Do Natural Portosystemic Shunts Need to Be Compulsorily Ligated in Living Donor Liver Transplantation?

BACKGROUND: Natural portosystemic shunt ligation practices in liver transplant vary widely across transplant centres and are frequently undertaken to prevent the serious consequence of portal steal phenomenon. No concrete indications have so far been convincingly identified for their management in living donor liver transplant. METHODS: We retrospectively studied the outcome of 89 cirrhotic patients who either did (n = 63) or did not (n = 25) undergo shunt ligation during living donor liver transplantation between 2017 and 2020. RESULTS: The incidence of early allograft dysfunction/nonfunction (P = 1.0) and portal venous complications (P = 0.555) were similar between the two groups. Although overall complications, biliary complications, and the composite of Grade III and IV complications were significantly higher in the nonligated group (P = 0.015, 0.052 and 0.035), 1- year graft and patient survival were comparable between them (P = 0.524). CONCLUSION: We conclude that shunt ligation in living donor liver transplantation may not always be necessary if adequate portal flow, good vascular reconstruction, and good graft quality have been ensured.

Outcomes of Right and Left Hepatic Arterial Anastomosis in Right Lobe Living Donor Liver Transplant.

OBJECTIVES: Living donor liver transplant is a complex surgery with well-known complications. Here, we report the use of the right and left hepatic arteries of the recipient for anastomosis and the effects of each procedure on overall outcomes and any associated short-term or long-term biliary complications. MATERIALS AND METHODS: This was a prospective observational study with long-term follow-up of 200 patients (100 in the right hepatic artery group and 100 in the left hepatic artery group). RESULTS: The average donor age was 28.9 years in the left hepatic artery group and 30.9 years in the right hepatic artery group. Most of the donors (60%) were female. Overall, there was 10.5% mortality in the early postoperative period. Among survivors, there were more late strictures in the right hepatic artery group (29.7% vs 22.7%). Bile leak (P = .42), mortality (P = .71), and incidence of late-onset biliary strictures (P = .83) were less common in the left hepatic artery group. CONCLUSIONS: Left artery anastomosis was found to be technically safe and feasible and did not adversely affect patient outcome compared with right artery anastomosis. Left hepatic artery anastomosis may also reduce the incidence of the biliary complications compared with the right hepatic artery anastomosis.

Cystic duct anastomosis can be a viable option for biliary reconstruction in case of multiple ducts in right lobe living-donor liver transplantation.

BACKGROUNDS/AIMS: Multiple ducts in right lobe living-donor liver transplant (LDLT) pose a technical challenge in biliary reconstruction. In the absence of separate recipient hepatic ducts for duct-to-duct anastomoses and certain demerits of hepaticojejunostomy, duct to duct anastomoses with the recipient cystic duct might be a possible solution. METHODS: A total of 329 recipients of LDLT who underwent two or more separate biliary anastomoses at our centre between January 2014 and November 2019 were studied retrospectively. Records of demographic data, donor and graft characteristics, operative details, postoperative biochemical parameters, and biliary complications were analysed. RESULTS: Of 329 recipients, 236 patients (71.7%) underwent purely duct-to-duct (DD group) anastomoses, 38 patients (11.5%) underwent at least one anastomosis with the cystic duct (CD group), and 55 patients (16.7%) underwent at least one hepaticojejunostomy (HJ group). At one year, biliary complication rates of these three groups were 20.3%, 26.3%, and 20.0%, respectively (p = 0.68). Postoperative intensive care unit and overall hospital stay were similar among the three groups. Grades IIIa, IIIb, IV, and V Clavien-Dindo complications were identical. One-year patient survival and graft survival were also similar among the three groups. CONCLUSIONS: Biliary outcomes using the cystic duct may have acceptable outcomes. Similar postoperative results as other means of biliary reconstruction could be anticipated with the cystic duct anastomoses in case of multiple ducts in the graft.

