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Introduction: Laparoscopic cholecystectomy (LC) in patients with extrahepatic portal vein obstruction causing portal cavernoma (PC) is considered high risk because of portosystemic collateral veins in the hepatocystic triangle. The literature is limited to isolated case reports. We describe our experience of LC in patients with PC. Patients and Methods: Data of patients with PC who underwent LC for symptomatic gallstones or related complications was reviewed. Patients with simultaneous cholecystectomy with splenorenal shunt and open cholecystectomy were excluded. Pre-operative evaluation consisted of complete blood count, international normalisation ratio and liver function tests, ultrasound of the abdomen with Doppler, contrast-enhanced computerised tomography, magnetic resonance cholangiopancreatography and esophagogastroscopy as indicated. A standard four-port LC was performed. The technical principles followed were to avoid injury to the collateral veins, liberal use of energy sources and division of dominant collateral veins between clips. Results: Seven adult patients including three females underwent LC. Three patients had thrombosis of previous surgical shunt with persistent PC. The remaining four patients did not have any indication for shunt surgery. Successful LC was performed in six patients. The median duration of surgery was 170 (130–250 min). Blood transfusion was not required. All the patients had uneventful post-operative recovery. The histopathology of gall bladder consists of acute cholecystitis in three patients and chronic cholecystitis in four. Conclusion: LC is feasible in patients with PC at a centre with experience in both laparoscopic and portal hypertension surgeries. Excellent outcome with low rate of conversion to open surgery can be achieved.

Biliary complications (BCs) following living donor liver transplantation (LDLT) can lead to significant morbidity and occasional mortality. The present study describes our experience of the all-knots-outside technique (AKOT) of biliary reconstruction (BR) and its impact on BCs. A retrospective analysis was performed using prospectively collected data of 330 consecutive adult patients undergoing LDLT from July 2011 to February 2018 with a minimal follow-up of 24 months. Only 2.8% required hepaticojejunostomy and were excluded. In an initial 122 patients, BR was performed with the standard technique (ST), and AKOT was performed in the subsequent 208 patients. In the AKOT group, a single anastomosis was attempted even for multiple ducts whenever feasible. A major BC was defined as requiring endoscopic, percutaneous, or surgical interventions. In the AKOT group, significantly more patients received a left lobe graft (5.7% versus 18.3%; P = 0.001), had shorter warm ischemia time (44.6 versus 27 minutes; P < 0.001), and had a left hepatic artery (LHA) in the right lobe that was used for arterial reconstruction (48 [39.3%] versus 122 [58.6%]; P = 0.003). The incidence of BCs in the entire cohort was 47 (14.2%). For the ST versus AKOT groups, the overall BCs (27/122 [22.1%] versus 20/208 [9.6%]; P = 0.003) and major BCs (20.5% versus 6.7%; P < 0.001) decreased significantly. In the multivariate analysis, the number of bile ducts (hazard ratio [HR], 4.18; 95% confidence interval [CI], 1.62-10.78; P = 0.003), number of anastomoses (HR, 2.03; 95% CI, 1.03-4.02; P = 0.04), and technique of anastomosis (HR, 0.36; 95% CI, 0.19-0.68; P = 0.002) predicted BCs. In conclusion, in adult LDLT, with standardization of the donor and recipient surgery, preferential use of LHA for right lobe arterial reconstruction, reduction in the number of anastomoses, and AKOT for BR significantly decreased the incidence of BCs.

MHV reconstruction is essential to avoid anterior sector congestion in adult live donor liver transplantation (LDLT) using a modified right lobe graft. The objective of this study is to evaluate the graft and patient outcomes with single orifice outflow reconstruction technique (SORT) (RHV + neo-MHV combined reconstruction on IVC) vs. dual outflow reconstruction technique (DORT) (RHV and neo-MHV separately reconstructed on IVC) in a modified right lobe LDLT. Prospectively collected data of consecutive patients undergoing LDLT from June 2011 to August 2018 were analyzed. The patients were divided into two groups: SORT (n = 207) and DORT (n = 108). The perioperative morbidity and mortality were compared between two groups. The two groups were comparable in baseline preoperative characteristics. Intraoperatively, warm ischemia time (27 vs. 45 min, p < 0.001), anhepatic phase (132 vs. 159 min, p < 0.001), and operative time (680 vs. 840 min, p < 0.001) were significantly shorter in SORT group. SORT group also had significantly lower GRWR (0.92 vs. 1.06, p < 0.001) and higher portal flow (2.4 vs. 2.7 L/min, p = 0.02). Postoperatively, SORT group had lower peak AST (177 vs. 209 IU/L, p < 0.001), ALT (163 vs. 189 IU/L, p = 0.004), creatinine levels (0.98 vs. 1.10, p = 0.01), rate of severe sepsis (13.7% vs. 22.9%, p = 0.03), major morbidity (50.7% vs. 62.6%, p = 0.03), shorter ICU (9 vs. 14 days, p < 0.001), and hospital stay (21 vs. 26 days, p = 0.03). Overall survival rates were comparable. A SORT leads to improved early graft function and perioperative morbidity in modified right lobe LDLT in spite of having lower GRWR and higher portal flow.

