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Background Biliary complications, especially bile leaks, are an important cause of early postoperative morbidity and, rarely, mortality after liver transplant. The risk is higher in living donor liver transplant (LDLT) compared to deceased donor liver transplant (DDLT). Attempts to reduce bile leaks have included refinements in the biliary anastomosis technique and use of various external and internal stents, with inconsistent benefits. Recent availability and successful use of the absorbable Archimedes stent has prompted its intrabiliary placement across the anastomosis. Methods In this retrospective study, we analyzed the data of 20 adult patients who underwent a liver transplant with duct-to-duct biliary anastomosis using the Archimedes stent. Both DDLT and LDLT were performed using cava-preserving hepatectomy followed by standard implantation methods. Duct-to-duct biliary anastomosis was performed in all cases using interrupted sutures with extracorporeal knots over an absorbable intrabiliary stent. In addition to standard postoperative care, patients were monitored for bile leak. Results Nine DDLTs had a single anastomosis over a 10-Fr stent. Out of 11 LDLT patients, 7 had a single anastomosis and 4 patients had 2 anastomoses, all over a 6-Fr stent. Two patients died, 1 as a result of graft primary nonfunction and another because of multidrug-resistant pneumonia. One patient had ascending cholangitis owing to stent migration in the duodenum. This episode was treated with endoscopic stent removal and appropriate antibiotics, with good recovery. None of the other patients had bile leaks, biloma, or stent-related complications. Conclusions Archimedes internal absorbable biliary stents can be safely used in both living and deceased donor liver transplants to prevent bile leaks.

As of August 2020, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has affected more than 213 countries, leading to more than 18 million cases and 690,000 deaths. India is the second most affected country, with the majority of cases in metropolitan cities, such as Mumbai, New Delhi, Chennai, and Bengaluru. There is limited literature on the outcomes and safety of performing living donor liver transplantation (LDLT) in coronavirus disease 2019 (COVID-19) epicenters.

BACKGROUND Health-related quality of life (HRQOL) is an important measure of the effects of end stage liver disease in affected patients that helps to improve well-being after Liver transplantation (LT). One study has been performed to access HRQoL pre and post liver transplant (LT) patients in India. Our study was aimed to determine HRQoL in pre and post orthotopic liver transplant (OLT) with correlation between severity of liver disease by Model for End-Stage Liver Disease (MELD)/Child-Turcotte-Pugh (CTP) score and Diabetes Mellitus (DM) status with HRQoL post OLT. METHODS Study was designed as a single center, observational, prospective and longitudinal study. HRQoL was evaluated by SF-36 questionnaire in sixty (50 male and 10 female with average age of 45 years) patients with end stage liver disease; having HCV related cirrhosis with alcoholic and cryptogenic liver disease forming the second and third largest groups respectively. HRQoL was evaluated pre and post OLT also correlation of MELD/CTP scores and diabetes status with post-OLT HRQoL was determined. Patients were followed up for a period of 3 months after OLT. RESULTS Post OLT patients had higher scores in comparison to pre OLT. There was a significant difference in all eight domains of the SF-36 scores (p

Accidental or suicidal poisoning with yellow phosphorus or metal phosphides (YPMP) such as aluminum (AlP) zinc phosphide (Zn3P2) commonly cause acute liver failure (ALF) and cardiotoxicity. These are used as household, agricultural and industrial rodenticides and in production of ammunitions, firecrackers and fertilizers. In absence of a clinically available laboratory test for diagnosis or toxin measurement or an antidote, managing their poisoning is challenging even at a tertiary care center with a dedicated liver intensive care unit (LICU) and liver transplant facility. Patients and methods Patients with YPMP related ALF were monitored using standardized clinical, hemodynamic, biochemical, metabolic, neurological, electrocardiography (ECG) and SOFA score and managed using uniform intensive care, treatment and transplant protocols in LICU. Socio-demographic characteristics, clinical and biochemical parameters and scores were summarized and compared between 3 groups i.e. spontaneous survivors, transplanted patients and non-survivors. Predictors of spontaneous survival and the need for liver transplant are also evaluated. Results Nineteen patients with YPMP related ALF were about 32 years old (63.2% females) and presented to us at a median of 3 (0 – 10) days after poisoning. YPMP related cardiotoxicity was rapidly progressive and fatal whereas liver transplant was therapeutic for ALF. Spontaneous survivors had lower dose ingestion ( 6.5 had higher mortality risk. Patients undergoing liver transplant and with spontaneous recovery required longer ICU and hospital stay. At median follow-up of 3.4 (2.6 – 5.5) years, all spontaneous survivors and transplanted patients are well with normal liver function. Conclusions Early transfer to a specialized center, pre-emptive close monitoring, and intensive care and organ support with ventilation, CVVHDF, plasmapheresis and others may maximize their chances of spontaneous recovery, allow accurate prognostication and a timely liver transplant.

