering it after a 6 unit intraoperative blood loss) before the situation becomes irreversible. Patients and methods: Between January 1997 and September 2008, abdominal packing for uncontrollable bleed was done in 49 patients (M:F 34:15, mean age 43 years) . The risk factors for mortality were analyzed. The reasons for uncontrollable bleed were : liver trauma (8), liver tumours (3), following liver transplantation (4), pancreatic necrosectomy (17) and miscellaneous causes (17). Results: There were 16 postoperative deaths (32.7%). On univariate analysis, hypovolaemic shock, a low urine output, raised INR, blood requirement of more than 6 units, hypothermia <340C, metabolic acidosis and sepsis were associated with an increased mortality. However, on multivariate logistic regression only hypothermia was significantly associated with mortality. Conclusion: A fair survival rate can be achieved by early and judicious use of abdominal packing especially before hypothermia supervenes.

Living donor liver transplantation in India.

The world over, liver transplantation has emerged a panacea for thousands of patients suffering from end-stage liver disease. The strides made in living donor liver transplantation (LDLT) by Asian centres particularly in Japan, Korea, Hong Kong and Taiwan made many Indian centres realise that in order to sustain liver transplant activity in the country, a similar solution had to be found. Even though LDLT is very resource intensive and requires skilled multidisciplinary manpower, 22 centres in India have performed liver transplants, of which 14 have performed at least one LDLT procedure. 140 LDLT procedures have been performed at our centre, of which 13 have been done in emergency circumstances. LDLT has certain advantages over DDLT. It allows for adequate preparation of the patient for elective transplant and recipients are not in competition with others over the same donor organ. Major concerns with LDLT are of donor safety and biliary complications. In conclusion, establishing a high volume LDLT centre with excellent success rates is feasible in the Indian setting.

Liver transplantation in the developing world.

Liver transplantation is an accepted therapy for acute and chronic liver failure. Advances in preoperative and postoperative management and surgical techniques have extended the indications and improved results. Most international centres report one year actual survival rates of between 58-90% and 5-8 years survival of 75-80%. These developments, however, have been limited largely to the West. While the need for liver transplantation is well recognised in the developing world, liver transplantation has only recently been performed successfully in India. This article examines the challenges of liver transplantation in the developing world.

Primary hyperparathyroidism--an Indian study.

Twenty eight patients of sporadic primary hyperparathyroidism seen over a period of 10 years were studied. There were 18 females and 10 males with a mean age of 35.9 years. Bone involvement was the commonest clinical presentation (90%) followed by renal involvement (65%) and more than half the patients (54%) had involvement of both the skeletal and renal systems. The tumor was clinically palapable in six patients. Thalliumtechnetium subtraction scan had a sensitivity of 87% followed by computerised tomography (70%), and ultrasound (65%) in diagnosing parathyroid pathology. All the patients underwent surgical excision of the abnormal gland (S). Adenomas constituted the single largest group (90%). Histologically, only 32% of the patients had chief cell morphology. Clear cell (32%) mixed cell, and oxyphil cell (7.2%) types accounted for the remaining adenomas. Majority of the patients (82%) had symptomatic postoperative hypocalcemia requiring intravenous calcium with or without vitamin D supplementation. In contrast to western reports most of our patients were young, presented late with florid bone and renal disease and had large palpable tumors.