Background Accurate volumetric assessment of graft and remnant liver is essential in living donor liver transplantation (LDLT) for optimal clinical outcome in both donors and recipients. Recently, three-dimensional (3D) volumetry is proposed over conventional computed tomography (CT) volumetry to minimise errors. The aim of this study is to assess the correlation of estimated graft volume (EGV) by both the methods with actual graft weight (AGW). Methods One hundred fifty-four consecutive donors were enrolled prospectively. Conventional CT volumetry (semiautomatic) and 3D volumetry were performed using Myrian software. Total liver volume (TLV), EGV, and remnant liver volume (RLV) were assessed using both methods and correlated with intraoperatively measured AGW as the reference standard. Error of estimation was calculated accordingly. Results One hundred eighteen donors underwent right hepatectomy excluding middle hepatic vein (MHV), twenty-nine donors had left hepatectomy including MHV and six donors underwent left lateral sectionectomy. The median EGV on CT and 3D volumetry was 628.5 ml (140–1300) and 634.5 ml (156–1349), respectively. The median AGW was 647 gm (200–1004). Both CT and 3D volumetry showed strong correlation with AGW (correlation coefficients: 0.834 and 0.856, respectively). Linear correlation is as follows: (a) AGW = 99.75 + 0.818 × EGV (CT) and (b) AGW = 96.03 + 0.835 × EGV (3D). The mean percentage error for CT and 3D volumetry was 14.2 ± 12.5% and 12.2 ± 11.8%, respectively. The overall accuracy of estimation of EGV improved using 3D software (P=0.015). For the subgroup of types of graft, the difference did not reach statistical significance (P=0.062, 0.214 and 0.463 for right, left and left lateral grafts, respectively) Conclusion Both conventional CT and 3D volumetric methods strongly correlate with AGW in donors of LDLT, whereas overall accuracy of estimation of graft weight improved marginally by 3D volumetry.

Circumportal pancreas is a rare embryological anomaly where the dorsal and ventral pancreatic anlages are fused resulting in a band of pancreatic tissue encasing the portal vein. This can be easily missed if one is not aware of the entity. This report discusses the implication of finding this anomaly during pancreaticoduodenectomy, describes the existing classification system, management strategies to complete surgery safely, and reduce the incidence of postoperative pancreatic fistula.

Regeneration of the remnant liver in early postoperative period determines the outcome in live liver donors (LLDs). The aim of the current study is to evaluate the factors that influence liver regeneration following live donor hepatectomy. Total liver volume (TLV), estimated graft volume (EGV), and remnant liver volume (RLV) were calculated preoperatively in a prospective study of 154 LLDs. Absolute and percentage growth of remnant liver (regeneration index) in donor was estimated at 7th postoperative day (POD) by computed tomography (CT) volumetric analysis. One hundred eighteen donors underwent right hepatectomy (RH), 29 underwent left hepatectomy (LH), 6 donors had left lateral sectionectomy (LLS), and one had right posterior sectionectomy. The median percentage growth of remnant liver at the end of the first week was 46.14% (51.74%, 35.32%, and 17.38% for RH, LH, and LLS, respectively). On univariate analysis, female donors (p = 0.051), RH graft (p = 0.001), no steatosis on ultrasonography (p = 0.042), lower TLV (p = 0.029), RLV (p =