Background: spontaneous bacterial peritonitis (SBP) is a common complication in patients with cirrhosis and is associated with a high mortality rate. Only a few reports have analyzed the impact of treated SBP that occurs in the immediate pre-operative period on outcome after a living donor liver transplantation (LDLT). The results of whether post-transplant patients are dependent on pre-transplant infections are still debatable and unclear. Therefore, this study examined the outcomes of LDLT recipients with recent episodes of SBP and LDLT recipients without prior episodes of SBP. Patients: the records of 62 LDLT recipients who underwent LDLT were retrospectively reviewed. Twenty-four (36 %) recipients had at least one episode of SBP before LDLT. However, active SBP was not present in any of the recipients at the time of LDLT. Both recipient groups were compared in terms of demographic profile, perioperative and postoperative variables and outcomes. Results: higher pre-operative Child-Turcotte-Pugh (CTP) score (mean [SD] 11.77 [1.37] vs 10.5 [1.22], p < 0.001) and prior history of renal dysfunction (mean serum creatinine [SD] 1.715 [1.08] vs 1.02 [0.479] mg/dl, p = 0.002) were more commonly associated with the SBP group as compared to the non-SBP group. However, there was no statistically significant difference between the two groups in terms of the following variables: previous diabetes mellitus (3 [12.5 %] vs 6 [15.8 %]), pre-operative model for end-stage liver disease (MELD) score (median [IQR] 21 [10-37] vs 22 [9-39]), operative time (mean [SD] 789.57 [153.49] vs 800.86 [138.69] min), total number of blood transfusion (median [IQR] 10 [2-19] vs 8 [1-18]), hospital stay (median 21 vs 20 days), re-exploration (4 [16.6 %] vs 2 [5.3 %]), postoperative sepsis (8 [33 %] vs 5 [13 %]) and 30-day mortality (3 [12.5 %] vs 2 [5.3 %]). Conclusions: the presence of previous episodes of pre-operative SBP in LDLT recipients does not result in adverse post-operative short-term outcomes.

CONTEXT Access to information is crucial in decision making for viable and sustainable farm business. Thus, the farmers need different types of information from various sources to refine existing practices and adopt new technologies for yield and income advantages. Knowledge about farmers' information needs, access and its impact in different production contexts help in improving the effectiveness of extension and advisory services in the country. OBJECTIVE This paper examines the farmers' information needs, access to information from different sources and its impact on cotton output and value of output in two different regions having predominantly rainfed and irrigated production contexts. METHODS Household level survey data of 644 cotton farmers were collected using multistage sampling from two districts representing distinct production contexts in the Maharashtra state of India. Factors determining the access to information from particular sources were obtained using the Probit model. The impact of access to information was estimated using Inverse Probability Weighted Regression Adjustment (IPWRA). RESULTS AND CONCLUSIONS The information needs of the farmers from the two regions were slightly different. In the Jalgaon district with predominantly irrigated cotton production, farmers receiving information from at least one formal source had a significant positive impact on cotton output and the value of output per unit area. While considering each formal information source separately, heterogeneity in impact was observed. Access to information from public sources and mass media had a significant positive impact on cotton output. Mass media sources played a significant role in increasing the value of output per unit area. Despite government and other agencies' efforts and better access to information in predominantly rainfed areas (Yavatmal district), information received by farmers could not produce the desired impact. It necessitates appropriate tailoring of information, specific for these regions; as general information failed to produce much impact. SIGNIFICANCE This is a holistic study about information dynamics in agriculture, covering information need to its impact in two different cotton producing regions. The study reflects the heterogeneous impacts of access to agricultural information considering different sources. It suggests the importance of region specific customization of agricultural information and emphasizes more role of public sources in provision of market intelligence. Study advocates efforts to effectively channelize agro-advisories through Farmer Producer Organizations (FPOs) and Information Communications Technology (ICT) sources.

