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Auxiliary partial orthotopic liver transplant is a complex technique whereby a partial liver graft is transplanted in the orthotopic position, leaving behind a portion of the native liver. In acute liver failure, auxiliary partial orthotopic liver transplant serves as a rescue therapy and bridge for the native liver to regenerate. Auxiliary partial orthotopic liver transplant was initially considered a technically challenging procedure with inferior results versus orthotopic liver transplant. However, advancements in surgical techniques have led to improved results with auxiliary partial orthotopic liver transplant. Auxiliary partial orthotopic liver transplant is now increasingly accepted as a valid treatment option for acute liver failure. We present 2 cases of acute liver failure treated with auxiliary partial orthotopic liver transplant using an extra-small-for-size graft. The first case was a 12-year-old female patient who presented with druginduced acute liver failure and required an auxiliary partial orthotopic liver transplant with an extra-small left lobe graft (graft-to-recipient weight ratio of 0.45). The second case was a 23-year-old male patient with acute liver failure of unknown etiology who underwent an auxiliary partial orthotopic liver transplant with a small right lobe graft (graft-torecipient weight ratio of 0.5). In both cases, computed tomography liver volumetry was performed to determine the appropriate graft size for the recipient. Both patients underwent successful auxiliary partial orthotopic liver transplants, with good postoperative recovery. Follow-up examinations showed satisfactory liver function without evidence of graft failure or rejection. Auxiliary partial orthotopic liver transplant using extra-small grafts can be an effective treatment option for acute liver failure when no other suitable option exists, including as a rescue procedure for small grafts. However, careful patient selection and surgical planning are essential to ensure successful outcomes.

Background: Living donor liver transplantation in small infants is a significant challenge. Liver allografts from adults may be large in size. This is accompanied by problems of graft perfusion, dysfunction, and the inability to achieve primary closure of the abdomen. Monosegment grafts are a way to address these issues., Methods: Two recipients in our cohort weighed less then 6 kg. The prospective left lateral segments from their donors were large for size. Therefore, monosegment 2 liver grafts were harvested. Data regarding the preoperative, intraoperative, and postoperative events in the donor and the recipient were recorded., Results: We were able to achieve significant reduction in the sizes of the grafts harvested. The donors underwent surgery and hospital stay uneventfully. The recipients had normal graft perfusion and no graft dysfunction, and we could achieve primary abdominal closure. One recipient had self-limiting bile leak postoperatively., Conclusions: Monosegment 2 liver allografts are safe and effective for use in living donor liver transplantation in small infants weighing less than 6 kg., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Laparoscopic Heller's myotomy (LHM) and endoscopic balloon dilation are two main treatment modalities for achalasia cardia. The best treatment modality in Indian setting, however, is still unknown. Here, we present the early results of LHM in achalasia. Hospital data from January 2009 to October 2013 was analyzed. Preoperative assessment included Eckardt's scoring, esophagogastroduodenoscopy, barium swallow examination, and esophageal manometry. Thirty-five patients (19 males and 16 females, median age 31 years, range 12-65) underwent LHM with partial fundoplication (with intraoperative endoscopy). All patients had dysphagia (median duration 48 months, range 1-240), and eight (22.8 %) had chest pain. Four (11 %) patients had recurrent achalasia. Most of the patients (80 %) came from rural areas, and 68.5 % were ≤40 years of age. Fundoplication was added in all except four patients (megaesophagus in one, left lobe hepatomegaly in one, and postsurgical recurrent achalasia in two). The median operative time was 180 min (range 120-300). Intraoperative complications included esophageal mucosal injury ( n  = 2) and pleural breach ( n  = 3) with one conversion. The median postoperative stay was 7 days (range 4-27) with a morbidity of 5.7 % (leak in one and subphrenic collection in one patient) and a mortality of 1 % (due to myocardial infarction). After a median follow-up of 9.5 months (range 1-47 months), four (11.4 %) patients had recurrent dysphagia and three (8.5 %) had gastroesophageal reflux. Most of the patients (six of eight) had relief in chest pain. To conclude, predominance of rural, young, and male patients in this study suggests that LHM might be the first-line treatment for achalasia in developing countries like India where predominant population is still rural that prefers one-time treatment, though it needs to be compared with a newly described procedure per oral endoscopic myotomy (POEM).

Bleeding following restorative proctocolectomy for chronic ulcerative colitis is an uncommon complication. Usually bleeding occurs from the ileal pouch-anal anastomotic site in the early postoperative period. Significant pouch bleeding in the late postoperative course is rarely encountered. A mesenteric artery pseudoaneurysm along the ileal pouch staple line may be a cause of late-presenting massive per-rectal bleed. Although a rare phenomenon, it must be considered to be a differential in such a situation., Competing Interests: Conflicts of Interest: None declared., (2016 BMJ Publishing Group Ltd.)

Pancreatitis induced ruptured pseudoaneurysm (PSA) of the peri-pancreatic and splenic arteries may become a source of life-threatening hemorrhage. Its management is challenging and requires an individualized and multidisciplinary approach. The index case is a 32-year-old chronic alcoholic male presented with multiple episodes of hematemesis and melena. Pathological and imaging findings were consistent with anemia and acute pancreatitis with ruptured PSA of branch of splenic artery, portal cavernoma formation, and splenomegaly. Thrombosis of PSA sac, embolization of offending branch of splenic artery, and splenic infarction were successfully contemplated in a single session by direct percutaneous embolization with gelfoam and glue as embolic agents under guidance of duplex ultrasound imaging. We describe a modified sandwich embolization technique, its long-term success and complications of simultaneous management of ruptured PSA of branch of splenic artery and hypersplenism syndrome in limited resource scenario.