Evaluation of implantable Doppler probe continuous monitoring of hepatic artery anastomosis after liver transplantation.

BACKGROUND: Thrombosis of hepatic artery anastomosis (HAT) after liver transplantation is a catastrophic and dreaded complication. Early identification of HAT can salvage the situation. To monitor the anastomosis, conventional daily transcutaneous Doppler is performed. However, it has disadvantages of being noncontinuous, operator-dependent and technically difficult. Implantable Doppler probes wrapped around the anastomosed vessel giving continuous signal may be an important tool; however, very few studies are performed to study its efficacy after intra-abdominal vascular anastomosis, and its role is not clearly established. METHODS: Patients who underwent deceased donor liver transplant surgery were part of the study. On hepatic arterial anastomosis, implantable Doppler probe was fixed for monitoring. Conventional daily transcutaneous Doppler was also performed and the results were compared. RESULTS: A total of 40 hepatic arterial anastomoses were studied. The incidence of HAT was 10.53%. For the implantable Doppler probe monitoring, sensitivity and negative predictive value was 100%, whereas specificity was 94.44% and positive predictive value was 66.66% with an overall accuracy of 95%. A mean of 10 h of lead time was gained by implantable Doppler probe monitoring. CONCLUSION: Our study showed that there was high sensitivity and negative predictive value of implantable Doppler probe monitoring system, which makes it ideal for post-operative vascular anastomoses surveillance monitoring; however, abnormal positive finding on implantable Doppler probe monitoring needs to be confirmed by conventional transcutaneous Doppler. The implantable Doppler probe monitoring, because of its round the clock and continuous nature gives us a good lead time in identifying vascular complication, which translates into graft salvage and reduction in morbidity and mortality.

Mesh infection in cases of polypropylene mesh hernioplasty.

BACKGROUND: Mesh hernioplasty is the most common surgery for hernia repair with Polypropylene mesh as the preferred one. But the use of synthetic prosthesis is associated with the inherited risk of developing a prosthetic infection that may manifest even after a very long time as subtle symptoms in the form of fever, myalgia, erythema of overlying skin and in some cases as chronic discharging sinus. With this in view a systematic prospective observational study has been carried out to estimate the incidence of mesh infections, to identify the type of associated organism and to study the outcome of the cases with hernioplasty using Propylene mesh. METHODS: Mesh hernioplasty performed in all adult patients using propylene mesh exclusively on 161 males and 20 females were considered in this prospective observational study carried out for 3 years (2016-2019) at tertiary care centre and teaching hospital in India. A standard size of the propylene mesh and well laid procedures were used for surgery as well as post operative care, identification and culture of microorganism. The patients were followed up to identify any symptoms of SSI or mesh infection. The entire data was statistically analyzed using Statistical Package for Social Sciences (SPSS ver 21.0, IBM Corporation, USA) for MS Windows. RESULTS: Out of 181 cases, the mesh contamination was observed in 59 cases while total cases of mesh infection were nine (09), which include 07 males and 02 females. The cases that developed infection were of mostly groin hernias. The cases commonly presenting with erythema, seroma and surgical wound dehiscence with identification of methicillin sensitive Staphylococcus aureus (MSSA) in the few samples of the wound discharge were managed conservatively and none of the cases had to undergo mesh explantation. Of the numerous factors viz. age, sex, associated co-morbidities, educational status, socio-economic status, duration of surgery and expertise of the operating surgeon, the two factors viz. duration of surgery and the mesh contamination were found to be associated with mesh infection in a statistically significant way. CONCLUSION: The incidence of mesh infection was observed in 4.97% of total 181 cases. To the best of knowledge, this seems to be the first prospective observational carried out in this country. Of the numerous factors studied, the duration of surgery and mesh contamination were the factors found to have statistical significance on the incidence of mesh infection. Although a clear picture to differentiate surgical site infection from acute mesh infection is yet to be obtained, the study provided better understanding of the management as no mesh explantation was required in either of the cases.

A study on outcome of binding pancreaticogastrostomy following pancreaticoduodenectomy: A prospective observational study.