Background: Hemorrhoids are one of the most frequent diseases of the anal region with high prevalence involving all age groups. Multiple treatment options exist with none being perfect. Rubber band ligation of hemorrhoids is a non-operative treatment which can be performed on outpatient basis. Objective: The study was undertaken to determine efficacy of banding in treatment of Grade II and III hemorrhoids and to follow-up patients treated by banding to evaluate for symptomatic relief, recurrence and complications. Study design: A prospective, interventional study with clearance from the institutional ethics committee was undertaken over the period of 2 years in a tertiary referral center with a sample size of 60. Result: Out of 60 patients, 41 patients (68.30%) had Grade II and 19 patients (31.7%) had Grade III hemorrhoids. At first follow up, success rate for Grade II hemorrhoids was 85% (35/41) as compared to 21% (4/19) in Grade III. The unsuccessful 20 patients were re-banded, however only 2 of them responded to procedure. At the end of 6 weeks, 36 patients with Grade II hemorrhoids (88%) were cured. Failure rate was higher for Grade III hemorrhoids (68.42%, n = 13). Success rate was 86.6% for single hemorrhoid. There were no major complications. Anemia reverted significantly with successful band ligation. Conclusion: Rubber band ligation is a simple, safe and effective method for treating symptomatic second and third degree hemorrhoids as an outpatient procedure. It gives better results for Grade II and single hemorrhoids. Recurrence rate after successful band ligation is low. RESUMO Background: As hemorroidas são uma das doenças mais frequentes da região anal, com alta prevalência envolvendo todas as faixas etárias. Existem várias opções de tratamento, sendo que nenhuma é perfeita. A ligadura elástica de hemorroidas é um tratamento conservador que pode ser realizado em ambulatório. Objetivo: O estudo foi realizado para determinar a eficácia da ligadura no tratamento de hemorroidas de Grau II e III e para acompanhamento dos pacientes tratados por ligaduras para avaliar o alívio sintomático, a recorrência e as complicações. Design do estudo: Estudo prospectivo e intervencionista com liberação do comitê de ética institucional foi realizado durante o período de 2 anos em um centro de referência terciário com um tamanho de amostra de 60. Resultado: Dos 60 pacientes, 41 (68,30%) apresentaram hemorroidas de Grau II e 19 (31,7%) de Grau III. No primeiro seguimento, a taxa de sucesso para hemorroidas de grau II foi de 85% (35/41), em comparação com 21% (4/19) no Grau III. Os 20 pacientes sem sucesso foram novamente submetidos a ligadura, mas apenas 2 deles responderam ao procedimento. Ao final de 6 semanas, 36 pacientes com hemorroidas de Grau II (88%) foram curados. A taxa de falha foi maior para as hemorroidas de grau III (68,42%, n = 13). A taxa de sucesso foi de 86,6% para hemorroida única. Não houve grandes complicações. A anemia reverteu significativamente com ligadura elástica bem-sucedida. Conclusão: A ligadura elástica é um método simples, seguro e eficaz para o tratamento de hemorroidas sintomáticas de segundo e terceiro graus, como procedimento ambulatorial. Ela promove melhores resultados para hemorroidas de Grau II e únicas. A taxa de recorrência após ligadura elástica bem-sucedida é baixa.

Introduction Pure laparoscopic left lateral sectionectomy (LLS) is fast becoming the standard technique for donor hepatectomy in pediatric liver transplantation. We present the first case of pure laparoscopic LLS performed in Western India. Methods An 11-month-old male child suffering from biliary atresia with history of failed Kasai operation at the age of 3 months presented to our center in Mumbai for a living donor liver transplantation. The donor was his father, 32-year-old with body mass index of 22, LAI +10 and MRE fat fraction of 1%-3%. Projected graft weight of LLS was 187 grams with GRWR of 2.4. He had favorable vascular and biliary anatomy with left hepatic artery (LHA) arising from hepatic artery proper and segment 4 artery from LHA, type A portal vein and A1B1 biliary anatomy. Patient underwent pure laparoscopic LLS. Results The technique of pure laparoscopic LLS is demonstrated in the attached video. The graft warm ischemic time was 7 minutes, blood loss 300 mL and operating time 7 hours. The donor was discharged on 5th post-operative day with a minor post-operative bile leak that resolved spontaneously and is well at 1 month follow-up. Conclusions Pure laparoscopic living donor LLS is safe and should be performed by a team experienced in open donor hepatectomy, advanced laparoscopic surgery after specific training in the procedure and negotiating the learning curve under supervision. The operative time was long, but consistent with worldwide data for early cases, which we anticipate will reduce with more experience.

Introduction Liver grafts are often reduced for pediatric liver transplant in infants to accommodate them in the child's abdomen and avoid portal hypoperfusion. However, the most common technique of non-anatomical reduction does not reduce graft thickness. We describe the technique of anatomical segment 2 graft for liver transplant in an infant with acute liver failure. Methods A six-month-old child with acute liver failure required an emergency liver transplant in our unit. The child's mother was found medically suitable on pre-operative evaluation. However, the donor left lateral segment (LLS) was "blowfish" type with estimated GRWR of 3.5. The donor graft and recipient abdominal cavity measurements revealed that the donor's liver was too large for the child's abdominal cavity (distance from anterior abdominal wall to IVC-MHV-LHV confluence in the donor was 75 mm compared to 50 mm in the child). Results The dissection for LLS donor hepatectomy was performed using the standard technique followed by reducing segment 3 to obtain segment 2 graft, in-situ. The segment 3 pedicle was identified in the umbilical fissure and clamped. The ischemic plane was oblique, as demonstrated in the video, substantially reducing the graft thickness. Parenchymal transection was done using CUSA and the segment 3 pedicle and hepatic vein tributary were secured. The GRWR was 1.5 allowing good fit and primary closure of the child's abdomen. Post-operatively, the child had high transaminases (peak 2,000 IU/L) and high drain output (2.5 mL/kg/day) that settled down in a week. Conclusions The technique of anatomical mono-segment liver grafts is valuable for pediatric liver transplantation in.