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Background The western recommendations for the use of organs from liver donors with tuberculosis (TB) come from an environment where the burden of disease is low and cadaveric organ donation rates are high—in complete contrast to the Indian scenario, where these recommendations may be too restrictive. Methods A questionnaire relating to current practice on the use of organs from liver donors with TB was sent to all liver transplant centres in India. Results Responses were obtained from 94% of centres. Two-thirds accepted organs from deceased donors with TB in the elective setting, especially for recipients with a high MELD (Model for end-stage liver disease) score. The proportion rose by 1.5 times in the setting of acute liver failure. Two-thirds advised anti-TB treatment (ATT) for corresponding recipients, and the remaining advised isonicotinic acid hydrazide (INH) prophylaxis. Untreated living donors with TB were not accepted. Half the respondents accepted living donors after completion of ATT, and did not treat recipients postoperatively. The remainder accepted them after 8 weeks of treatment and advised INH prophylaxis or ATT for recipients. Conclusions That this practice has not impacted recipient outcomes suggests that the guidelines for management of liver donors and recipients may need to be altered for populations endemic for TB.

Aim: To compare the outcomes of deceased donor liver transplantation (DDLT) using either the University of Wisconsin solution (UW) or the Institute Georges Lopez-1 (IGL-1) solution. Materials and Methods: Adult patients who underwent DDLT between November 2015 and March 2018 were included in the study. All patients received grafts from brain-dead donors. In 30 patients, the UW solution was used to preserve the liver and in 53 patients, the IGL-1 solution was used. The data of these two groups of the patients were analyzed and compared. Results: Between the two groups of patients, donor and recipient demographics and surgery-related variables were found to be similar. No difference was observed in the incidence of postreperfusion syndrome, number of days of hospitalization, and in the 30-day mortality. Early graft dysfunction was observed in 9 (16.98%) patients in the IGL-1 group and in 7 (23.33%) patients in the UW group (P = 0.48). One patient had primary nonfunction in each group. The postoperative levels of the liver transaminases were also not found to be significantly different. Conclusions: The efficacies of liver preservation by the IGL-1 and UW solutions were found to be comparable.

The pathogenesis of portal hypertension differs in patients with small for size syndrome (SFSS) after living donor liver transplantation (LDLT) and postoperative liver failure (POLF) after liver resection. This difference has important implications in the prevention and management of POLF.

Backgrounds/aims En-bloc vein resection (VR) for pancreatic ductal adenocarcinoma (PDAC) of the head of pancreas adherent to the portomesenteric axis benefits patients when the vein wall is not infiltrated by tumour and an R0 resection is achieved, albeit at the expense of greater morbidity and mortality. Methods A retrospective review of pancreaticoduodenectomy for PDAC over 6 years was conducted. Patients were divided into a standard resection group (Group SR) and simultaneous vein resection group (Group VR) and compared for outcome. Results The study group consisted of 41 patients (Group SR 15, Group VR 26). VR was performed by end-to-end reconstruction in 12 patients and with interposition grafts in 13 cases (autologous vein in 10, PTFE in 3). R1 resections occurred in 49% patients, with the superior mesenteric artery margin most commonly involved. Patients with Ishikawa grade III and IV vein involvement were more likely to carry a positive SMA margin (p=0.04). Involvement of the splenoportal junction was associated with a significantly greater risk of pancreatic transection margin involvement. No difference in morbidity was seen between the groups. Median survival in the entire group of patients was 17 months and did not vary significantly between the groups. The only significant predictor of survival was lymph node status. Conclusions Venous involvement by proximal PDAC is indicative of tumor location rather than tumor biology. VR improves outcomes in patients with tumor adhesion to the portomesenteric venous axis despite a high incidence of R1 resections and greater operative mortality.

Biliary complications (BCs) remain a significant cause of morbidity following liver transplantation (LT). This series of 640 LT recipients with a blend of living and deceased donor transplants was analyzed to determine the incidence, risk factors, management protocol, and outcomes in these patients. Review of a prospectively collected database of transplant recipients operated between August 2009 and June 2016 was performed. Patients were divided into those with and without BCs and data analyzed. The 640 LT recipients from both living (n = 481) and deceased donors (n = 159) were evaluated for BCs. The overall incidence of BCs was 13.7%. It reduced from 23% to 5% (P = 0.003) over a 6-year period. Risk factors for BCs on multivariate analysis were living donor liver transplantation, prolonged time to rearterialization, recipient age above 16 years, prolonged cold ischemia time (CIT) after deceased donor liver transplantation, and biliary reconstruction performed by anyone but the senior author. One-fifth of bile leaks progressed to strictures, and 40% of strictures followed leaks. Endoscopic therapy resolved 60% of the strictures. Surgical repair of strictures was successful in 90% of those in whom endoscopy failed, those who could not undertake the follow-up schedules endoscopic therapy entails, and those presenting with late strictures. BCs significantly prolonged hospital stay but did not alter survival after LT. BCs affect 1 in 7 recipients, although they are not associated with increased mortality. The frequency of these complications is influenced by potentially modifiable factors like evolving surgical expertise and CIT. Liver Transplantation 23 478-486 2017 AASLD.