Living Donor Liver Transplant for Budd-Chiari Syndrome Without Caval Replacement: A Single-Center Study.

OBJECTIVES: Adequate venous outflow is one of the most important factors responsible for optimal graft function in liver transplantation. Thrombosis of the inferior vena cava in cases of Budd-Chiari syndrome poses a major challenge to a transplant surgeon in establishing proper graft outflow. In deceased donor liver transplant, this problem can be dealt with relative ease as the liver graft includes donor inferior vena cava. However, this is not the case in living donor liver transplant. We present our findings of living donor liver transplant for Budd-Chiari syndrome and discuss techniques that have helped overcome this unique problem without the need for complete inferior vena cava replacement. MATERIALS AND METHODS: Our retrospective analysis included living donor liver transplant recipients from November 2006 to March 2020 at our center and selected patients who underwent this transplant for Budd-Chiari syndrome. We studied the extent and severity of inferior vena cava involvement in these cases. We developed a classification that not only helped to stratify patterns of venacaval disease but also helped to plan the surgical technique. The role of interventional radiology combined with surgery in management of extensive inferior vena cava stenosis was studied. RESULTS: Among 2952 cases of liver transplant in our unit from November 2006 to March 2020, 36 patients had Budd-Chiari syndrome; 21 had significant level of inferior vena cava thrombosis, which was managed with inferior vena cava thrombectomy with either patchplasty (n = 20) or segmental replacement (n = 1). None of our patients showed recurrence of primary disease during the median follow-up of 36 months (range, 8-158 mo). CONCLUSIONS: Establishment of adequate venous ouflow in thrombosed inferior vena cava is possible with proper planning of surgical technique and timely involvement of interventional radiology-guided interventions in patients with Budd-Chiari syndrome.

Protocol to ensure continued pediatric liver transplantation service during the COVID pandemic and the encouraging outcomes.

Coronavirus disease 2019 is a global pandemic, and to deal with the unexpected, enormous burden on healthcare system, liver transplantation (LT) services have been suspended in many centers. Development of robust and successful protocols in preventing the disease among the recipients, donors and healthcare workers would help in re-starting the LT programs. We adapted a protocol at our center, which is predominantly a living donor liver transplant center based in north India, and continued the service as the pandemic unfolded and peaked in India with good results and shared the experience of the same. Between March 24 and June 7, 2020, during the government-enforced public curfew-"lockdown"-7 children received LT. The protocols of infection control were drafted in our team by local customization of published guidelines. The number of pediatric LT done during the lockdown period in 2020 was similar to that done in corresponding pre-COVID period in 2019. The outcomes were of 100% survival, and none of recipients developed COVID. One potential donor was asymptomatic positive for COVID, responded well to conservative treatment, and was later accepted as a donor. LT program during the COVID pandemic can successfully function after putting in place standard protocols for infection control. These can be implemented with minimal extra involvement of healthcare infrastructure, hence without diversion of resources from COVID management. In conclusion, pediatric liver transplantation services can be continued amid COVID-19 pandemic after establishing a properly observed protocol with minimum additional resources.

Living Donor Liver Transplant in Patients Aged 60 Years or Older: Experience from a Large Volume Centre in India.

BACKGROUND: With ageing population and higher prevalence of nonalcoholic steatohepatitis (NASH) and hepatocellular carcinoma (HCC) in older patients, more and more living donor liver transplants (LDLTs) are being considered in this group of patients as eligibility for deceased donor liver transplant is restricted to those aged 65 years and younger. However, the short- and long-term outcomes of this group have not been reported from India, which does not have a robust national health scheme. The aim of this study was to provide guidelines for transplant in this group. METHODS: All patients aged 60 years and older (group 1) who underwent LDLT in our centre between January 2006 and December 2017 were studied. A propensity score-matched group in 1:2 ratio was created with comparable sex and Model for End-Stage Liver Disease score (group 2). The 2 groups were compared for duration of hospital stay, surgical complications, hospital mortality and 1-, 3- and 5-year survival. RESULTS: Group 1 consisted of 207 patients, and group 2 had 414 patients. The number of patients in group 1 gradually increased with time from 4 in 2006 to 33 in 2017 accounting for 15% of total cases. Group 1 had more patients with viral hepatitis, NASH and HCC, and they had a higher 30-day mortality due to cardiorespiratory complications. Although 1- and 3-year survival was similar, the 5-year survival was significantly lower in group 1. CONCLUSION: Five-year survival was lower in the elderly group due to cardiorespiratory complications and recurrence of HCC. Outcomes in the elderly group can be improved with better patient selection and preventing HCC recurrence.

