Peri-operative outcomes of pancreaticoduodenectomy comparing an isolated Roux loop or single loop for reconstruction: An ambispective observational study.

BACKGROUND: A post-operative pancreatic fistula is a major cause of morbidity and mortality in patients undergoing pancreaticoduodenectomy. We compared two methods of reconstruction of pancreaticojejunal anastomosis, an isolated loop with a single loop, to assess their effects on the incidence and severity of fistula. METHODS: The data was collected in an ambispective manner. The drain fluid was sent for amylase measurement on post-operative day 3 and a fistula was defined and classified according to the 2016 modification of the International Study Group for Pancreatic Surgery definition. The patients were divided into the isolated (Group I) and single (Group II) loop groups and compared for the incidence and severity of clinically relevant fistula along with other parameters. RESULTS: A total of 349 (Group I: 201, Group II: 148) patients were included in the study. The incidence of clinically relevant fistula was comparable (p = 0.206). Grade C fistula was found to be lower in the group I (7 % vs 11.6 %, p = 0.137), in patients with a soft pancreas (8.5 % vs 18.3 %, p = 0.049) and pancreatic duct diameter less than 5 mm (9.8 % vs 17.2 %, p = 0.036). The operative time was lower in Group I than in Group II (438 min vs 478, p < 0.001). CONCLUSION: We found that the incidence of clinically relevant fistula was similar in both the groups but the isolated reconstruction method reduced the incidence of severe fistula. In patients with a smaller pancreatic duct, soft pancreas echotexture and obesity, it provides a safer alternative and can be performed in less time than a single loop reconstruction.

Surgical management of hilar cholangiocarcinoma: Controversies and recommendations.

Hilar cholangiocarcinomas are highly aggressive malignancies. They are usually at an advanced stage at initial presentation. Surgical resection with negative margins is the standard of management. It provides the only chance of cure. Liver transplantation has increased the number of 'curative' procedures for cases previously considered to be unresectable. Meticulous and thorough preoperative planning is required to prevent fatal post-operative complications. Extended resection procedures, including hepatic trisectionectomy for Bismuth type IV tumors, hepatopancreaticoduodenectomy for tumors with extensive longitudinal spread, and combined vascular resection with reconstruction for tumors involving hepatic vascular structures, are challenging procedures with surgical indications expanded. Liver transplantation after the standardization of a neoadjuvant protocol described by the Mayo Clinic has increased the number of patients who can undergo operation.

Cystic lesions of the adrenal gland.

Cystic lesions of the adrenal glands are relatively uncommon and most of them are clinically silent. Though rarely associated with malignant changes, they may carry clinically detrimental consequences if misdiagnosed. Cystic adrenal lesions exhibit a broad histomorphological spectrum, ranging from pseudocysts, endothelial cysts, epithelial cysts and parasitic cysts. Here we present the case of a young woman with left-sided abdominal pain and contrast-enhanced CT showing a 10.4×7.7×7.8 cm fluid-filled left suprarenal lesion. The patient underwent exploratory laparotomy with cyst excision, and the histopathological examination of the specimen revealed a pseudocyst of the left adrenal gland. Despite being rare, usually benign and asymptomatic, the diagnosis and management of these cystic lesions of the adrenal glands are often unclear. Any functional lesion, potentially malignant lesion or lesion more than 5 cm deserves surgical management, whereas others can be managed conservatively.

Obstructing primary squamous cell carcinoma of caecum: A case report.

Squamous cell carcinoma (SCC) of the colon is a rare malignancy and usually a pathological surprise. Clinical presentation is usually very similar to adeno carcinoma variety. We report a case of a 56 year old male with primary SCC of caecum presenting as small bowel obstruction and managed with surgery and adjuvant chemotherapy. It was labelled as primary SCC after extensive search for other primary malignant SCC in body with possible metastasis to caecum. Due to rarity of the disease and lack of literature standardized protocols for neo-adjuvant and adjuvant therapy are not available.

Liver Transplant Society of India Guidelines for Liver Transplant During COVID-19 times.

