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Background In adult right lobe living donor liver transplantation (LDLT), venous drainage of the anterior sector is usually reconstructed on the bench to form a neo-middle hepatic vein (MHV). Reconstruction of the MHV for drainage of the anterior sector is crucial for optimal graft function. The conduits used for reconstruction include cryopreserved allografts, synthetic grafts, or the recipient portal vein. However, the ideal choice remains a matter of debate. This study compares the efficacy of the native recipient portal vein (RPV) with PTFE grafts for reconstruction of the neo-MHV. Methods Patients in this equivalence-controlled, parallel-group trial were randomized to either RPV (62 patients) or PTFE (60 patients) for use in the reconstruction of the neo-MHV. Primary endpoint was neo-MHV patency at 14 days and 90 days. Secondary outcomes included 90-day mortality and post-transplant parameters as scored by predefined scoring systems. Results There was no statistically significant difference in the incidence of neo-MHV thrombosis at 14 days (RPV 6.5 per cent versus PTFE 10 per cent; P = 0.701) and 90 days (RPV 14.5 per cent versus PTFE 18.3 per cent; P = 0.745) between the two groups. Irrespective of the type of graft used for reconstruction, 90-day all-cause and sepsis-specific mortality was significantly higher among patients who developed neo-MHV thrombosis. Neo-MHV thrombosis and sepsis were identified as risk factors for mortality on Cox proportional hazards analysis. No harms or unintended side effects were observed in either group. Conclusion In adult LDLT using modified right lobe graft, use of either PTFE or RPV for neo-MHV reconstruction resulted in similar early patency rates. Irrespective of the type of conduit used for reconstruction, neo-MHV thrombosis is a significant risk factor for mortality. Registration number CTRI/2018/11/016315 (www.ctri.nic.in).

Robotic right live donor hepatectomy (r-LDRH) has been reported with reduced morbidity compared to open donor right hepatectomy (o-LDRH) in few recent series. Nevertheless, its routine use is debated. We present a large series comparing pure r-LDRH with o-LDRH. Consecutive r-LDRH performed from June 2018 to June 2020 (n = 102) were compared with consecutive donors undergoing o-LDRH (n = 152) from February 2016 to February 2018, a period when r-LDRH was not available at this center. Propensity score matched (PSM) analysis of 89 case-control pairs was additionally performed. Primary endpoints were length of high dependency unit (HDU) and hospital stay and Clavien-Dindo graded complications among donors. Although r-LDRH took longer to perform (540 vs. 462 min, P .001), the postoperative peak transaminases levels (P .001), the length of HDU (3 vs. 4 days, P .001), and hospital stay (8 vs. 9 days, P .001) were lower in in donors undergoing r-LDRH. Clavien-Dindo graded complications were similar (16.67% in r-LDRH and 13.16% in o-LDRH). The rates of early allograft dysfunction (1.6% vs. 3.3%), bile leak (14.7% vs. 10.7%), and 1-year mortality (13.7% vs. 11.8%) were comparable between r-LDRH and o-LDRH recipients. PSM analysis yielded similar results between the groups. These data support the safety and feasibility of r-LDRH in select donors.

Background Corticosteroids are an integral part of immunosuppression following solid organ transplantation, despite their metabolic complications. We conducted a randomized trial to evaluate the efficacy of steroid-free immunosuppression following live donor liver transplantation (LDLT). Methods We randomized 104 patients stratified based on pre-transplant diabetic status to either a steroid-free arm (SF-arm) (Basiliximab + Tacrolimus and Azathioprine,n = 52) or Steroid arm (S-Arm) (Steroid + Tacrolimus + Azathioprine,n = 52). The primary endpoint was the occurrence of metabolic complications (new-onset diabetes after transplant (NODAT), new-onset systemic hypertension after transplant (NOSHT), post-transplant dyslipidemia) within 6 months after transplant. Secondary endpoints included biopsy-proven acute rejection (BPAR) within six months, patient and graft survival at 6 months. Results The incidence NODAT was significantly higher in S-arm at 3 months (64.5%vs. 28.1%,p-0.004) and 6 months (51.6% vs. 15.6%,p-0.006). Likewise, the incidence of NOSHT (27.8% vs. 4.8%,p-0.01) and hypertriglyceridemia (26.7% vs. 8%,p-0.03) at six months was significantly higher in S-arm. However, there were no differences in BPAR (19.2% vs. 21.2%, p-0.81), time to first rejection (58 vs. 53 days, p-0.78), patient and graft survival (610 vs. 554 days,p- 0.22). Conclusion Following LDLT, basiliximab induction with tacrolimus and azathioprine maintenance resulted in significantly lower metabolic complications compared to the triple-drug regimen of steroid, tacrolimus, and azathioprine.

