Analysis of donor morbidity in 177 donor hepatectomies for living donor liver transplant: Experience from a high-volume centre in western India.

BACKGROUND: Living donor liver transplant (LDLT) is based on the principle of double equipoise. Organ shortage in Asian countries has led to development of high-volume LDLT programs with good outcomes. Safety of live liver donor is the Achilles heel of LDLT program and every effort should be made to achieve low morbidity and near zero mortality rates. METHODS: We retrospectively analyzed our prospectively maintained donor morbidity data (outcomes) of 177 donors in a new transplant program setup in western India by an experienced surgeon. The primary end point was to analyze the morbidity rates and the factors associated with it. RESULTS: None of the donors in our cohort of 177 donors developed grade IV or V complication (Clavien-Dindo classification). One-fourth (1/4th) of the donors developed complications ranging from grade I to grade III(b). The rate of complications according to modified Clavien-Dindo classification is as follows: (1) grade I in 5.6% (n = 10), (2) grade II in 14.6% (n = 26), (3) grade III(a) in 3.9% (n = 7), (4) grade III(b) in 2.2% (n = 4). Three donors (1.6%) developed post-hepatectomy intra-abdominal bleeding and required re-exploration (grade IIIb). All of them recovered well post-surgery and are doing well in follow-up. The mean follow-up of the entire cohort was 2871 ± 521 days (range 1926-3736 days). CONCLUSION: Donor safety (outcome) is determined by meticulous donor surgery and good-quality remnant.

The "W" Technique: A Safe and Reproducible Technique for Hepatic Artery Reconstruction in Living Donor Liver Transplantation.

BACKGROUND Reconstruction of the hepatic arterial inflow can be technically demanding in living donor liver transplantation, and thrombosis can result in graft loss and mortality. We describe the safe and reproducible "W" technique to reconstruct the hepatic artery and outcomes before and after adoption of the technique in a consecutive series of liver transplants at 2 high-volume living donor liver transplant centers. MATERIAL AND METHODS Prospectively collected data were analyzed to compare the outcomes before and after introduction of a standardized "W" technique for reconstruction of the hepatic artery in 2 high-volume living donor liver transplant programs. RESULTS In a consecutive series of 675 liver transplants, of which 27 were deceased donor transplants and 648 were living donor transplants, 443 transplants were performed with a standard interrupted reconstruction of the hepatic artery under loupes. These transplants were performed by a single surgeon, with an incidence of hepatic artery thrombosis of 2%. After introduction of the "W" technique, despite the arterial reconstruction being done by several surgeons in the early part of their learning curve, the incidence of hepatic artery thrombosis decreased to 0.86% in the next 232 transplants. CONCLUSIONS The "W" technique is a simple, easy to learn and teach technique for reconstruction of the hepatic artery without the use of the operating microscope in living donor liver transplantation.

Abernethy malformation: Single-center experience from India with review of literature.

Abernethy malformation is a rare congenital anomaly in which there is direct communication between the portal and systemic venous circulation. The clinical presentation ranges from asymptomatic with incidental detection on imaging to secondary complications of disease or related to associate anomalies. This is a retrospective analysis of data from nine patients with Abernethy malformation at a single center. This is a referral center for Pediatric Cardiology and for Hepatobiliary and Pancreatic Surgery. The patients presented to the Pulmonary Hypertension Clinic/the Hepatobiliary Surgery Clinic. Out of nine patients, four were male. Type II Abernethy malformation was present in five patients whereas three patients had type I malformation. One of the patients had communication between inferior mesenteric vein and internal iliac vein. Five out of nine patients were erroneously diagnosed as idiopathic primary pulmonary hypertension and were treated with vasodilators. One patient required living donor liver transplant. One patient was managed with surgical shunt closure whereas two patients required transcatheter shunt closure. The rest of the patients were managed conservatively. Abernethy malformation is more common than previously thought and the diagnosis is often missed. There are various management options for Abernethy malformation, which includes surgical or transcatheter shunt closure and liver transplant. Management of Abernethy malformation depends upon type, presentation, and size of shunt.

An Overview of Liver Transplant Pathology: Data from a Tertiary Referral Centre in Western India.