Background An ideal definition of early allograft dysfunction (EAD) after live donor liver transplantation (LDLT) remains elusive. The aim of the present study was to compare the diagnostic accuracies of existing EAD definitions, identify the predictors of early graft loss due to EAD, and formulate a new definition, estimating EAD-related mortality in LDLT recipients. Methods Consecutive adult patients undergoing elective LDLT were analyzed. Patients with technical (vascular, biliary) complications and biopsy-proven rejections were excluded. Results There were 19 deaths due to EAD of a total of 304 patients. On applying the existing definitions of EAD, we revealed their limitations of being either too broad with low specificity or too restrictive with low sensitivity in patients with LDLT. A new definition of EAD-LDLT (total bilirubin >10 mg/dL, international normalized ratio [INR] > 1.6 and serum urea >100 mg/dL, for five consecutive days after day 7) was derived after doing a multivariate analysis. In receiver operator characteristics analysis, an AUC for EAD-LDLT was 0.86. The calibration and internal cross-validation of the new model confirmed its predictability. Conclusion The new model of EAD-LDLT, based on total bilirubin >10 mg/dL, INR >1.6 and serum urea >100 mg/dL, for five consecutive days after day 7, has a better predictive value for mortality due to EAD in LDLT recipients.

Deceased donor liver transplant (DDLT) is an uncommon procedure in India. We present our experience of DDLT from a public sector teaching hospital. A retrospective analysis of all DDLT was performed from April 2012 till September 2016. Demographics, intraoperative, donor factors, morbidity, and outcome were analyzed. During the study period, 305 liver transplants were performed, of which 36 were DDLT (adult 32, pediatric 4; 35 grafts; 1 split). The median age was 42.5 (1–62) years; 78% were men. The median donor age was 28 (1–77) years; 72.2% were men. About 45% of organs were procured from outside of Delhi and 67% of all grafts used were marginal. Three of 38 liver grafts (7.8%) were rejected due to gross steatosis. Commonest indication was cryptogenic cirrhosis (19.4%). The median model for end-stage liver disease sodium and pediatric end-stage liver disease scores were 23.5 (9–40) and 14.5 (9–22), respectively. Median warm and cold ischemia times were 40 (23–56) and 396 (111–750) min, respectively. Major morbidity of grade III and above occurred in 63.8%. In hospital (90 days), mortality was 16.7% and there were two late deaths because of chronic rejection and biliary sepsis. The overall survival was 77.8% at median follow up of 8.6 (1–54) months. DDLT can be performed with increasing frequency and safety in a public sector hospital. The perioperative and long-term outcomes are acceptable despite the fact that most organs were extended criteria grafts.

Selection of appropriate donors after rigorous evaluation is of paramount importance in living-donor liver transplantation. Despite this, donor surgery may not proceed due to unforeseen reasons. The aim of this paper is to study reasons for “no go” donor hepatectomy in living liver donors. Donor operations stopped after surgical start, directly due to donor safety-related reasons, qualified for inclusion as “no go” donor hepatectomy. Living-donor evaluation was performed as per standard protocol. Data for consecutive living liver donors operated between April 2012 and November 2016 were analyzed to evaluate reasons for “no go” donor hepatectomy in a liver transplantation unit at a tertiary care teaching hospital. In 307 donors, the operation was aborted in 7 (2.3 %). One patient had unexpected biliary pathology with fibrosis found intraoperatively. Operations in five donors were abandoned in view of liver parenchymal abnormalities (fibrosis/steatohepatitis). One donor had hemodynamically significant bradycardia after handling the round ligament. All these donors recovered uneventfully and remained well on follow-up. “No go” donor hepatectomy remains a real possibility despite rigorous assessment. Although thresholds for on-table rejection of the donor after complete evaluation vary, “no go” hepatectomy is a calculated risk-avoidance approach.

Optimal management of large and locally advanced hepatocellular carcinoma (HCC) remains a clinical challenge especially in patients with chronic liver disease (CLD). We present our experience of major liver resection for large and locally advanced HCC. Prospectively collected data of patients with large and locally advanced HCC who underwent major liver resection between March 2011 and May 2015. The outcome measures of interest were the characteristics of tumor, surgical outcome, and overall as well as disease-free survival. Eighteen patients (14 male) with median age of 59 years (20 to 73 years) with good performance status underwent resection. Fifteen patients were in Child Pugh class A and three in class B. On contrast-enhanced computed tomography (CECT) scan, four patients had lobar/segmental portal vein involvement, two patients had bilobar disease, and one had biliary obstruction. Seven patients underwent extended resection (>5 segments), five right hepatectomy, two modified right hepatectomy, one modified right hepatectomy with wedge resection of segment six, two left hepatectomy, and one left lateral sectionectomy. On histopathology, 12 were solitary and six were multiple, the median tumor diameter was 9 cm (5–18 cm). All 18 patients had R0 resection. Eight patients had cirrhosis, six had fibrosis, and four had chronic hepatitis. Vascular invasion was noticed in 12 and out of these, six had large-vessel embolization. Morbidity according to Clavien-Dindo class was grades 1–11, grades 2–5, grade 3B-1, and grades 5–1. After a median follow-up of 32 months (6–54 months), the overall survival at 1 and 3 years was 83 and 54 %, respectively. The disease-free survival at 1 and 3 years was 75 and 54 % respectively. In carefully selected patients with large and locally advanced HCC, acceptable perioperative and medium term outcomes can be achieved with major liver resection.