Coronavirus disease-2019 (COVID-19) pandemic has affected liver transplantation in many ways. There is risk of infection to the transplant recipients; and COVID-19 is associated with significant risk of mortality in patients on wait list. The Liver Transplant Society of India (LTSI) has prepared guidelines regarding selection of adult and pediatric patients for liver transplantation, transplant for acute liver failure, use of deceased donor organs, transplant techniques and minimally invasive donor hepatectomy, pre- and postsurgery testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related coronavirus disease 2019 in donors and recipients, role of COVID-19 antibody testing, shifting of recipients from COVID-19 to non-COVID-19 areas after recovery, isolation policy of team members exposed to COVID-19 patients, drug therapy of proven or suspected COVID-19 infection early posttransplant, care of SARS-CoV-2 positive donors and recipients and a separate COVID-19 consent for surgery.

Whipple's Pancreatoduodenectomy in the Background of Chronic Liver Disease (CLD): An Institutional Experience.

INTRODUCTION: Whipple's pancreatoduodenectomy (PD) is a formidable operation, associated with a high risk of morbidity and mortality. In the setting of an underlying chronic liver disease, the incidence of complications and mortality increases manifold. Patients and Outcomes. Of the 112 Whipple's PD performed between 2018 to 2020 at a high-volume HPB and liver transplant centre, 4 patients underwent the surgery in the background of an underlying chronic liver disease (CLD). All except one were performed in Child's A cirrhotics. There was a single 30-day mortality in this series of 4 patients that occurred in the background of Child's B cirrhosis. On follow-up at 1 year, there was one more mortality in the series, owing to liver decompensation following chemotherapy. CONCLUSION: Judicious preoperative selection criteria, adequate preoperative nutritional and physiological optimisation, and prudent weighing of risk vs. benefit of undergoing Whipple's PD in periampullary malignancies in the setting of CLD are the major determinants of the surgical outcome.

Intestinal obstruction in a tertiary care centre in India: Are the differences with the western experience becoming less?

BACKGROUND: Patients with intestinal obstruction consist of a major proportion of emergency room visits and the complication is associated with a significant morbidity and mortality. It has a diverse aetiology which varies from country to country. In developed countries it is mainly due to adhesions and in developing countries due to obstructed hernias. Although there are numerous studies from the western world on this subject there have been few recent publications from the developing world. PATIENTS AND METHODS: We retrospectively analyzed all the patients admitted with intestinal obstruction to our department from January 1996 to December 2019. Their demographic data, duration of symptoms before presenting to the hospital and interval between admission and surgery were noted along with the cause and level of obstruction. The type of procedure, post-operative complications, mortality or whether re-exploration was done were also noted. Post-operative complications were graded according to the Clavien Dindo classification. RESULTS: A total of 986 patients presented with intestinal obstruction during this period out of which 743 patients underwent surgery. The commonest cause of obstruction was adhesions in 273 (36.7%) - the proportion increased significantly from 23% in 1996-2004 to 51.6% in 2013-2019. This was followed by carcinoma [130(17.5%)], tuberculosis [111(14.9%)], strictures [94(12.7%)] and hernia (5.4%). Colorectal surgery was the most common previous procedure in the adhesions group [85(31.1%)].The overall operative mortality was 41 (5.5%). CONCLUSION: The aetiology of intestinal obstruction in our hospital is now mainly due to adhesions and is thus shifting towards the western pattern. But tuberculosis and obstructed inguinal hernias still constitute of a sizable proportion of our patients.

Rare Pseudopapillary Neoplasm of the Pancreas: A 10-Year Experience.

INTRODUCTION: The solid pseudopapillary epithelial neoplasm (SPN) is a rare form of pancreatic neoplasm with an incidence of 2-3% of all pancreatic tumours. The recent increase in incidence is attributed to the increasing use of imaging techniques for nonspecific abdominal complaints. We report our institutional experience in the management of this tumour over the last decade. METHOD: We retrospectively analyzed from a prospectively maintained database of patients from January 2011 to December 2020 who were operated upon for SPN. All the patients were followed till date. RESULTS: Of 479 patients operated on for various types of pancreatic tumours during this period, 15 (3.1%) had SPN. The mean age of presentation was 28 years with a female preponderance (12/15, 80%). The most common location was the body and tail of the pancreas (66%), and the mean size was 6.4 cm (2-15 cm). The tumour extent was defined as 'borderline resectable' in 20% of cases. Distal pancreatectomy was done in 11 patients with spleen preservation in 3. R0, R1, and R2 resection were done in 12, 2, and 1 patient(s), respectively. The operative mortality was 6.7%. All the patients are doing well on follow-up. CONCLUSION: SPN is a low-grade malignant tumour with a strong female predilection. Clinical manifestations have no specificity, imaging examination only contributes tumour location, and the final diagnosis rests on pathology. Surgery is the main modality of treatment and carries a good prognosis.