INTRODUCTION AND AIM: 1. Study of liver explants - Etiologic types of end-stage chronic liver disease (ESCLD) and acute liver failure (ALF) in adults and children. 2. Assessment of donor steatosis and incidental granulomas. 3. Post-transplant liver biopsies. MATERIAL AND METHODS: Specimens of 180 explant hepatectomies, 173 donor wedge and 30 core liver biopsies, and 58 post transplant liver biopsies received in our department from April 2013 to March 2017. RESULTS: 1. Most common causes of ESCLD in adults were: alcohol related (30.32%), hepatitis virus related (18.71%) and non-alcoholic steatohepatitis related (18.06%); and in children ≤ 12 years were: biliary atresia (27.27%), autoimmune disease (18.18%) and Wilson's disease (18.18%). Most common causes of ALF in adults and children were anti-tubercular therapy induced and idiopathic respectively. 2. Prevalence rate of moderate steatosis (between 30-60%) was 4.28%. Incidental granulomas were seen in 5 cases. 3. Most common diagnoses of post-transplant biopsies in adults included acute cellular rejection (ACR) (36.17%), recurrence of viral disease (8.51%) and moderate non-specific portal triaditis (8.51%). Among children ≤ 12 years, most common diagnoses included unremarkable liver parenchyma, ACR and ischemia/reperfusion injury. CONCLUSION: 1. Alcohol- and hepatitis- virus related ESCLD, and biliary atresia are leading indications for liver transplantation in adults and children respectively. 2. Prevalence of 4.28% of moderate steatosis, is much lower than that documented in western literature. Only 5 cases of incidental granulomas is unexpectedly low in a country endemic for tuberculosis. 3. Most common diagnoses of post-transplant liver biopsies in adults has been acute rejection, which is similar to the findings from much larger published series.

Kinetics of liver regeneration in donors after living donor liver transplantation: A retrospective analysis of "2/3rd partial hepatectomy" model at 3 months.

BACKGROUND/AIM: Right lobe living donor (2/3rd partial hepatectomy) model is the best way to accurately study liver regeneration process in human beings. We aimed to study the kinetics of liver regeneration after 2/3rd partial hepatectomy in donors. METHODS: Retrospective analysis of prospectively maintained volumetric recovery data in donors was performed in 23 donors, who underwent 29 contrast-enhanced computed tomography within 3 months for various clinical indications. RESULTS: The absolute volumetric growth percentages were as follows: 37.60 ± 21.74 at 1st week, 92 ± 53.27 at 2nd week, 115.55 ± 59.65 at 4th week, and 110.79 ± 64.47 at 3 months. On sub-group analysis of our cohort, we found that 4.3%, 17%, 30.4%, and 39% donors attended ≥ 90% volumetric recovery at 1st, 2nd, 4th week, and 3 months, respectively. One patient at 4th week revealed 128% volumetric recovery. There was one more patient who exceeded original total liver volumes (TLV) (111% of TLV) at 2.5 months. The serum bilirubin and INR values peaked at postoperative day (POD) 3rd and then started showing a downward trend from POD 5th onwards. CONCLUSION: Our study is the first to document complete volumetric recovery in donors as early as 3 weeks. Two of the donors overshot their original TLV during the early regenerative phase.

Simultaneous living donor liver transplant with sleeve gastrectomy for metabolic syndrome and NASH-related ESLD-First report from India.

Nonalcoholic steatohepatitis (NASH) with morbid obesity and metabolic syndrome is now a common cause of end-stage liver disease (ESLD). These patients are high-risk candidates for liver transplant, and require bariatric surgery to prevent recurrent disease in the new liver. Data reports bariatric surgery after transplant, which maybe difficult because of adhesions between the stomach and liver in living donor liver transplant (LDLT) recipient. We report the first case of combined LDLT with sleeve gastrectomy (SG) from India. A morbidly obese diabetic woman with NASH-related ESLD was planned for combined right lobe LDLT with open SG, in view of failed diet therapy, musculo-skeletal complaints, and restricted mobility. Postoperatively, with liver graft functioning adequately, bariatric diet restrictions resulted in maximum reduction of 25% weight, achieving a target BMI below 30 kg/m2 within 2 months, along with complete cure of diabetes and better ambulation. Thus, combination of LDLT and bariatric surgery in the same sitting is safe and effective in management of metabolic syndrome and associated NASH-related ESLD.