Living Donor Liver Transplant for Dengue-Related Acute Liver Failure: A Case Report.

Dengue is a common viral infection, especially in tropical countries, and it is a well-known cause of acute liver failure. The effects on the liver range from a mild illness to acute liver failure. Dengue-related acute liver failure has a high mortality rate, and the role of liver transplant in such cases has been less studied, due to the rapid progression and often associated multiorgan dysfunction in severe cases. Here, we report the first living donor liver transplant for an acute liver failure due to dengue. Although liver transplant is not the choice of treatment for sick patients, timely intervention in specific patients may have a role.

Outcome of Pediatric Liver Transplants in Patients With Less Than 10 kg of Body Weight Is Not Worse.

OBJECTIVES: Liver transplant in pediatric patients with body weight < 10 kg poses a challenge to the entire liver transplant team. Many reports have considered 10 kg to be a cutoff pointfor body weightforfavorable posttransplant outcomes. With evolving surgical techniques and postoperative management, there is potential to improve outcomes in this subset of recipients. We compared the outcomes in pediatric patients with body weight < 10 kg with those > 10 kg; also, we studied the factors of influence. MATERIALS AND METHODS: We performed a retrospective analysis to evaluate the outcomes of liver transplants in pediatric patients with < 10 kg body weight. The cohort consisted of 90 children subdivided into the following 2 subgroups: group A (n = 35) with > 10 kg body weight at liver transplant and group B (n = 55) with < 10 kg body weight at liver transplant. We compared the following pretransplant characteristics between the groups: graft weight, graft-to-recipient weightratio, cold ischemia time, warm ischemia times, and liver transplant outcomes. RESULTS: Pediatric End-stage Liver Disease score was significantly higher in group B (score of 24) versus group A (score of 18). Group B had significantly higher graft-to-recipient weight ratio (2.8 in group B vs 1.7 in group A). Graft function showed no significant difference between the 2 groups. Portal vein thrombosis was seen only in group B, whereas biliary leaks were observed among 5 patients in group B and 1 patientin group A. Patient survivalrate was higherin group B (86%) than in group A (77%). CONCLUSIONS: Pediatric patients weighing < 10 kg have similarif not better survivalrates after liver transplant compared with patients > 10 kg. Advancements in surgical techniques and a careful monitoring for complications and timely intervention are important to facilitate these outcomes.

Cystic duct patch closure of remnant bile duct in living donor hepatectomy when primary closure is difficult: An easy solution.

BACKGROUNDS/AIMS: In living donor hepatectomy, hepatic duct division is a crucial step and often a technical challenge, with the aim of obtaining a good hepatic duct for anastomosis in the recipient and an adequate stump in the donor for closure. Very rarely, after duct division, the remaining stump may not be adequate for primary closure. In such a difficult situation, the options would be either to close stump transversely or a Roux-en-Y Hepaticojejunostomy. METHODS: We describe a novel surgical technique of "Cystic duct patch repair", utilizing the available local tissues for closure of bile duct wall. RESULTS: Two year follow up of this technique showed satisfactory results with no evidence of stricture and normal liver functions. CONCLUSIONS: In living donor hepatectomy, "Cystic duct patch closure" may be used if the post closure cholangiogram is not satisfactory. Although the best method is prevention by ensuring a stump for closure, very rarely this error can occur and can be sorted by cystic duct patch repair.