HCC is the second most common malignant liver tumor of childhood. It typically affects children with a median age of 10-14 yr on background hepatitis B-related liver disease and is often metastatic or locally advanced at diagnosis. Children below the age of five yr typically constitute

Introduction Left-sided liver resection (LLR) for perihilar cholangiocarcinoma (PHC) may require right hepatic artery (RHA) resection and reconstruction because of its intimate relationship with the biliary confluence. Consequently right-sided resections (RLR) are preferred for Bismuth-Corlette IIIb tumours, and resections avoided in Bismuth-Corlette IV tumours with left lobar atrophy when the RHA is involved by tumour. Methods A retrospective analysis of patients with PHC who presented between December 2009 and June 2015. Results Thirty-six patients underwent resection for PHC (23 LLR, 13 RLR). The number of Bismuth-Corlette IV patients undergoing LLR was significantly greater than those undergoing RLR (8/23 vs 0/13, p = 0.032). The need for arterial reconstruction (AR) was significantly greater during LLR than RLR (10/23 vs 0/13, p = 0.006). Postoperative liver dysfunction was greater after RLR (5/13 vs 0/23, p = 0.003), and hospital stay was shorter after LLR (10 vs 15 days, p = 0.013). Conclusions Safe AR increases the ability to perform potentially curative LLR for PHC. This improves the resectability rate for PHC, particularly for Bismuth-Corlette Type IV tumours. The larger liver remnant after LLR results in less postoperative liver dysfunction and shorter hospital stay without increased operating time, blood loss or morbidity.

Recurrent HCV infection (rHCV) of the liver allograft following transplantation is universal and is associated with poor graft and patient survival in comparison with other indications. Treatment of rHCV infection in the previous era with pegylated interferon and ribavirin was associated with low sustained virological response (SVR) due to poor tolerability, adverse events and graft rejection. Recently, directly acting antiviral drugs (DAA) have been approved for the treatment of hepatitis C infection and a number of clinical trials have been conducted across various centers in the management of rHCV infection of the graft. In this review we discuss about recent studies that have emerged on the use of NS5b polymerase inhibitor, sofosbuvir in combination with second generation protease inhibitor, simeprevir, fixed dose ledipasvir or daclatasvir with or without ribavirin in the treatment of post transplant rHCV infection.

Background and aim Transarterial chemoembolization (TACE) or sorafenib is recommended for hepatocellular carcinoma BCLC stages B and C respectively. We studied the role of combination of TACE and sorafenib in BCLC stages B/C. Material and methods We undertook an observational study on a cohort of cirrhotics with HCC from August 2010 through October 2014. Patients in BCLC stages B/C who had received TACE and/or sorafenib were included. mRECIST criteria were used to assess tumor response. The primary end point was overall survival. Results Out of 124 patients, 47.6% were in BCLC-B and 52.4% in BCLCC. Baseline characteristics were comparable. The predominant etiology was cryptogenic (37.2% and 38.5%, p = NS). 49.1% in BCLC-B and 56.9% in BCLC-C had received TACE+sorafenib. In BCLC-B, the overall survival improved from 9 months (95% CI 6.3-11.7) using TACE only to 16 months (95% CI 12.9-19.1) using TACE+sorafenib (p l 0.05). In BCLC-C, addition of TACE to sorafenib improved the overall survival from 4 months (95%CI 3-5) to 9 months (95%CI 6.8-11.2) (p l 0.0001). As per mRECIST criteria, patients on TACE+sorafenib had reduced progressive disease (37.8% vs. 83.3%), improved partial response (43.2% vs. 3.3%) and one had complete response compared to those on sorafenib alone (p l 0.0001) in BCLC-C but not in BCLC-B group. Hand foot syndrome was noted in 27.7% patients on sorafenib and post TACE syndrome in 80.2% patients, but both were reversible. No major adverse events were noted. Conclusion TACE+sorafenib was more effective than TACE or sorafenib alone in HCC BCLC stages B or C with a significant survival benefit and improved tumour regression especially in BCLC-C patients.