Isolated ectopic jejunal varices in a patient with extrahepatic portal vein obstruction - A case report.

INTRODUCTION AND IMPORTANCE: Among the various causes for lower gastrointestinal bleeding, ectopic varices constitute a small chunk. Though rare, these can pose a diagnostic challenge with recurrent bleed leading to multiple admission and blood transfusions. CASE PRESENTATION: A 41-year-old male presented to our department with multiple episodes of melena. On further evaluation with CT angiography, a diagnosis of extrahepatic portal vein obstruction with moderate splenomegaly and ectopic jejunal varix was made. He underwent splenectomy with resection of involved jejunal segment with side to side anastomosis. CLINICAL DISCUSSION: The diagnosis of ectopic varices remains elusive in a large number of cases in view of the varied etiology. Various newer endoscopic and imaging modalities can play a diagnostic as well as therapeutic role but this also further complicates the management as there is a lack of substantial guidelines directing the treatment protocol. As a result, we have to resort to a case by case approach for the optimal management in these cases. CONCLUSION: The main modality of management for bleeding ectopic varices is percutaneous or endoscopic. Surgery is reserved for refractory cases, with decompressive shunts combined with segmental resection of involved intestine being at the forefront of surgical options.

Duodenal Perforation: Outcomes after Surgical Management at a Tertiary Care Centre-A Retrospective Cross-Sectional Study.

INTRODUCTION: Duodenal perforation is a common surgical emergency and carries mortality ranging from 4% to 30% reported in Western countries, but there is a paucity of reports from India. We aimed to determine the factors which influence the surgical outcomes in patients with duodenal perforation. METHODS: We retrospectively analyzed prospectively collected data from January 2010 to December 2018. RESULTS: A total of 55 patients were included in the study of which 69% (38) were males and 31% (17) were females (M : F = 4.5 : 2). The mean age was 52.3 years. The cause for duodenal perforation was duodenal ulcer (n = 25, 45.5%), followed by post-ERCP complications (n = 15, 27.3%), surgery (n = 11, 20%), and blunt trauma (n = 4, 7.2%) with perforations localized at D2 (n = 28, 51%) and at D1 (n = 27, 49%). Patients underwent primary repair with an additional diversion procedure (n = 28, 51%) and repair only in 18 (32.8%). There were 21 (38%) deaths. Patients with ERCP-associated duodenal perforation had longer hospital stay (P ≤ 0.001), ICU stay (P=0.049), duration of drainage (P ≤ 0.001), and higher leak rate (P=0.001) and re-exploration rate (P=0.037). A high mortality rate was seen in patients with preoperative organ failure (n = 18, 78% versus 9.4%, P=0.001), postoperative leak (n = 7, 64% versus 32%, P=0.05), and longer duration from onset of symptoms to surgery (≥4 days) (P=0.045). CONCLUSION: Perforation of the duodenum is associated with high morbidity and mortality regardless of its cause and is higher in those who have a longer interval to surgery, preoperative organ failure, and a postoperative leak.

Post pancreaticoduodenectomy hemorrhage: A retrospective analysis of incidence, risk factors and outcome.

BACKGROUND: The operative mortality after pancreaticoduodenectomy (PD) has declined but morbidity still remains considerable. Post pancreaticoduodenectomy hemorrhage (PPH) occurs in 3-13% of patients following PD. We studied the incidence and outcomes of patients with PPH after PD to determine the associated risk factors and effect on hospital stay. METHODS: We retrospectively analyzed from a prospectively collected data of patients developing PPH following PD between January 2007 and May 2018. ISGPS definition and grading system were used. By using univariate and multivariate analyses, independent predictors of PPH were identified. RESULTS: Of the 340 patients undergoing PD, PPH occurred in 39 patients (11.5%), of whom 5 (12.8%) had Grade A, 22 (56.4%) had Grade B and 12 (30.8%) had Grade C PPH. Six (15.4%) of the 39 patients with PPH died against an overall mortality in the study population of 16 out of 340 patients (4.7%), reflecting higher mortality (P = 0.019) in patients with PPH . The independent risk factors for PPH were a high pre-operative bilirubin (mean 4.7 vs. 7.4 mg/dl, P = 0.01) and INR (mean 1.2 vs. 1.72, P = 0.024), whereas it was closely followed by but, but not significantly associated with pre-operative biliary stent placement (P = 0.09). Pancreatico-jejunostomy (PJ) leak was seen in 20.7% in non-hemorrhage group vs. 41% in hemorrhage group (P = 0.008) and was an independent risk factor for PPH. CONCLUSION: PPH occurred in 11.5% of patients and resulted in a mortality four times greater than those without a PPH. It occurred more frequently in patents with a high pre-operative serum bilirubin, INR, biliary stenting or those with a PJ leak.