INTRODUCTION: The type of anastomosis of the pancreas following pancreaticoduodenectomy is often attributed to the reason for pancreatic leak. Results of various randomized trials comparing pancreaticojejunostomy and pancreaticogastrostomy are conflicting one suggesting advantage over the other and vice versa. In this study we intend to critically analyze a novel technique of binding pancreaticogastrostomy following pancreaticoduodenectomy. AIMS AND OBJECTIVES: The aim of this study is to see the outcome of binding pancreaticogastrostomy by evaluating the technical aspects of binding PG and study the incidence of post-operative complications. MATERIALS AND METHODS: The study included all patients who had undergone binding pancreaticogastrostomy from Mar 2012 to Mar 2016 at a tertiary care hospital. Patients' data, including patients demographics, type of procedure performed, complications, mortality, hospital stay, postoperative interventional procedures or reoperations were all documented. RESULTS: There were 60 men and 37 women (mean age was 55.4 ±â€¯11.6 years) with a mean BMI of 22.6 Kg/M2. 16% of the patients had evidence of cholangitis and 14 of them had to be stented preoperatively. Ninety-four percent of the patients were operated for malignant cause of obstructive jaundice. The mean operative time was 283 min s and average blood loss during surgery was 352 ml. 36% of the patients were operated by the senior residents undergoing training in Gastro intestinal surgery with the assistance of the available faculty. 60% of the patients had a pancreatic duct diameter less than 3 mm. 72% of the pancreatic stump were soft in consistency. In our study we had 3% patients with pancreatic leak. The most frequent complication was DGE, which was seen in 22% patients. The mean duration of DGE was 13.5 ±â€¯2.6 days. We had 2 deaths within 30 days of surgery of which one was due to massive intraabdominal bleed due to pancreatic leak. None of the parameters like pre-operative and operative parameters like age, bilirubin, total leucocyte count, preoperative stenting, pancreatic duct diameter, texture of pancreas and surgery performed by residents were found to be responsible for pancreatic leak. CONCLUSION: This novel method of binding PG is simple, secure, and reproducible. It possesses several advantages over the conventional PG: it is very easy to perform, it is less traumatic to the pancreatic stump, can be performed in all types of pancreatic stump irrespective of the texture and diameter of the pancreatic duct without any statistically significant adverse outcomes.

Impaired expression of testicular androgen receptor and collagen fibers in the testis of diabetic rats under HAART: the role of Hypoxis hemerocallidea.

INTRODUCTION: Wide spectrum of alterations associated with highly active antiretroviral therapy (HAART) has been reported. The current study aimed at evaluating the role of Hypoxis hemerocallidea (HH) aqueous extract on the testosterone levels, expression of androgen receptors and collagen fibers in the testes of streptozoto-cin-nicotinamide-induced diabetic rats under HAART regimen. MATERIAL AND METHODS: Sixty two adult male Sprague-Dawley rats (189.0 ± 4.5 g) were divided into eight groups (8 animals in each treatment groups and 6 rats in the control group). Diabetes was induced by a single intraperi-toneal injection of nicotinamide (110 mg/kg bw) followed by streptozotocin (45 mg/kg bw) and the animals were then subjected to various treatments with HAART, HH extract or melatonin. At the end of the experiment, blood samples were collected to measure serum testosterone levels. Testes were fixed in buffered formaldehyde and paraffin processed. The expression of androgen receptor (AR) was assessed by immunohistochemistry and collagen fibers were visualized by Masson trichrome staining. RESULTS: Serum testosterone level was drastically (p < 0.0001) reduced in all rats with induced diabetes. In the testis of diabetic rats increased collagen fibers deposition with varying derangements in germinal epithelium of spermatogenic layers were observed. Intertubular hemorrhages and absence of spermatozoa were also noted in the testes of diabetic rats subjected to HAART. Reduced immunoexpression of ARs was found in the nuclei of Sertoli cells and the cytoplasm of spermatogonia and spermatocytes in III-IV stages of the seminiferous epithelium cycle of diabetic animals treated with different dosages of HH alone and those treated with HAART concomitantly with melatonin and HH. The expression of ARs was almost negative in the testes of rats treated with HAART alone. CONCLUSIONS: Concomitant treatment of rats with aqueous HH extract during the HAART did not change se-rum testosterone level nor mitigate the altered expression of collagen fibers and androgen receptor resulting from STZ-nicotinamide-induced diabetes. Therefore, anti-diabetic properties of Hypoxis extract require further investigation.

Hydrogen peroxide test for intraoperative bile leak detection.

BACKGROUND: Bile leakage (BL) is a common complication following liver surgery, ranging from 3 to 27% in different series. To reduce the incidence of post-operative BL various BL tests have been applied since ages, but no method is foolproof and every method has their own limitations. In this study we used a relatively simpler technique to detect the BL intra-operatively. Topical application of 1.5% diluted hydrogen peroxide (H2O2) was used to detect the BL from cut surface of liver and we compared this with conventional saline method to know the efficacy. METHODS: A total of 31 patients included all patients who underwent liver resection and donor hepatectomies as part of Living Donor Liver Transplantation. After complete liver resection, the conventional saline test followed by topical diluted 1.5% H2O2 test was performed on all. RESULTS: A BL was demonstrated in 11 patients (35.48%) by the conventional saline method and in 19 patients (61.29%) by H2O2 method. Statistically compared by Wilcoxon signed-rank test showed significant difference (P = 0.014) for minor liver resections group and (P = 0.002) for major liver resections group. CONCLUSION: The topical application of H2O2 is a simple and effective method of detection of BL from cut surface of liver. It is an easy, non-invasive, cheap, less time consuming, reproducible, and sensitive technique with no obvious disadvantages.

The effect of laparoscopic sleeve gastrectomy (LSG) on glycemic control in morbidly obese patients.