G6PD deficiency (G6PDd) is the commonest genetic enzyme defect in the world. However, baring a single case report, there is no published literature regarding the safety of donor hepatectomy in G6PDd individuals.Potential donors with World Health Organization class III or class IV G6PDd without evidence of hemolysis were evaluated for donation, if there was no other suitable donor. Postoperatively, donors were closely monitored for hemolysis and medications, which can induce hemolysis, were avoided. Outcomes of our first 14 G6PDd donors are presented. Postoperative course of these donors was also compared with a matched cohort of 30 non-G6PDd donors.There were 9 left lateral segment, 2 left lobe, and 3 right lobe donors. Two G6PDd donors had biochemical evidence of postoperative hemolysis not needing any specific treatment. Postoperative liver function tests, intensive care unit stay, hospital stay, and morbidity (greater than Clavien II) were similar in the G6PDd and non-G6PDd donor cohorts. Donors in the G6PDd group had lower trough hemoglobin in postoperative period (P = 0.006), greater drop in postoperative hemoglobin (P = 0.007), and a higher need for postoperative blood transfusion (4/14 vs 2/30, P = 0.071).This is the first case series reporting the safety of liver resection in G6PDd individuals. Hepatectomy in G6PD-deficient donors is associated with a greater drop in postoperative hemoglobin and a marginally increased need for postoperative transfusion. Use of these donors can be considered with caution, and it should not be an absolute contraindication for live liver donation.

Background: Mycobacterium fortuitum is an uncommon cause of soft tissue infections. Treatment is often inadequate with persistence of infection unless the aetiological agent and its antibiotic sensitivity are accurately established. Methods: Medical records of 23 patients with chronic soft tissue infection caused by M. fortuitum over a 12-year period from 1991 to 2002 were studied. Results: In 20 patients the cause was iatrogenic, following intramuscular injections (12), laparoscopy (5) and other surgical procedures (3) and in three patients discharging sinuses developed spontaneously. Patients presented with recurrent abscesses or chronic discharging sinuses that did not respond to conventional surgical drainage. The diagnosis was established by isolating M. fortuitum from the tissues in all cases. The treatment consisted of a more aggressive surgical intervention in form of excision, debridement and extensive lay open with curettage and prolonged administration of appropriate antibiotics. The organism showed maximum sensitivity to amikacin and ciprofloxacin. Healing occurred in all cases. Three patients suffered recurrences: two responded to further debridement and antibiotics and are well at 2 and 5 years, respectively. Conclusion: A high index of suspicion based on clinical presentation is essential to diagnose M. fortuitum as a cause of soft tissue infection. Treatment involves aggressive surgical debridement and administration of combination antibiotics based on sensitivity, which should be continued for a period that will ensure complete healing and prevent recurrence.

Complete resection of primary liver tumours and selected liver metastases offers patients the best chance of cure or long-term survival although it puts them at risk of postoperative liver failure (PLF), which remains the commonest cause of death after major hepatectomy [1]. An insufficient future liver remnant (FLR) either in terms of volume or quality is the main determinant of PLF. Most surgeons would accept a FLR of 25–30 % in patients with a normal liver, and 40 % or more in patients with steatosis, fibrosis or cirrhosis [1].

Ante-situm liver resection under hypothermic total vascular exclusion is used to resect large tumours that involve the hepatic veins close to the vena cava or the cava itself. This procedure traditionally requires venovenous bypass when it is necessary to clamp the cava, or portocaval shunt when caval continuity is maintained by piggyback dissection of the liver. We present a technique of ante-situm liver resection, operating on one side of the liver at a time while maintaining prograde portal flow through the opposite side of the liver, thereby avoiding venovenous bypass, portacaval shunt and portal vein reconstruction.

Resection and reimplantation of the superior mesenteric artery (SMA) as part of a pancreaticoduodenal resection for cancer is rarely performed even in high-volume centers because of the risks inherent in this procedure and the perceived lack of oncological benefit associated with arterial resection during pancreaticoduodenectomy. The role of arterial resection during pancreaticoduodenectomy has recently been reevaluated, and this procedure may be of greater benefit than previously believed in selected patients. It also has a definite role when necessary to resect low-grade pancreatic and peripancreatic malignancies or to salvage intraoperative injury to the SMA. This small case series presents the authors experience with this procedure.