Percutaneous Recanalization of Anastomotic Portal Vein in a Pediatric Patient After Liver Transplant Without Any Recognizable Portal Vein Remnant on Imaging.

In patients with complete portal vein thrombosis, the main portal vein is obstructed, resulting in development of hepatopetal collateral vessels. In cases of complete portal vein thrombosis, interventional procedures are challenging, with the greatest difficulty in the form of passing the guide wire across the level of obstruction. A recognizable main portal vein remnant has been deemed as a mandatory criterion in previous reports. Here, we report a case of cavernous trans-formation of the portal vein in a pediatric patient after liver transplant who had no obvious detectable portal vein remnant on radiologic imaging. Using digital subtraction angiography, we were successful in passing a guide wire through the level of obstruction and placing a stent, thus causing successful recanalization of the occluded segment.

A Comparison Between the Comprehensive Complication Index and the Clavien-Dindo Grading as a Measure of Postoperative Outcome in Patients Undergoing Gastrointestinal Surgery-A Prospective Study.

BACKGROUND: The Clavien-Dindo (CD) grading system reports the most severe of all the postoperative complications. The comprehensive complication index (CCI) sums up all the complications in postoperative period. We compared the CCI and CD to assess which of the two was a better measure of postoperative outcomes. MATERIALS AND METHODS: Between June 2015 and December 2016, we recorded the complications using CD grading and CCI in 1000 consecutive patients in our gastrointestinal and hepatopancreaticobiliary surgery unit. The outcome variables studied were postoperative length of hospital stay (LOS), postoperative intensive care unit (ICU) stay, and time to normal activity. The results were expressed as strength of correlation and predictive accuracy of the outcome variables. RESULTS: There were 600 males and 400 female patients, with a mean age of 50.3 y. A total of 788 (78.8%) elective and 212(21.2%) emergency procedures were performed. The overall 90-day/in-hospital mortality was 7.9%. Both CD and CCI showed a good correlation with LOS (r = 0.58; P = 0.001, r = 0.57; P = 0.001), ICU stay (r = 0.62; P = 0.002, r = 0.62; P = 0.001), and time to normal activity (r = 0.48; P = 0.01; r = 0.49; P = 0.01). The accuracy of CCI to predict the LOS (area under the curve [AUC] = 0.89; P < 0.001), ICU stay (AUC = 0.85; P < 0.001), and time to normal activity (AUC = 0.76; P < 0.001) was comparable to that of CD (AUC = 0.90; P < 0.001, AUC = 0.87; P < 0.001, AUC = 0.77; P < 0.001). CONCLUSIONS: Both CD and CCI were equally accurate in measuring the postoperative outcomes and in their ability to predict the same in patients undergoing gastrointestinal and hepatopancreaticobiliary surgeries. Considering the relative ease of determination of CD, it remains a more commonly used measure for assessing the severity of complications and outcomes compared to CCI.

Brunner's gland hyperplasia: an unusual duodenal submucosal lesion seen in four patients.

Brunner's gland hyperplasia is an extremely rare benign hamartomatous lesion seen in proximal duodenum. Difficulty in diagnosing the condition pre-operatively puts the surgeon in dilemma for deciding appropriate management. We retrieved details from prospectively maintained retrospective data from January 2014 to April 2018. Four patients were identified of which three were males and one was female. Symptoms ranged from 4 days to 4 years, with abdominal pain, vomiting and malena being predominant. No patients were identified with diagnosis pre-operatively. Diagnosis was made on histopathological examination of the resected specimen and none of them were having malignant features. At a median follow up of 11 months, no patient had recurrence and were symptom free. Brunner's gland hyperplasia is a rare elusive duodenal pathology, symptomatically mimicking alarming duodenal lesions and mostly diagnosed on histopathology of specimen. Patients may harbour the lesion for long periods with little symptoms and upon treatment have good outcomes.