Urgent Redo-Laparotomies: Patterns and Outcome-A Single Centre Experience.

A proportion of the operations performed in a surgical gastroenterology department are unplanned repeat laparotomies for complications of the original procedure. We examined why, in our department, these 'redo' laparotomies were performed and what was their outcome. We retrospectively analyzed 6530 patients operated between September 1996 - December 2010, of these 257 redo laparotomies were performed in 193(2.5 %) patients. There were 138 males and 55 females who had a mean age of 42 years (range 7-68 years). Eighty one (42 %) of the index surgeries were elective and 112 (58 %) performed in the emergency situation. Pancreas was the commonest organ for the index operation {50 (25.9 %)}, followed by the colon and rectum {45 (23.3 %)} and the small bowel {36 (18.7 %)}. Postoperative bleeding was the most common cause for re-exploration 66 (34.2 %) followed by an abscess or fluid collection that required surgical drainage 57 (29.6 %). The mortality rate after redo laparotomies was 33.2 % with sepsis and multi-organ failure being the commonest cause of death. Urgent redo-laparotomies that are performed following complicated abdominal operations have a high mortality rate. Postoperative bleeding, intrabdominal abscess and peritonitis are the commonest cause for redo-laparotomy. Multiple redolaparotomies and associated co-morbid conditions are significant predictors of mortality.

Implementation of a surgical safety checklist and postoperative outcomes: a prospective randomized controlled study.

The implementation of a surgical safety checklist is said to minimize postoperative surgical complications. However, to our knowledge, no randomized controlled study has been done on the influence of checklists on postoperative outcomes in a developing country. We conducted a prospective randomized controlled study with parallel group study design of the implementation of WHO surgical safety checklist involving 700 consecutive patients undergoing operations in our hospital between February 2012 and April 2013. In 350 patients, the checklist was implemented with modifications-the Rc arm. The control group of 350 patients was termed the Rn arm. The checklist was filled in by a surgery resident, and only the participants in the study were blinded. Postoperative wound-related (p = 0.04), abdominal (p = 0.01), and bleeding (p = 0.03) complications were significantly lower in the Rc compared to the Rn group. The number of overall and higher-grade complications (Clavien-Dindo grades 3 and 4) per patient reduced from 0.97 and 0.33 in the Rn arm to 0.80 and 0.23 in the Rc arm, respectively. A significant reduction in mortality was noted in the Rc arm as compared to the Rn arm (p = 0.04). In a subgroup analysis, the number of overall and higher-grade complications per patient with incomplete checklists was higher than that with fully completed checklist group. Implementation of WHO surgical safety checklist results in a reduction in mortality as well as improved postoperative outcomes in a tertiary care hospital in a developing country.

Complicated Perianal Sepsis.

Management of benign anorectal conditions like abscesses and haemorrhoids is usually uneventful. However, complicated perianal complications can result and have sparsely been reported in literature. Hereby, we report a series of seven patients who presented with rare sequelae like necrotising fasciitis, intraperitoneal or retroperitoneal involvement. All patients responded well to surgical management. Accordingly, complicated perianal sepsis warrants a timely and aggressive surgical intervention.

Acute Mesenteric Ischaemia-An Indian Perspective.

In Western countries, acute mesenteric ischaemia is commonly due to arterial occlusion and occurs in patients who are usually in their seventh decade. A venous cause for intestinal gangrene has been reported in only about 10 %. We examined whether this was so in India and compared the clinical features of patients with mesenteric arterial and venous ischaemia and relate these to their ultimate prognosis. We studied retrospectively, the records of all patients admitted or referred to the department with a diagnosis of acute mesenteric ischaemia between January 1997 and October 2012, noting their demographic details and mode of presentation, the results of preoperative imaging and blood investigations, the extent of bowel ischaemia, and the length of bowel that was resected at operation and their outcome. There were 117 patients, 85 males and 32 females whose median age was 53 years. Mesenteric venous thrombosis was seen in 56 patients (48 %) and mesenteric arterial occlusion in 61 (52 %). Forty six patients died (39 %); 15 with venous occlusion (27 %) and 31 with arterial occlusion (51 %). Compared to patients with arterial occlusion, the patients with venous obstruction were younger, had a longer duration of symptoms, were less frequently hypotensive at presentation, had higher platelet counts, had a shorter length of bowel resected, had fewer colonic resections and had a lower mortality. Other predictors of mortality on multivariate analysis were a longer duration of symptoms, lower serum albumin and higher creatinine levels at presentation and a shorter length of residual bowel. In India, acute mesenteric ischaemia in tertiary care centres is due to venous thrombosis in almost half of the patients who are at least a decade younger than those in the West. Significant predictors of mortality include low serum albumin and raised creatinine levels, a shorter residual bowel length and an arterial cause for mesenteric ischaemia.