This study aimed to evaluate the association of postoperative thrombocytopenia with outcome following adult living donor liver transplantation (LDLT) for end-stage liver disease (ESLD). It was a prospective study of 120 consecutive adult LDLT from September 2012 to May 2015. Preoperative platelet counts (PLTs) and postoperative PLTs were recorded at regular intervals till 3 months after LDLT. Univariate and multivariate analyses were performed. The median pretransplant PLT was 61 × 10(9) /l. The lowest median PLT after LDLT was observed on POD 3. Patients were stratified into low platelet group (n = 83) with PLT

Biliary complications after donor hepatectomy can result in significant morbidity. We herein present our experience of donor hepatectomy, highlighting surgical techniques that prevent complications. Data were reviewed from a prospectively maintained database of all donors who underwent hepatectomy from April 2011 to April 2015. Standard operative technique as described was followed in all patients. Biliary complications and morbidity were recorded and stratified as per Clavien-Dindo classification. Results were compared with published literature. During the study period, 160 donors underwent hepatectomy. The majority of the graft types were right hemiliver without the middle hepatic vein (71.9%). Major complications (grade III and above) occurred in 5.6% of the donors. There was no donor mortality. Only 1 out of the 160 donors (0.6%) has had a grade III biliary complication requiring endoscopic retrograde cholangiography and papillotomy. There were 3 grade II biliary complications, all occurring after left lateral sectionectomy, necessitating prolonged retention of the intra-abdominal drain. The median duration of hospital stay was 11 days (range, 5-67 days), and the duration of follow-up was 16 months (range, 3-52 months). There was no loss to follow-up, and no donor required readmission or outpatient procedures for any biliary complication. In conclusion, with careful donor selection and a standardized surgical technique, biliary complications can be minimized. Liver Transplantation 22 607-614 2016 AASLD.

BACKGROUND In live donor liver transplantation portal flush only of the graft is done on the bench. There are no data on antegrade arterial flush along with portal flush of the graft. METHODS Consecutive patients undergoing elective right lobe live donor liver transplantation were block-randomized to receive either portal flush only or both portal and antegrade arterial flush. The primary objectives were safety, rate of early allograft dysfunction (EAD), and impact on vascular and biliary complications. RESULTS After randomization, there were 40 patients in each group. Both groups had comparable preoperative, intraoperative, and donor variables. There were no adverse events related to arterial flushing. The portal and antegrade arterial flush group had significantly lower postoperative bilirubin on days 7, 14, and 21 (all P < 0.05), EAD (P = 0.005), intensive care unit/high dependency unit (P = 0.01), and hospital stay (P = 0.05). This group also had lower peak aspartate aminotransferase (P = 0.07), alanine aminotransferase (P = 0.06) and lower rates of sepsis (P = 0.08) trending toward statistical significance. Portal and antegrade arterial flush groups had lower ascitic fluid drainage and in-hospital mortality. Arterial and biliary complications were not statistically different in the 2 groups. Multivariate analysis of EAD showed portal with antegrade arterial flush was associated with lower rate (P = 0.007), whereas model for end-stage liver disease Na (P = 0.01) and donor age (P = 0.03) were associated with a higher rate of EAD. CONCLUSIONS Portal with antegrade arterial flushing of right lobe live liver grafts is safe, significantly decreases postoperative cholestasis, EAD, intensive care unit/high dependency unit, and hospital stay and is associated with lower rates of sepsis, ascitic drainage and inhospital mortality in comparison to portal flush only.

