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Coronavirus disease (COVID-19) vaccine and its utility in solid organ transplantation (SOT) needs to be revised timely and updated. These guidelines have been formalized by the experts -the apex technical committee members of the National Organ and Tissue Transplant Organization (NOTTO), and the heads of transplant societies for the guidance of transplant communities. In our general recommendations, we recommend that all personnel involved in organ transplantation should get vaccinated as early as possible and continue COVID-19 appropriate behaviour, despite a full course of vaccination. For specific guidelines of recipients, we suggest completing the full schedule before transplantation whenever the clinical condition permits. We also suggest a single dose, rather than proceeding unvaccinated for transplant, in case a complete course is not feasible. In case, vaccination is planned before surgery, we recommend a gap of at least 2 weeks between the last dose of vaccine and surgery. For those not vaccinated prior to transplant, we suggest waiting for 4-12 weeks after transplant. For the potential living donors, we recommend the complete vaccination schedule before transplant. However, if not feasible, we suggest getting at least a single dose of vaccine, 2 weeks prior to donation. We suggest that suitable transplant patients and those on the waiting list should accept a third dose of the vaccine when one is offered to them. In the context of Vaccine-induced thrombotic thrombocytopenia (VITT), we recommend organs from a deceased donor with suspected/proven VITT should be notified and best avoided and are justified only in case of emergency situations with informed consent and counselling.

Purpose: To understand the actual impact of the Covid-19 pandemic and frame the future strategies, we conducted a pan India survey to study the impact on the surgical management of gastrointestinal cancers.Methods: A national multicentre survey in the form of a questionnaire from 16 tertiary care gastrointestinal oncology centres across India was conducted from January 2019 to June 2021 that was divided into a 15-month pre-Covid era and a similar period of active Covid pandemic era.Results: There was significant disruption of services; 13 (81%) centres worked as dedicated Covid care centres and 43% reported suspension of essential care for more than 6 months. In active Covid phase there was a 14.5% decrease in registrations and proportion of decrease was highest in the centres from South zone (22%). There was decrease in resections across all organ systems; maximum reduction was noted in hepatic resections (33%) followed by esophageal and gastric resections (31 and 25% respectively). There was minimal decrease in colorectal resections (5%). A total of 584 (7.1%) patients had either active Covid-19 infection or developed infection in the post-operative period or had recovered from Covid-19 infection. Only 3(18%) centres reported higher morbidity, while rest of the centres reported similar or lower morbidity rates when compared to pre-Covid phase; however 6 (37%) centres reported slightly higher mortality in the active Covid phase.Conclusion: Covid -19 pandemic resulted in significant reduction is new cancer registrations and elective gastrointestinal cancer surgeries. Perioperative morbidity remained similar despite 7.1% perioperative Covid -19 exposure.

Deterioration of kidney function is the most worrisome long term complication following liver transplantation. This study was performed to identify the risk factors of renal dysfunction following living donor liver transplant and the effect of immunosuppressant dosage adjustment on the recovery of renal function. A retrospective observational study was conducted on 133 consecutive adult living donor liver transplant recipients over an 8 year period from 2006 onwards. An increase in serum creatinine of >1.4 mg/dl was taken as a marker for renal insufficiency. The incidence of post living donor liver transplant renal dysfunction was 35% and maximum incidence occurred at one year of liver transplantation. Male gender, pretransplant diabetes, hepatorenal syndrome, posttransplant hypertension, bilirubin >1.2 mg/dl, albumin 1.4 mg/dl and tacrolimus trough level >7mcg/l at 3rd month of liver transplantation were significant risk factors for the development of renal dysfunction. Reduction of tacrolimus dosage was the most effective intervention to restore renal function. This however resulted in abnormal liver function tests secondary to rejection and necessitated the addition of alternative non-nephrotoxic immunosuppressants. Two and four year survival rates were 98.9% and 96.6% for patients without renal dysfunction compared to 97.4% and 91.6% for those complicated by renal dysfunction after living donor liver transplant. Maintaining lower levels of tacrolimus along with addition of non-nephrotoxic immunosuppressants may be a worthwhile strategy to protect the kidneys and preserve long term graft function in patients at high risk of post living donor liver transplant renal dysfunction.

Background One possible aetiology of pancreatitis following endoscopic retrograde cholangio pancreatography (ERCP) is cannulation-induced spasm of the sphincter of Oddi and consequent pancreatic duct obstruction. Sublingual glyceryl trinitrate (GTN) has been shown to produce periampullary sphincter relaxation. The aim of this study was to determine whether prophylactic long-acting GTN could reduce the incidence of ERCP-induced pancreatitis. Methods In a randomized double-blind study, prophylactic treatment with GTN (2 mg given sublingually 5 min before endoscopy) was compared with placebo in 186 patients who presented for elective ERCP. The primary endpoint was the occurrence of pancreatitis within 24 h, defined as a serum amylase concentration greater than 1000 units/ml in association with a visual analogue pain score of more than 5. Results The incidence of pancreatitis was lower in the GTN group compared with placebo (seven of 90 versus 17 of 96; P < 0·05). Mean serum amylase values were similar in the two groups. The protective effect of GTN appears to be highest in the diagnostic ERCP group (one of 54 versus ten of 66; P = 0·012) and in the group in which cholangiography alone was performed (one of 54 versus eight of 57; P = 0·032). Conclusion Prophylactic treatment with GTN reduces the incidence of pancreatitis following ERCP but does not seem to reduce the extent of hyperamylasaemia or the severity of pancreatitis.

Editor—Does the result of Wilson et al's trial from a district general hospital justify routine preoperative administration of inotropes and fluids to all patients having major elective surgery?1 Detailed mortality data, in particular on the cause of death, are lacking in their results, surprisingly. The morbidity data show that there was a significantly increased rate of surgical complications in the control group compared with the study group (seven of the 46 patients in the control group developed surgical complications (four cases of anastomotic breakdown and three of deep haemorrhage) compared with four of the 92 in the study group (all cases of deep haemorrhage); P=0.04). If any of these surgical complications were the direct cause of death in the controls then the effectiveness of the preoperative regimen in the study group in reducing mortality becomes ambiguous. This would be particularly pertinent with regard to the two late deaths in the control group, since these deaths are unlikely to have been due to inadequate preoperative optimisation of oxygen delivery. The use of 4.5% albumin and of red cell transfusion below a blanket threshold haemoglobin concentration of 110 g/l is a controversial issue.2–4