Penoscrotal swelling-an unusual occurrence in a patient with an anastomotic leak following ileostomy closure.

Diverting loop ileostomy is a frequently done procedure accompanying colorectal surgeries. Dreaded complication is anastomotic leak. Early identification of anastomotic leak and apt management is required for better outcomes. Most often leak presents with fever, abdominal pain, rigidity, fever and hemodynamic instability. We report a rare occurrence of penoscrotal oedema in a patient with anastomotic leak and spontaneously subsiding with drainage of leaked contents.

A Review of 2255 Emergency Abdominal Operations Performed over 17 years (1996-2013) in a Gastrointestinal Surgery Unit in India.

There is little information regarding the clinical spectrum and outcome of emergency abdominal operations from specialized units in India. We examined these in our gastrointestinal surgery and liver transplantation unit from a prospective database maintained between July 1996 and April 2013. Out of 9966 operations performed, 2255 (26%) were emergency procedures (reoperations during the same admission, e.g., for necrotizing pancreatitis were excluded). The primary outcome was 30-day postoperative mortality. The mean age of the patients was 47 years (range 1-107) and included the following age groups: 0-18 years (n = 105, 4.7%); 19-64 years (n = 1766, 78.3%), and >65 years (n = 384, 17.0%). The majority were males (1609, 71%), and there were 646 females (29%). The most common indications were small bowel emergencies (598, 26.5%), followed by pancreatic (417, 18.5%) and colonic (281, 12.5%) emergencies. Pancreatic operations were the second commonest in the adult and middle aged group. Colorectal operations were the second commonest in the geriatric age group (>65 years). Emergency operations for other conditions were: postoperative complications following elective operations 171 (7.5%), gastroduodenal bleeding or perforation in 144 (6.3%), and liver surgery in 93 patients (4.1%) patients. In the small bowel emergencies, 223 patients (37.2%) had primary diagnosis of adhesive obstruction, gangrene in 135 patients (22.5%), perforation in 121 patients (20%), and fistula in 56 patients (9.3%). Mesenteric venous thrombosis was found to be the primary cause of small bowel emergencies, either as a primary cause in gangrene or as a secondary cause in perforations and adhesions. The postoperative mortality after emergencies was 12.6% compared to 2% in elective procedures. Mortality was significantly higher in males (14%) than females (9.6%), p < 0.005. Category wise mortality was as follows: pancreatic surgery (n = 86, 20.6%), surgery for postoperative complications (n = 33, 19.3%), duodenal surgery (n = 18, 12.5%), small intestinal surgery (n = 68, 11.4%), and colonic surgery (n = 35, 12.45%). Emergency operations comprise a significant proportion of a GI surgical unit's workload. The mortality is greatest after pancreatic operations followed by those done for postoperative complications. Despite advances in surgical and postoperative care, emergency operations for abdominal emergencies are associated with mortality which is six times higher compared to elective procedures.

Limited distal duodenal resection: Surgical approach and outcomes. A case series.

INTRODUCTION: Tumours involving the duodenum are usually treated with pancreaticoduodenectomy, which may be associated with considerable morbidity. Limited distal duodenal resection, a relatively smaller procedure, can be done in some of these patients. We describe our experience with this operation for such lesions. METHODS: We retrospectively analyzed, from prospectively collected data 10 consecutive patients who underwent limited duodenal and proximal jejunal resection between March 2011 and Nov 2015. RESULTS: There were 8 males and 2 females who had a median age of 47 years. Their common presentations were abdominal pain (50%) and upper gastrointestinal bleeding (40%). Five had malignancy (adenocarcinoma: 2, neuroendocrine tumours: 2, non Hodgkin's lymphoma 1). Three had gastrointestinal stromal tumours (GISTs) and 2 had other benign tumours (lipoma 1, ectopic pancreas 1). The 30-day post-operative morbidity rate was 60% (n = 6) with mostly minor complications (Clavien grade 1 or 2). Median post-operative stay was 9 (range, 6-13) days. All ten patients were alive without recurrence after a median follow up of 26.5 months. CONCLUSION: Limited distal duodenal resection is a feasible surgical alternative to a pancreaticoduodenectomy in carefully selected patients with benign and some malignant tumours of the third and fourth part of the duodenum.