Complex Rectovaginal Fistula-an Experience at a Tertiary Care Centre.

Complex rectovaginal fistulae are difficult to manage. With an initial failed attempt, a simple fistula becomes complex and the success rate of a subsequent repair decreases. A review of our prospectively maintained records over a period of 16 years revealed 25 patients with rectovaginal fistulae. A variety of procedures was performed in these patients according to their aetiology, site and if there had been a previous attempt at repair. The mean age of the patients was 45 years. The most common cause was operative trauma in 14 cases. Ten patients had previous attempts at repair which had not been successful. The surgical procedures we performed included re-enforcement flaps, resection with diversion, repair with re-enforcement with omentum and simple diversion. Two patients developed recurrence, and one of them healed after a second repair. No recurrence developed in 10 patients who had failed attempts at repair elsewhere. Our experience has shown that most complex rectovaginal fistulae can be successfully repaired but they might require repeated operations. Faecal diversion is usually necessary, and in recurrent fistulae, we found that rather than a local repair, a muscle flap or omental interposition improves the chances of healing.

Readmission after living donor liver transplantation: predictors, causes, and outcomes.

BACKGROUND: Complications following liver transplantation requiring readmission may be serious and potentially life threatening. Most reports on readmission have been about after deceased donor liver transplantation (DDLT). We hypothesized that readmission after living donor liver transplantation (LDLT) is due to different reasons and analyzed our experience. METHODS: We retrospectively analyzed the records of 172 consecutive patients who underwent liver transplantation at our institute between January 2010 and June 2012. The primary outcome measure was readmission. We classified readmission into early (<3 months after discharge) and late (>3 months). RESULTS: The study population was 140 after excluding pediatric patients (12), DDLT recipients (2), and those who died during the index admission (18). Their median age was 42 years, and there were 117 males and 23 females. Thirty-eight patients were readmitted (56 episodes) after LDLT. There were 35 early and 21 late readmission episodes. The most common cause for early readmissions was infection (46 %) and that for late readmissions was biliary stricture (62 %). On univariate analysis, pretransplant portal vein thrombosis, more than one bile duct in the liver graft, revised arterial anastomosis or two arteries in the graft, and higher serum alkaline phosphatase levels at discharge were significantly associated with readmission. Readmission was also significantly associated with a higher overall mortality than non-readmission in which there was no mortality. CONCLUSION: Pretransplant portal vein thrombosis, more than one bile duct in the liver graft, revision of the arterial anastomosis or two arteries in the graft, and higher serum alkaline phosphatase levels at discharge were significantly associated with readmission. Infective and biliary complications were the commonest causes of early and late readmission after LDLT.

Post-Resection Surveillance in GI Cancers.

Recurrence after curative resection of gastrointestinal (GI) cancers is common. Early detection of resectable recurrences may result in a curative resection. In un-resectable recurrences, early detection may improve the quality of life by palliation or with the use of newer chemotherapeutic drugs. The guidelines regarding follow-up of patients after curative resection of GI cancers are from the West which is very different from the Indian population in terms of a disease pattern and social milieu. The guidelines which are commonly used are also not strictly followed. We have proposed in this article the protocols which we follow at our centre after curative resection of GI cancer and how these are different from the guidelines proposed by the West.

Portal cavernoma cholangiopathy: consensus statement of a working party of the Indian national association for study of the liver.