The role of N-acetylcysteine (NAC) in improving outcomes following live donor liver transplantation (LDLT) is not well established. We designed a randomized double-blind placebo-controlled trial to study the role of NAC infusion in recipients undergoing LDLT. We assigned 150 patients who underwent LDLT by computer-generated random sequence on 1:1 ratio to either NAC group or placebo group. Patients in the NAC group received NAC infusion which was started at beginning of graft implantation at an initial loading dose of 150 mg/kg/h over 1 h, followed by 12.5 mg/kg/h for 4 h and then at 6.25 mg/kg/h continued for 91 h. Placebo group received normal saline. The primary endpoint was composite occurrence of acute kidney injury (AKI) and early allograft dysfunction (EAD) in the recipient. Secondary endpoints included levels of bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), creatinine, INR, primary graft non-function, intraoperative bleeding, post-transplant hospital stay and in-hospital mortality. The composite endpoint did not show any significant difference between the NAC and placebo group (21.3% vs 29.3%, p = 0.35). Peak AST (425.65 IU/L vs 702.24 IU/L, p = 0.02) and peak ALT (406.65 IU/L vs 677.99 IU/L, p = 0.01) levels were significantly lower in the study group. Time to normalization of transaminases was also significantly low in the study group. Perioperative NAC infusion following LDLT resulted in significantly lower postoperative AST and ALT levels. Rapid normalization of transaminases was also observed. This, however, did not translate to improvement in AKI or EAD.

Small bowel transplants are performed all over the world with acceptable success rates. Although there are isolated reports of small bowel transplants from India, a robust intestinal transplant programme similar to western countries is lacking. Our aim is to share our experience to build up on the evolving field of small bowel transplants in India. Deceased donor small bowel transplant was performed for three patients with intestinal failure, two for short gut syndrome following surgery and one for visceral myopathy. All were on preoperative total parenteral nutrition for varying periods of time (6 to 13 months). There were multiple episodes of line sepsis in all patients. Post-transplant, all received induction immunosuppression with anti-thymocyte globulin (first two patients) or alemtuzumab (3rd patient). All had systemic venous drainage and stoma. Protocol weekly intestinal biopsies were done in all patients. All died in hospital at 24, 12 and 28 days following surgery. Biopsy-proven rejection was observed in only patient who had received ABO-compatible non-identical graft (O to A). This patient subsequently developed vascular thrombosis necessitating explant of the graft. Sepsis due to multidrug resistant bacteria was the reason for mortality in the remaining two patients. Despite the absence of technical complications, successful small bowel transplant seems to be an elusive entity for the Indian transplant community.

Arboviral transmission through transplanted organs is rare. We report a highly probable case of dengue viral transmission during live donor liver transplantation. Fever with severe thrombocytopenia was observed in the donor and recipient within 6 and 9 days after transplantation, respectively. Dengue diagnosis was confirmed by testing blood and explant tissue from the donor and recipient using dengue-specific NAT (nucleic acid testing) and serology. Serology indicated the donor had secondary dengue infection that ran a mild course. However, the dengue illness in the recipient was severe and deteriorated rapidly, eventually proving fatal. The recipient's explant liver tissue tested negative for viral RNA indicative of a pretransplant naive status. The prM-Envelope gene sequence analysis of the donor and recipient viral RNA identified a similar serotype (DENV1) with almost 100% sequence identity in the envelope region. Molecular phylogenetic analysis of donor and recipient viral envelope sequences with regional and local dengue strains further confirmed their molecular similarity, suggesting a probable donor-to-recipient transmission via organ transplantation. Screening of living donors for dengue virus may be considered in endemic regions.