Distal Bowel Re-feeding in Patients with Proximal Jejunostomy.

BACKGROUND: Patients who have a proximal jejunostomy are difficult to manage because of their high stoma output which results in fluid and electrolyte imbalance with repeated hospital admissions and the necessity for expensive parenteral nutrition (PN). There are few reports on the use of re-feeding of the proximal effluents in this situation. METHODS: We here relate our experience with this manoeuvre in 35 patients between Jan 2010 and Feb 2016 who had stomas less than 120 cm away from the duodenojejunal flexure. RESULTS: There were 26 males and 9 females, whose median age was 47 (19-74) years. The most common indications for massive bowel resection were gangrene in 25 (71%) and intestinal perforation in 7 (20%). The median proximal and distal small bowel lengths were 45 (15-120) cm and 90 (0-240) cm respectively. The ileocaecal (IC) valve was preserved in 33 (94%) and there was only colon distally (without the ileocaecal valve) in 2 (6%) patients. Twenty-five (71%) patients required post-operative ICU care. Additional PN was required in 6 (17%) patients during their index admission with the average extra cost of treatment being 20,000 rupees. Their median hospital stay was 13 (6-60) days. Patients were discharged without intravenous (IV) lines. Eight (26%) patients required re-admission for acute renal failure which was managed conservatively. No major problems were associated with re-feeding. None of the patients required PN after discharge from hospital. Thirty (86%) patients had their stomas closed at 65 (14-224) days. Both the patients with colon only as their distal bowel remnant died. Sepsis was the cause of mortality in 4 (11%) during index admission and 3 after their discharge. On follow-up after bowel re-connection, 2 patients died after 1 and 12 months, both due to intracranial bleeding, and the overall survival was 74%. CONCLUSIONS: Patients with proximal jejunostomies can be managed with distal re-feeding. It is a cost-effective and effective substitute for PN, is associated with few problems, and has a fairly good long-term outcome.

Live donor liver transplantation for acute liver failure: A single center experience.

INTRODUCTION: Acute liver failure (ALF) is an indication for emergency liver transplantation (LT). Although centers performing only deceased donor liver transplants (DDLT) have shown improved outcomes in this situation, they still have relatively long waiting lists. An alternative would be living donor liver transplantation (LDLT), which has shown equivalent outcomes in the elective situation but there is limited evidence of its results in ALF. AIM: The purpose of this study was to assess the outcomes in patients with ALF undergoing emergency LDLT in our center in Delhi, India. METHODS: We prospectively collected data on 479 patients who underwent LT in our hospital between January 2009 and December 2015 to evaluate the outcomes of those with ALF. The ALF patients were listed for transplantation after they met the Kings' College criteria and rapid evaluation was done following a protocol consisting of three phases. Patients with grade III/IV encephalopathy were put on mechanical ventilation. Data regarding their postoperative course, morbidity, and mortality were analyzed. RESULTS: Thirty-six (7.5%) out of the 479 patients underwent emergency LT for ALF. Their mean age was 27.5 years (range 4-59 years) and the male to female ratio of 2:3. Preoperative intubation was required in 15 of 25 patients who had encephalopathy. Wilson's disease was the most common cause of ALF in children while in adults, it was acute viral hepatitis. The time interval between listing and transplantation was a mean of 36 ± 12.4 h. The mean graft to recipient weight ratio (GRWR) was 1.06 ± 0.3. The recipients were extubated postoperatively after a mean period of 2.6 days and their mean ICU stay was 6.3 days. Postoperative infection was the most common complication and required upgradation of antifungal and antibiotic treatments. Neurological complications occurred in five patients. Thirty-one of 36 (86.1%) patients survived and progressive cerebral edema and sepsis were the most common causes of mortality. Patients who died had higher model for end-stage liver disease scores, longer cold ischemia time (CIT), and higher grades of encephalopathy (though 80% patients with encephalopathy survived). There was no donor mortality. At long-term follow up of a median of 56 months, 29 (80.5%) of 36 patients were still alive. CONCLUSIONS: In our experience, LDLT is an alternative procedure to DDLT in patients with ALF and is associated with good outcomes even in patients with high grades of encephalopathy.