MDR3 is a hepatocyte canalicular membrane protein encoded by the ABCB4 gene located on chromosome 7. MDR3 mediates the translocation of phosphatidylcholine into bile. Severe MDR 3 deficiency typically presents during early childhood with chronic cholestasis evolving to cirrhosis and portal hypertension, requiring liver transplantation. Herein, we report a case of severe MDR3 deficiency in a male child diagnosed with negative MDR3 immunostaining in hepatic canaliculi who underwent LDLT at our centre. We also describe single incidentally detected early well-differentiated HCC in the explant liver. The patient is on regular follow-up and is doing well. Our report shows that MDR3 deficiency may be a risk factor for the development of HCC.

Despite progress in the field of liver surgery, centrally located tumors that involve the inferior vena cava or the hepatic veins adjacent to the vena cava are a technical challenge. These patients usually need to be operated upon under total vascular exclusion to prevent massive blood loss. The duration of vascular exclusion often exceeds the maximum permissible warm ischemia time tolerated by the liver, particularly when vascular reconstructions are necessary as part of the resection. The role of hypothermia as an adjunct to total vascular exclusion (TVE) was first introduced in 1974 but is used infrequently. A clearer understanding of this technique might allow clinicians to consider tumors in these awkward situations for resection. Additional techniques that may extend the benefits of hypothermic TVE are ante situm and ex vivo resections with autotransplantation. This review discusses the role of hypothermic TVE in the modern management of liver tumors.

Flexible aluminum panels of various thickness subjected to blast loads have been analyzed by different techniques; an equivalent single degree of freedom program using the DUHAMEL integration technique and a multiple‐degree‐of‐freedom finite element program. Panels of various thickness have been modeled as simply supported plates using equivalent beams with moment of inertia adjusted to account for the greater stiffness of plate action. Two dynamic load types were examined. The first type correctly depicts nonlinear blast loads. The second type, a triangular load, is a commonly employed approximation of nonlinear blast pressures. Comparisons of dynamic reduction factors for the structural response shows that the dynamic nature of blast loads reduce panel response significantly. Frequently used triangular pressure distribution for simulation of blast pressure, is found to be overly conservative. A better match is obtained by reducing the duration of triangular pressure pulse. An equivalent pulse duration i...

Pancreatic anastomotic dehiscence after pancreaticoduodenectomy (PD) remains a common problem. Although the management of this condition is mostly conservative, some patients require surgical intervention. This study reviews our experience with surgical intervention in this clinical setting. All patients who underwent PD by the author between 1999 and 2011 were reviewed. The causes for reoperation and mortality after PD were evaluated. The nature of the operative intervention and outcome in those who underwent reoperation for postoperative pancreatic fistula were analyzed. Reoperation was necessary in a total of 36/208 patients in this series and the overall mortality for the entire series was 6.25 % (13/208). Twelve of these 36 reoperations in 208 patients were for treatment of pancreatic anastomotic dehiscence after PD. Five (42 %) patients reoperated for anastomotic dehiscence died, including four of six patients that underwent surgical drainage of percutaneously inaccessible collections and one of two patients that underwent completion pancreatectomy. None of those who underwent salvage pancreaticogastrostomy (PG) died, nor did they require additional interventions prior to discharge from hospital. In our experience, salvage PG was an effective and organ function preserving technique to manage pancreatic anastomotic dehiscence after PD.

The need for routine use of preoperative biliary drainage (PBD) for major liver resection in jaundiced patients has recently been questioned.We present our experience of 22 consecutive patients with hilar biliary obstruction who underwent major liver resection without PBD between January 2007 and January 2011.Twenty-two patients with hilar biliary obstruction underwent major liver resection without PBD over a 4-year period; nineteen had malignant and 3 benign hilar strictures. Fifteen patients underwent right hepatectomy (7) or right trisectionectomy (8) and seven underwent left hepatectomy. Segment 4a was spared in all patients who underwent right trisectionectomy. Six patients had concomitant portal vein resection. Fourteen patients had varying degrees of lobar atrophy. The median preoperative bilirubin was 18 mg % (range 9.1 to 27 mg %). The median blood transfusion requirement was 2 units (range 1-6). There was one postoperative death from portal vein thrombosis. Three patients who underwent greater than 50 % resection developed postoperative ascites.Major liver resection leaving a liver remnant of 50 % is safe in jaundiced patients without PBD even when portal vein reconstruction is necessary. PBD should be used selectively.