A significant percentage of the general population is diabetic. Diabetes mellitus can be managed with oral medication, insulin injections, or continuous infusion of insulin via an insulin pump. Despite significant improvement in the treatment of diabetes, there are still patients with long-lasting and poorly managed disease. Diabetes mellitus can lead to numerous complications, including nephropathy, coronary artery disease, peripheral vascular disease, heart failure, and autonomic and peripheral neuropathy. Pancreas transplantation, indicated mainly in patients with poorly controlled diabetes, characterized by hypoglycaemic unawareness and multiple hypoglycaemic episodes. The results of pancreatic transplantation are improving with increased operator experience, as well as improved donor graft quality, immunosuppression, surgical techniques, and perioperative care. The benefits of pancreatic transplantation include a reduced need for daily injections of insulin, and the stabilisation of complications such as nephropathy, autonomic and peripheral neuropathy, and atherosclerosis. A shortage of donors is the main obstacle to carrying out pancreatic transplantation surgery. In addition to transplantation of the pancreas, pancreatic islet cell transplantation may be performed. Although this procedure is performed mainly under local anaesthesia, the use of general anaesthesia is increasingly common. In this chapter, we will describe anaesthetic perioperative management for pancreatic transplantation.

BACKGROUND: In living donor liver transplantation (LDLT), graft-to-recipient weight ratio (GRWR) > 0.8% is perceived as the critical graft size. This lower limit of GRWR (0.8%) has been challenged over the last decade owing to the surgical refinements, especially related to inflow and outflow modulation techniques. Our aim was to compare the recipient outcome in small-for-size (GRWR 0.8) and to determine the risk factors for mortality when small-for-size grafts (SFSG) were used. METHODS: Data of 200 transplant recipients and their donors were analyzed over a period of two years. Routine practice of harvesting middle hepatic vein (MHV) or reconstructing anterior sectoral veins into neo-MHV was followed during LDLT. Outcomes were compared in terms of mortality, hospital stay, ICU stay, and occurrence of various complications such as functional small-for-size syndrome (F-SFSS), hepatic artery thrombosis (HAT), early allograft dysfunction (EAD), portal vein thrombosis (PVT), and postoperative sepsis. A multivariate analysis was also done to determine the risk factors for mortality in both the groups. RESULTS: Recipient and donor characteristics, intraoperative variables, and demographical data were comparable in both the groups (GRWR 0.8. CONCLUSION: Graft survival after LDLT using a small-for-size right lobe graft (GRWR

Background Portal hyperperfusion as a cause of small for size syndrome (SFSS) after living donor liver transplantation (LDLT) remains controversial. Portal venous pressure (PVP) is often measured indirectly and may be confounded by central venous pressure (CVP). Methods In 42 adult cirrhotics undergoing elective LDLT, PVP was measured by direct canulation of portal vein and porto systemic gradient (PSG) was obtained after subtracting CVP from PVP. None underwent portal inflow modulation. SFSS was looked in 27 patients after excluding 15 with technical complications. Results Clinical features of SFSS found in 6 patients, 5 with graft recipient weight ratio (GRWR)>0.8% and PVP 20mm of Hg (14.3% vs 0%, P =0.259) or PSG>13mm of Hg (33.3% vs 0%, P =0.111). Intensive care unit (ICU) stay was longer in patients with elevated PVP (14.55 vs 9.13 days, P =0.007) and PSG (16.8 vs 9.72 days, P =0.009). There was no difference in graft functions, post-operative complications and mortality in first month post-LDLT. Conclusion Elevated PVP or PSG increased morbidity but neither predicted SFSS nor affected survival.

BACKGROUND Recipient outcomes in adult living donor liver transplantation depend on various characteristics in both recipient and donor. We aimed to derive a score based upon preoperative characteristics in donor and recipient that could predict the recipient mortality in adult living donor liver transplantation. MATERIAL AND METHODS Retrospective data of 100 living donor liver transplantation recipients and their respective donors were analyzed for preoperative factors that correlated with recipient mortality. Statistically significant factors were weighted appropriately to derive a regression equation to obtain a donor-to-recipient match (DORMAT) score. This score was applied to 71 patients prospectively and their outcome was analyzed. RESULTS Donor-recipient match (DORMAT) score, derived using regression analysis of the significant variables was [0.002 (Recipient age) + 0.013 (Recipient BMI) + 0.055 (SBP) + 0.344 (HRS) + 0.022 (Pre-op culture positivity) + 0.01 (Donor age) - 0.639]×100. DORMAT score, when validated to a prospective cohort of 71 adult-to-adult LDLT patients, had a C-statistic (area under ROC curve) of 0.712. The mortality rate was seen to increase with increasing DORMAT score. CONCLUSIONS DORMAT score is a useful clinical decision-making tool to predict recipient mortality in adult living donor liver transplantation.