Portal cavernoma cholangiopathy (PCC) is defined as abnormalities in the extrahepatic biliary system including the cystic duct and gallbladder with or without abnormalities in the 1st and 2nd generation biliary ducts in a patient with portal cavernoma. Presence of a portal cavernoma, typical cholangiographic changes on endoscopic or magnetic resonance cholangiography and the absence of other causes of these biliary changes like bile duct injury, primary sclerosing cholangitis, cholangiocarcinoma etc are mandatory to arrive a diagnosis. Compression by porto-portal collateral veins involving the paracholedochal and epicholedochal venous plexuses and cholecystic veins and ischemic insult due to deficient portal blood supply or prolonged compression by collaterals bring about biliary changes. While the former are reversible after porto-systemic shunt surgery, the latter are not. Majority of the patients with PCC are asymptomatic and approximately 21% are symptomatic. Symptoms in PCC could be in the form of long standing jaundice due to chronic cholestasis, or biliary pain with or without cholangitis due to biliary stones. Endoscopic retrograde cholangiography has no diagnostic role because it is invasive and is associated with risk of complications, hence it is reserved for therapeutic procedures. Magnetic resonance cholangiography and portovenography is a noninvasive and comprehensive imaging technique, and is the modality of choice for mapping of the biliary and vascular abnormalities in these patients. PCC is a progressive condition and symptoms develop late in the course of portal hypertension only in patients with severe or advanced changes of cholangiopathy. Asymptomatic patients with PCC do not require any treatment. Treatment of symptomatic PCC can be approached in a phased manner, coping first with biliary clearance by nasobiliary or biliary stent placement for acute cholangitis and endoscopic biliary sphincterotomy for biliary stone removal; second, with portal decompression by creating portosystemic shunt; and third, with persistent biliary obstruction by performing second-stage biliary drainage surgery such as hepaticojejunostomy or choledochoduodenostomy. Patients with symptomatic PCC have good prognosis after successful endoscopic biliary drainage and after successful shunt surgery.

Surgical management of portal cavernoma cholangiopathy.

The majority of patients with portal cavernoma cholangiopathy (PCC) are asymptomatic, however some (5-38%) present with obstructive jaundice, cholangitis, or even biliary pain due to bile duct stones which form as a result of stasis. Most patients with extrahepatic portal venous obstruction (EHPVO) present with variceal bleeding and hypersplenism and these are the usual indications for surgery. Those who present with PCC may also need decompression of their portosystemic system to reverse the biliary obstruction. It is important to realize that though endoscopic drainage has been proposed as a non-surgical approach to the management of PCC it is successful in only certain specific situations like those with bile duct calculi, cholangitis, etc. A small proportion of such patients will continue to have biliary obstruction and these patients are thought to have a mechanical ischemic stricture. These patients will require a second stage procedure in the form of a bilioenteric bypass to reverse the symptoms related to PCC. In the absence of a shuntable vein splenectomy and devascularization may resolve the PCC in a subset of patients by decreasing the portal pressure.

Hepatic artery pseudoaneurysms: a single-center experience.

BACKGROUND: The management of hepatic artery aneurysms has evolved largely because of changes in etiology and presentation, and advances in endovascular therapy. Although many case reports have been published on the condition, few have been from developing countries and few have compared patient outcomes after angioembolization and surgery. PATIENTS AND METHODS: This study retrospectively analyzed patients admitted with hepatic artery pseudoaneurysms between 1999 and 2011. The patients were divided into those who presented before 2007 (surgery group) and after 2007 (embolization group), and their demographic characteristics, presentation, and investigations; the technical and clinical success of treatment; and in-hospital mortality were studied. RESULTS: A total of 29 patients were studied, 17 of whom men, with a median age of 42 years. Of these 29 patients, 8 underwent surgery and 21 had embolization (24 total procedures). No mortality was seen in the surgery group, and their hospital stay was longer and transfusion requirement higher than those in the embolization group, in whom technical success was achieved in all procedures and clinical success in 19 of 24 (79%). Clinical failure and complications were seen when common hepatic artery aneurysms were embolized. Three patients (14%) died in the embolization group from ischemic hepatitis and bowel gangrene, coagulopathy, and a leak from a previous pancreaticojejunal anastomosis. CONCLUSIONS: Both surgery and angioembolization are equally effective for hepatic artery pseudoaneurysms, but the latter has the advantages of more rapid bleeding control, shorter hospital stay, and lower transfusion requirement.