INTRODUCTION: Bariatric procedures have become popular in treating not only the morbid obesity but also the metabolic derangements. Sleeve Gastrectomy has recently become popular as a standalone procedure and its usefulness as a metabolic procedure especially glycemic control is still under investigation. One of the most commonly used measure of insulin resistance is statistically derived 'Homeostatic model assessment of insulin resistance (HOMA-IR). AIM: The effect of Laparoscopic Sleeve Gastrectomy (LSG) on clinical and measurable change in glycemic control as seen by reduction of insulin resistance ie HOMA-IR levels in morbidly obese patients. MATERIAL AND METHODS: All the patients with BMI ≥35 kg/m(2) with co morbidities and BMI ≥40 kg/m(2) even without co morbidities were included in the study. The period of the study was from Feb 2013 to Sep 2014. Fasting (FBS), post prandial blood sugar (PPBS) and Insulin levels were checked before the surgery, 1month and 3 month after the surgery. We also recorded BMI and diabetic status. HOMA-IR was calculated and trends were recorded. STATISTICAL ANALYSIS: Statistical analysis was carried out using SPSS 16.0. RESULTS: Out of 28 patients 8 were males and 20 were females. The mean age was 43 yrs. 11 (39%) patients were diabetic and mean BMI was 44 kg/m(2) and a range of (35-61.3) kg/m(2). 11 patients had BMI > 45 kg/m(2). The HOMA-IR values decreased significantly after the surgery both in diabetics and non diabetics. CONCLUSION: LSG results in improvement in glycemic control in both diabetics and non diabetics.

Comparison of outcomes in ideal donor and extended criteria donor in deceased donor liver transplant: a prospective study.

INTRODUCTION: The number of patients who could benefit from liver transplantation markedly exceeds the number of available donors. This increasing gap has fuelled efforts to maximize existing donor pool and identify new avenues. AIMS AND OBJECTIVES: To compare the outcome in deceased donor liver transplant (DDLT) based on extended donor selection criteria. MATERIALS AND METHODS: Donor and recipients' data were analyzed following DDLT from Mar 2007 to Feb 2013. Donors were grouped into either ideal donor (ID) or extended criteria donor (ECD) based on donor and graft related characteristics. Primary nonfunction (PNF) and patient survival were the primary endpoints while early graft dysfunction (EGD) and incidence of major postoperative complications were the secondary endpoints of the study. RESULTS: We had a total of 6 mortalities (13%) at the end of 1 year. The Kaplan Meier survival analysis at 7 days, 3, 6 and 12 months were not statistically different (p > 0.05). PNF occurred in three (6.5%) patients and was not significantly different nor influenced by cumulative number of risk factors in the subgroup analysis (p < 0.3). However, the incidence of EGD was significantly influenced by the cumulative number of risk factors (p < 0.005). A total of 12 (26.1%) patients were graded with 3 or more complications according to the 'Clavien Dindo Grade' for major post operative complications, although it did not reach a statistical significance in the various subgroups. Univariate analysis of the donor risk factors showed that none of these factors were predictive for PNF and mortality in deceased donor liver transplant recipients. CONCLUSION: Although the incidence of early graft dysfunction is statistically more with increase in number of donor risk factors, the overall survival and outcome in extended criteria liver donors are similar to that of an ideal donor. With the supply demand gap widening, extended criteria for selection of deceased donors will definitely expand the donor pool without adversely affecting the outcome of liver transplantation.

Donor outcome in live-related liver transplantation.

BACKGROUND: Live donor liver transplant has become an accepted, effective and lifesaving alternative to deceased donor transplant. The effect on donor and his safety remains a cause of concern. The donors are all in productive age and in our setting may have to go back to active service. This study is aimed at knowing the results of donor hepatectomies at our centre. METHODS: Data of all donor hepatectomies done at our centre from Apr 2007 to Jun 2013 reviewed. This included the preoperative workup, operative details and postoperative follow-up. RESULTS: 35 Donors of age between 20 and 50 years were taken up for procedure of which one was abandoned due to haemodynamic instability after intubation. In the 34 procedures done the percentage of the residual liver was at least 30%. No donor required blood transfusion. The overall complication rate was 26.5% which was stratified according to the modified Clavien classification of postoperative complications. There was transient rise of bilirubin and liver enzymes in all which returned back to normal with time. Infections were the most common cause of complication. All the donors had gone back to their work after a mean of 42 days after surgery. All donors were willing to donate again if needed. CONCLUSION: Living donor liver transplant a widely practiced modality for end-stage liver disease. It is a safe procedure with good recovery and results. Our study shows that meticulous selection criteria and strict adherence to protocols leads to good outcome.

IS CLEAN DISSECTION OF CALOT'S TRIANGLE NECESSARY IN CHOLECYSTECTOMIES?

In this study when patients were followed up for post-operative symptoms, it was seen that the incidence of narrowing of lumen of the common bile duct was more in cases where the operation was done by retrograde cholecystectomy with clean dissection of Calot's triangle. Though this was a coincidental finding, it raises a doubt whether the narrowing is a result of impairment of blood supply to the common bile duct, which may result from clean dissection and display of Calot's triangle area. The above dissection removes the fascial layer over the common bile duct and is likely to result in damage to end-arteries piercing through it to the common bile duct. This conjecture requires further study in a larger series.