Successful biliary drainage in case of intraductal papillary mucinous neoplasm (IPMN) with thick mucus by ERCP and internal drainage alone is usually inadequate. The mucolytic properties of acetylcysteine can offer a therapeutic benefit in this setting. We report a 50-year-old man with chronic pancreatitis and IPMN who had recurrent episodes of biliary obstruction due to mucous occlusion, despite multiple stent exchanges. A nasobiliary catheter was placed and infusion of acetylcysteine was performed which resulted in significant improvement of jaundice. He later underwent surgery after nutritional rehabilitation. This case report highlights the role of intrabiliary acetylcysteine infusions for mucous occlusions in IPMN.

Background Pancreatic cystic neoplasms remain uncommon. Although data are accumulating on the incidence of pancreatic cystic neoplasms in the published literature, Indian data on these tumors are sparse. Material and Methods We collated data from prospectively maintained databases of patients operated for cystic tumors of the pancreas from 2007 to 2016 at 7 academic centers across India to gain insights into clinical presentation and outcome of the operative treatment of these tumors. Data were compared with large series across the world to understand the regional differences in this pathology. Results Of the 423 patients, there were 98 (23.2%) serous cystic neoplasms, 128 (30.2%) mucinous neoplasms, 34(8%) intraductal papillary mucinous neoplasms, and 121 (28.6%) solid pseudopapillary epithelial neoplasms managed in these 7 academic centers. Malignancy (adenocarcinoma, malignant intraductal papillary mucinous neoplasms, and mucinous cystadenocarcinoma) was reported in 39 (9.2%) patients. Median age at presentation was 41 years, and the female-to-male ratio was 3.4:1. At presentation, 81% of patients were symptomatic. A total of 66.7% of lesions were located in body and tail region of the pancreas. Median tumor size was 6 cm. Operative resection with curative intent was performed in 405 of these 423 patients. Major morbidity occurred in 12%, and 30-day perioperative mortality was 0.9%. Laparoscopic resections were performed in 18% and spleen-preserving resections were performed in 3% of patients. Conclusion Female preponderance, young age, and a benign nature of most pancreatic cystic neoplasms were observed. Large size of tumors on presentation, fewer intraductal papillary mucinous neoplasm resections, and a much greater incidence of solid pseudopapillary epithelial neoplasms were distinctive of this study. Although the proportion of laparoscopic resections and splenic preservation was less compared with Western centers, the perioperative morbidity and mortality was on par with established standards.

Traditionally, deceased donor liver grafts receive dual perfusion (DP) through the portal vein and the hepatic artery (HA) either in situ or on the back table. HA perfusion is avoided in living donor liver grafts for fear of damage to the intima and consequent risk of hepatic artery thrombosis (HAT). However, biliary vasculature is predominantly derived from the HA. We hypothesized that antegrade perfusion of the HA in addition to the portal vein on the back table could reduce the incidence of postoperative biliary complications. Consecutive adult patients undergoing living donor liver transplantations were randomized after donor hepatectomy to receive graft perfusion of histidine-tryptophan-ketoglutarate solution either via both the HA and portal vein (DP group, n = 62) or only through the portal vein (standard perfusion [SP] group, n = 62). The primary endpoint was the occurrence of biliary complications (biliary leak/stricture). Secondary endpoints included HAT and patient survival. The incidence of biliary stricture was significantly lower in the DP group (6.5% versus 19.4%; odds ratio, 0.29; 95% confidence interval, 0.09-0.95; P = 0.04). There was no significant reduction in the incidence of HAT, bile leak, or hospital stay between the 2 groups. The 3-year mortality and graft survival rates were significantly higher among patients who received DP compared with SP (P = 0.004 and P = 0.003, respectively). On multivariate analysis, nonperfusion of the HA and preceding bile leak were found to be risk factors for the development of biliary stricture (P = 0.04 and P < 0.001, respectively). In conclusion, DP of living donor liver grafts through both the HA and portal vein on the back table may protect against the development of biliary stricture. This could translate to improved patient survival in the short term.