Managing Recipient Hepatic Artery Intimal Dissection During Living Donor Liver Transplantation.

Recipient hepatic artery intimal dissection (HAD) followed by hepatic artery thrombosis (HAT) is a serious complication of liver transplantation. Once this is recognized intraoperatively, the accepted approach is to use an alternative arterial inflow, which may not be possible in all patients. We describe a new classification and technique for the management of HAD during living donor liver transplantation. On the basis of the longitudinal extent of intimal dissection, HAD was classified into 4 types. Management was based on the type of dissection, availability of an adequate length of hepatic artery (HA), and an alternate source of inflow. The dissected HA itself was used for arterial anastomosis in patients with preserved pulsatile flow in the dissected artery and a lack of an alternative source of arterial inflow. The technique of using the dissected artery was based on close approximation of the tunica intima to the media with the first 2 sutures of the arterial anastomosis. Of 47 (2.4%) patients who developed HAD, 22 (46.8%) had a type 2 dissection for whom the other (right or the left) undissected HA was used for the anastomosis, and 20 (42.6%) had major (type 3 or 4) dissection. The dissected artery was used for the anastomosis in 9 (45%) of these patients. Postoperative HAT developed in only 1 of 9 patients. Pre-existing portal vein thrombosis and prior transarterial embolization were found to be major risk factors for the development of HAD. Using the technique described, the dissected artery can be successfully used for a satisfactory HA anastomosis with low thrombosis rates.

Minimum absolute graft weight of 650 g predicts a good outcome in living donor liver transplant despite a graft recipient body weight ratio of less than 0.8.

In living donor liver transplant (LDLT), it is recommended to have a minimum graft recipient body weight ratio (GRBWR) 0.8 for good outcomes. Recent reports have, however, shown that good outcomes can be obtained even with GRBWR less than 0.8. We hypothesized that in patients receiving a graft with GRWR less than 0.8 absolute graft weight rather than GRBWR may be more relevant for predicting good outcome. Early post-transplant outcomes were assessed in adult patients undergoing elective right lobe LDLT. Patients were categorized as having good (survival) or poor (mortality) outcome. A ROC curve was drawn based on their graft weights and a cutoff value that provided the highest sensitivity and specificity for a good outcome was chosen. 147 patients received right lobe grafts with GRBWR less than 0.8. The 90-day mortality rate was 13.6% (n = 20). AUROC was 67.7%. Graft weight cutoff of 643 g gave the best combination of sensitivity (51.2%) and specificity (77.8%). There were 15 (19.4%) deaths in group with graft weight less than 643 g compared to 5 (7.1%) patients with graft weight 643 g or above. This cutoff value of 643 g (rounded of to 650 g) gave a positive predictive value (PPV) of 94%.

Gallbladder adenomyomatosis with tubercular portal lymphadenopathy masquerading as gallbladder carcinoma.

Gallbladder carcinoma is more likely to occur in elderly females and the presence of periportal adenopathy often signifies advanced disease. Such patients are generally not taken up for surgery and are treated palliatively. Isolated periportal tuberculosis without the evidence of disease elsewhere is in itself a rarity. Here we present a case study of gallbladder mass suspected of being gallbladder carcinoma with portal lymphatic metastasis actually turning out to be that of gallbladder adenomyoma with periportal tuberculosis. This case illustrates how mass lesions of the gallbladder are commonly and falsely interpreted to be malignant.

Isolated traumatic bilateral first rib fracture: a rare entity.

Since the first rib is protected very well by the overlying soft tissue and bones, its fracture is a major injury and a considerable force is required to do it. Therefore, an isolated fracture of this rib is unusual. A 28-year-old healthy female had an accident while crossing the road and a heavy object fell on her. She had severe pain behind her clavicle region and was immediately hospitalized and examined. Thorough clinical examination and different relevant investigations surprisingly disclosed isolated bilateral first rib fracture which is a very rare clinical condition.