Background. Choledochal cyst, a common surgical problem of childhood, can have a delayed presentation in adults. The clinical course in adults differs from that in children because of a higher incidence of associated hepatobiliary pathology. Methods. The clinical data of 57 adults with choledochal cyst managed in a general surgical unit between January 1988 and March 2003 were analysed. Results. The male:female ratio was 1:1.38 and the mean age was 34.5 years; 71.9% of the cysts belonged to Todani type I, 26.3% to type IV and 1.8% to type V. Abdominal pain and recurrent cholangitis were the commonest presentations followed by acute pancreatitis, palpable mass and bronchobiliary fistula. Anomalous pancreaticobiliary ductal junction was demonstrated in 14% of the cases. In all, 37% of the patients had undergone either wrong or suboptimal surgical procedures prior to presentation. All patients underwent complete excision of the cyst and hepaticojejunostomy. Two patients required cholangiojejunostomy and three patients required resection of the involved segments of the liver in addition. There were three anastomotic leaks and two postoperative deaths. Two anastomotic leaks resolved spontaneously while the third required surgical intervention. Forty-eight patients were available for follow-up and have remained symptom-free over a mean period of 17.6 months. Conclusions. Choledochal cyst should be considered in all patients below 40 years of age presenting with biliary colic, pancreatitis or recurrent cholangitis with associated dilatation of bile duct. Complete excision of the cyst with restoration of biliary–enteric communication by hepaticojejunostomy form the basis of ideal treatment.

With the increasing numbers of living-related donor liver transplantation, accurate means of calculating standard liver volume (SLV) based on patient body indices becomes important. Three formulae reported in literature for this purpose have been derived from studies on Western and Japanese populations.To assess the existing formulae for calculation of SLV in Indian population.Total liver volume (TLV) of 238 patients was measured using axial helical CT images obtained for conditions unrelated to the hepatobiliary system. Body surface area (BSA) was calculated from height and weight. Measurements obtained using CT were compared with the SLV calculated based on the previously reported formulae.Though there was significant difference (p0.001) between the TLV obtained by CT and the SLV calculated using the three formulae, they also showed good agreement. On an average the formula derived from the Japanese population underestimated the SLV by 63 (202) cc (p0.001). Regression models for SLV (SLV = 243 + [186 x BSA] + [11.4 x Weight], SLV = 375.23 + [14.24 x body weight], SLV = -204.092 + [874.461 x BSA]) were derived from the data obtained from our population. Age and gender had no effect on the SLV.Formulae derived from Japanese population for calculation of SLV is not suitable for the Indian population. The newly described formulae may prove useful in the Indian population.

This is a case report of a 29 year old woman who presented with painless and progressive obstructive jaundice. Imaging investigations of the abdomen revealed a tumour of the common bile duct. She was treated by complete excision of the bile duct and hepaticojejunostomy. The histopathology report of the tumour read as benign schwannoma.

A 70 year old man presented with retrosternal and epigastric pain. He was in shock. The diagnosis on admission was acute myocardial infarction. CT scan of the abdomen showed coeliac and superior mesenteric artery (SMA) occlusion. In addition there appeared to be large collateral from the inferior mesenteric artery (IMA) with a retroperitoneal collection. He underwent emergency laparotomy and a ruptured IMA aneurysm was detected. The aneurysm was excised and the IMA was ligated. He developed progressive multi-system organ failure post operatively. We discuss the aetiology, presentation, diagnosis and treatment of IMA aneurysms.

The prevention of postoperative liver failure after extended hepatectomy often requires preoperative intervention to induce hypertrophy in the future liver remnant. Portal vein embolization (PVE) is the most commonly used intervention, but 4–6 weeks are required to induce significant hypertrophy in the remnant liver.1 Hepatic vein embolization can provide further hypertrophy over 2–3 weeks if PVE is inadequate.2 Two-stage hepatectomy with the use of PVE or portal vein ligation is an alternative strategy with which to address the challenge of residual liver volume.3 In a recent German multicentre study, Schnitzbauer and colleagues used a modification of the two-stage hepatectomy, designated the ‘associated liver partition with portal vein ligation staged hepatectomy’ (ALPPS).4 This procedure requires liver parenchymal transection just to the right of the umbilical fissure with simultaneous right portal vein ligation during the first stage of the operation, followed about a week later by completion right trisectionectomy. The ALPPS procedure resulted in a median increase in volume of the left lateral segment of 74% within 9 days with necrosis of segment IV (Fig. 1), but was associated with postoperative bile leak in five and death in three of 25 patients.4 The precise role and value of ALPPS are yet to be determined. Figure 1 Operative photograph demonstrating massive hypertrophy of the left lateral segment and necrosis of segment IV at 8 days after stage 1 of the associated liver partition with portal vein ligation staged hepatectomy (ALPPS) procedure