Despite advances in the practice of living donor liver transplantation (LDLT), the optimum surgical approach with respect to the middle hepatic vein (MHV) in right lobe LDLT remains undefined. We designed a randomized trial to compare the early postoperative outcomes in recipients and donors between extended right lobe grafts (ERGs; transection plane was maintained to the left of MHV and division of MHV performed beyond the segment VIII vein) and modified right lobe grafts (MRGs; transection plane was maintained to the right of MHV; the segment V and VIII drainage was reconstructed using a conduit of recipient portal vein). Eligible patients (n = 86) were prospectively randomized into the ERG arm (n = 43) and the MRG arm (n = 43) at the beginning of donor hepatectomy. The primary endpoint considered in this equivalence trial was patency of the MHV or the reconstructed "neo-MHV" in the recipient. The secondary endpoints included biochemical parameters, postoperative complications, mortality in recipients as well as donors and volume regeneration of remnant liver in donors, measured at 2 months. The patency of the MHV was comparable in the ERG and MRG arms (90.7% versus 81.4%; difference, 9.3%; 95% confidence interval [CI], -5.8 to 24.4; z score, 1.245; P = 0.21). Volume regeneration of the remnant liver in donors was significantly better in the MRG arm (111.3% versus 87.3%; mean difference, 24%; 95% CI, 14.6-33.3; P < 0.001). The remaining secondary endpoints in donors and recipients were similar between the 2 arms. To conclude, MRG with reconstructed neo-MHV has comparable patency to native MHV in ERG and confers equivalent graft outflow in the recipient. Furthermore, it allows better remnant liver regeneration in the donor at 2 months. Liver Transplantation 24 888-896 2018 AASLD.

Introduction In live donor liver transplantation (LDLT), bile duct division is a critical step in donor hepatectomy. Biliary complications hence are a feared sequelae even among donors. Long term data on biliary complications in donors from India are sparse. Methods Prospective evaluation of 452 live donors over 10 years was performed to ascertain the incidence & risk factors of clinically significant biliary complications. Results Of the 452 donor hepatectomies (M: F = 114:338, median age = 38), 66.2% (299) were extended right lobe grafts, 24.1% (109) modified right lobe and 9.7% (44) were left lobe grafts. Portal vein anatomy was Type-I in 85% (386), Type-II in 7.5% (34) and Type-III in 7.1% (32). Following donor hepatectomy, a single bile duct opening occurred only in 46.5% (210) of the grafts. Of the remaining 53.5% grafts, 2 ductal openings were noted in 217 (48%) and three ductal openings in 25 (5.5%). Incidence of multiple openings in the duct were more commonly noted in Type II (70.6%) and III (75%) portal vein anatomy than in grafts with Type I (50.4%) portal anatomy ( P = 0.001) Bile leak was noted in 15 (3.3%) donors which included one broncho-biliary fistula and bilio-pleural fistula. Analysis revealed no association between post-operative biliary complications and type of graft, portal vein anatomy or biliary anatomy. There was a single mortality in this series secondary to biliary sepsis. On long term follow, there were no biliary strictures in any of the patients. Conclusions Biliary complications although rare (3.3%), present significant peri-operative morbidity to the donors.

Cystic artery pseudoaneurysm is a rare pathology. Of the 20 cases reported so far, chronic cholecystitis and iatrogenic biliary injury form the majority of causes. Currently, there is no published report of such pseudoaneurysms caused secondary to pancreatitis, hence the management in such a scenario is unclear. We hereby present the first such report of cystic artery pseudoaneurysm occurring as a sequel of acute necrotising pancreatitis. A 33-year-old man who recovered from a recent attack of acute pancreatitis was readmitted for melena and fever. Computed tomography of abdomen revealed blood in the gall bladder with pericholecystic blush and resolving pancreatic necrosis. Percutaneous transarterial embolisation of the cystic artery was done. This stabilised the patient but persistent sepsis and clinical deterioration warranted a surgical exploration and cholecystostomy. Hence, transarterial embolisation followed by surgery in selected cases can be an ideal management protocol.

