Targeting the Achilles' heel of adult living donor liver transplant: Corner-sparing sutures with mucosal eversion technique of biliary anastomosis.

Biliary complications are regarded as the Achilles' heel of liver transplantation, especially for living donor liver transplantation (LDLT) due to smaller, multiple ducts and difficult ductal anatomy. Overall biliary complications reported in most series are between 10% and 30%. This study describes our modified technique of biliary anastomosis and its effects on incidence of biliary complications. This was a single-center retrospective study of 148 adult LDLT recipients between December 2011 and June 2014. Group 1 (n = 40) consisted of the first 40 patients for whom the standard technique of biliary anastomosis (minimal hilar dissection during donor duct division, high hilar division of the recipient bile duct, and preservation of the recipient duct periductal tissue) was used. Group 2 (n = 108) consisted of 108 patients for whom biliary anastomosis was done with the addition of corner-sparing sutures and mucosal eversion of the recipient duct to the standard technique. Primary outcome measures included biliary complications (biliary leaks and strictures). Biliary complications occurred in 7/40 patients in group 1 (17.5%) and in 4/108 patients in group 2 (3.7%). The technical factors mentioned above are aimed at preserving the blood supply of the donor and recipient ducts and hold the key for minimizing biliary complications in adult-to-adult LDLT.

Laparoscopy-assisted hepatectomy versus conventional (open) hepatectomy for living donors: when you know better, you do better.

The conventional incision for donor hepatectomy is a right subcostal incision with a midline extension. With increased experience in both donor hepatectomy and laparoscopy, the conventional incision can be shortened to a significant extent. Laparoscopic mobilization of the liver coupled with a hand port allows the insertion of one hand inside the abdomen for control; this makes small-incision donor hepatectomy a technically feasible alternative. We compared 26 right lobe donor hepatectomies performed with a laparoscopy-assisted technique (the laparoscopy-assisted donor hepatectomy group) to 24 donor hepatectomies performed with the conventional open technique (the conventional donor hepatectomy group). The donors in both groups and their recipients were followed for 6 months. Pain, discomfort related to the scar [including abdominal wall sensorineural deficits (numbness and differences in tactile and temperature sensations) and tightness around the scar], and donor quality of life (assessed with the International Quality of Life Assessment Short Form 8 scoring system) were compared between the 2 groups. In conclusion, laparoscopy-assisted surgery can be a technically feasible alternative in experienced hands, and as with other minimally invasive surgeries, it has advantages such as significantly less pain, reduced incision-related complications, and better donor quality of life during the early postoperative period without compromising donor safety.

Traumatic handlebar hernia associated with hepatic herniation: a case report and review of the literature.

A traumatic abdominal wall hernia (TAWH) is a rare type of hernia that occurs after blunt trauma to the abdomen. TAWH caused by direct trauma from bicycle handlebars is even more rare with fewer than 30 cases having being reported. Recognition of these hernias is important, because they may be associated with significant intrabdominal injuries. Despite an overall increase in incidence of blunt abdominal trauma, cases of TAWH remain rare, probably because of elasticity of the abdominal wall resists the shear forces generated by a traumatic impact. A high level of clinical suspicion is required for diagnosis of TAWH in patients with handlebar injuries. We present the case of a 20-year-old man with a traumatic handlebar hernia associated with herniation of the liver and hepatic ductal injury, which was managed successfully by a delayed repair of the hernia.

Primary squamous cell carcinoma of the renal pelvis masquerading as pyonephrosis: a case report.

Squamous cell carcinoma of the renal pelvis is a rare tumor, which is usually associated with nephrolithiasis. It is rarely associated with pyonephrosis. We report the case of a 69-year-old man who presented with features of pyonephrosis and underwent nephrectomy. The postoperative histological evaluation revealed an unsuspected squamous cell carcinoma of renal pelvis with a concomitant pyonephrosis. The rarity of this tumor in the absence of renal calculi and its association with pyonephrosis is highlighted.

Tuberculous gastric perforation: report of a case.

A 21-year-old woman presented with a 2-day history of acute abdominal pain. Contrast-enhanced computed tomography (CT) showed a perforation in the lesser curve of the stomach. The patient suffered a bout of hematemesis, following which an endoscopy showed a bleeding blood vessel at the edge of the perforation. We performed an emergency distal gastrectomy, including the ulcer site. Histopathological examination revealed tuberculous granulation tissue and acid-fast bacilli in the ulcer. The patient was given antituberculosis therapy (ATT) postoperatively, and was well when last seen 1 year 5 months after surgery. We analyzed the clinical data of five cases of tuberculous gastric perforation (TGP), reported between 1948 and 2003, including our patient. The patients ranged in age from 21 to 45 years, with a mean age of 36.8 years (SD +/- 10.21), and a male to female ratio of 3 : 2. The diagnosis was confirmed by surgery or autopsy. Abdominal lymphadenopathy was present in all patients. Gastrectomy was performed in four patients, and two were given ATT. All four patients in the previous reports died of their disease.

Bleeding gastric lipoma: case report and review of the literature.

We present a rare case of a bleeding gastric lipoma diagnosed by computed tomography. Surgical treatment was followed by an uneventful recovery. Histopathological confirmed the diagnosis.

Surgical drainage of primary iliopsoas abscess--safe and cost-effective treatment.

The report evaluates surgical drainage (SD) as a primary treatment of primary iliopsoas abscess (PIA). Seventy-two patients, who underwent SD for PIA at B P Koirala Institute of Health Sciences, Dharan, Nepal were studied. SD was performed through a lower abdominal, extra peritoneel, muscle splitting incision. Ultrasonography was used to diagnose the abscess in 53/54 patients (98%). Staphylococcus aureus was the most frequent organism grown in 45/65 patients (69%). The mean duration of drainage was 3.2 +/- 1.4 days (range, 1-7 days). The treatment was successful in resolving the abscesses in all patients. The mean hospital stay was 9.0 +/- 5.4 days (range, 3-40 days). Two patients (2.8%) developed a recurrence, 10 months and 1 year after the operation, respectively. Another patient developed an incisional hernia. There were no deaths. The average cost of treatment to the patient was approximately Nepali rupees 2800 (US$ 40). Surgical drainage appears to be a cost-effective and safe treatment for PIA.