Although morbidity following living liver donation is well characterized, there is sparse data regarding health-related quality of life (HRQOL) of donors. HRQOL of 200 consecutive live liver donors from 2011–2014 performed at an Indian center were prospectively collected using the SF-36 version 2, 1 year after surgery. The effect of donor demographics, operative details, post-operative complications (Clavien-Dindo and 50-50 criteria), and recipient mortality on the quality-of-life (QOL) scoring was analyzed. Among 200 donors (female/male=141:59), 77 (38.5%) had complications (14.5%, 16.5%, 4.5%, and 3.5%, Clavien-Dindo grades I–IV, respectively). The physical composite score (PCS) of donors 1 year after surgery was less than ideal (48.75±9.5) while the mental composite score (MCS) was good (53.37±6.16). Recipient death was the only factor that showed a statistically significant correlation with both PCS (p

Antitubercular therapy (ATT)-induced hepatotoxicity is often over looked and active tuberculosis is considered a contraindication for liver transplantation, however it might be the only lifesaving option to certain patients of acute liver failure (ALF) due to ATT. We have assessed the outcome of live donor liver transplantation in ATT-induced ALF. A retrospective analysis of all the cases of ALF that underwent liver transplantation from 2006 to 2014 at the Amrita Institute of Medical Sciences was done. A total of seven (7.7%) patients with ATT-induced ALF who had underwent live donor liver transplantation were included in the study. Out of seven patients, three (42.8%) had established diagnosis of tuberculosis and the remaining (58.2%) patients were started on ATT empirically. The median duration of ATT intake was 2 months. All the patients underwent live donor liver transplant as they met King's College criteria, and their model for end-stage liver disease score was above 35 on admission, receiving graft from first degree relatives. Histopathology of explant liver showed pan acinar necrosis. Restarting of ATT after transplant was individualized. It was restarted only in two (28%) patients with prior sputum-positive pulmonary tuberculosis after a median time of 27 days after transplant. ATT was not restarted in rest of the (72%) patients. Postoperative mortality was seen in two (28%) patients due to conditions that masquerade the ATT-induced acute liver failure. The overall survival rate was 71.4% with a median follow up of 22 months. Live donor-related transplantation is feasible option in ATT-induced acute liver failure. Restarting of ATT post liver transplant is feasible and should be individualized along with frequent monitoring of immunosuppressant levels; however, if the primary diagnosis of tuberculosis was empirical, reintroduction of ATT can be omitted.

Zinc phosphide (ZnP) containing rodenticide poisoning is a recognized cause of acute liver failure (ALF) in India. When standard conservative measures fail, the sole option is liver transplantation. Records of 41 patients admitted to a single centre with ZnP-induced ALF were reviewed to identify prognostic indicators for requirement of liver transplantation. Patients were analyzed in two groups: group I (n = 22) consisted of patients who either underwent a liver transplant (n = 14) or died without a transplant (n = 8); group II (n = 19) comprised those who survived without liver transplantation. International normalized ratio (INR) in group I was 9 compared to 3 in group II (p

Adult-to-adult living donor liver transplant (LDLT) frequently depend on using the right-lobes of the donor for obtaining adequate graft-to-recipient weight ratio (GRWR) of over 0.8% in the recipient. However, left-lobes remain an important option in adults, since the morbidity in the donor is considerably less with left donor hepatectomy when compared with right side liver resection. Further benefits of left-lobes in LDLT include more predictable anatomy of the left hepatic duct and left portal vein, which are usually long and single resulting in easier anastomosis in the recipient. Likewise, left-lobe grafts are easier to implant with an excellent venous outflow through the combined orifice of left and middle hepatic vein, as opposed to the complex hepatic vein reconstruction required in right-lobe grafts. However, left hepatic artery is often multiple unlike the right hepatic artery. The holy grail of left-lobe transplants is avoidance of small for size syndrome (SFSS) in the recipients. The strategies for overcoming SFSS currently depend on circumventing portal hyperperfusion in the graft. Measurement of portal pressure and modulating it if high, by splenic artery ligation, splenectomy, or hemiportocaval shunts are proving successful in avoiding SFSS. The future aim in adult LDLT should be to use the left-lobe as much as possible for the benefit of the donor at the same time avoiding SFSS even at very low GRWR for the benefit of the recipient.