Neuroendocrine tumor metastases to the liver can mimic primary hepatocellular carcinoma (HCC) on imaging, cytology, and core biopsy. We present a case study along with the literature review of a patient who presented as a solitary liver mass mimicking HCC and subsequently underwent a partial hepatectomy. The histopathology and immunohistochemisrty of the resected specimen revealed metastatic neuroendocrine carcinoma. Positron emission tomography (PET) scan with 68 Ga-DOTA-NaI-octreotide ( 68 Ga-DOTANOC) localized the primary tumor in the ileum. A curative follow-up surgery for resection of the small bowel containing the primary tumor was carried out. This case illustrates the shortcomings of routine imaging methods, utility of immunocytochemistry and the importance of 68 Ga-DOTANOC PET in determining the metastatic spread as well as the origin of neuroendocrine tumors (NETs). This case report attempts to highlight the current imaging paradigms and management strategy of midgut and other NET's at the point of detection, staging and follow-up.

Background The aim of the study was to study the four week patency rates of the reconstructed neo middle hepatic vein specifically using the explant portal vein (PV) in right hemiliver live donor liver transplantation (LDLT). We hypothesized that short term patency of the neo-MHV should result in good graft and patient outcomes. Methods Pre, intra and post operative variables were prospectively collected for 88 consecutive patients undergoing right hemiliver LDLT from January 2014 to October 2015. Results Explant PV was used to reconstruct neo-MHV in 76 (86.4%, 76/88) patients. Neo MHV patency rate at 28 days with explant PV was 89.4% (59/66) and with other conduit (PTFE) was 90.9% (10/11). All occlusions were detected after 7 days. There was no impact of the patency of the neo-MHV on the incidence of early allograft dysfunction, sepsis, rejection, morbidity or mortality, despite the contribution of the anterior sector to the graft volume being more than 50% in close to two-thirds of patients. Conclusion The reconstructed neo-MHV has excellent short term patency rates at 4 weeks. Perhaps due to the absence of early occlusions, there was no impact on graft or patient outcomes in the study population.

Progressive multifocal leukoencephalopathy caused by polyoma JC virus is a rare and severe demyelinating disease of the central nervous system. It occurs in immunocompromised patients and is scarcely reported in liver transplant recipients. Brain biopsy demonstrating demyelination with presence of foamy macrophages, relative preservation of axons, astrogliosis, and typical polyomavirus inclusions in the enlarged oligodendroglial nuclei is essential for diagnosis. Here, we report a case of JC virus-associated progressive multifocal leukoencephalopathy in a living-donor liver transplant recipient who was transplanted for hepatitis C virus-related decompensated cirrhosis. Brain biopsy with immunohistochemistry confirmed the diagnosis of progressive multifocal leukoencephalopathy secondary to JC virus. JC virus related-progressive multifocal leukoencephalopathy is associated with extremely poor prognosis. Awareness and consideration of this entity in liver transplant recipients who present with sudden progressive neurologic manifestations can help in prompt diagnosis and timely treatment.

Extensive portomesenteric thrombosis presents a technical challenge in liver transplantation. Establishing portal inflow in living donor liver transplantation (LDLT) is indispensable to ensure regeneration of the graft. The use of a pericholedochal varix for inflow has been described only in a few case reports. Described herein is one such instance in the setting of LDLT, highlighting the nuances of this procedure in the light of available literature.

A thorough donor evaluation in the living donation process is mandatory to ensure a safe outcome in an otherwise healthy individual. The aim of the current study was to evaluate the reasons for not proceeding to donation and the outcome of live liver donors.A prospective study of potential donors who underwent evaluation and proceeded to surgery from 1 April 2012 to 31 January 2015 was conducted. The process of donor selection, its outcome and peri-operative complications were recorded.A total of 460 donors were evaluated in a stepwise manner for 367 potential recipients. Of the 321 (69.7 %) donors not proceeding to donation, the reasons were donor-related in 63.6 % and recipient-related in the rest. Common donor-related reasons were: donor reluctance (23.5 %), negative liver attenuation index (16.2 %), anatomic variations (10.3 %), inadequate remnant liver volume (9.8 %), unacceptable liver biopsy (8.8 %), and inadequate graft volume (5.4 %). A majority of donors (82.8 %) were turned down early in the (steps 1 and 2) evaluation process. Recipient death was the most common recipient-related reason [n = 51 (43.6 %)] for not proceeding to donation. There was no donor mortality. The overall complication rate was 19.8 % and major complication rate (grade 3 or higher) was 4.4 %.A stringent stepwise donor evaluation process leads to early recognition of unsuitable donors and a low complication rate.

Cytokines and growth factors have prominent roles in liver regeneration. The aim of this study was to evaluate the biological markers of liver regeneration in healthy donors undergoing right lobe donor hepatectomy for living donor liver transplantation. Twenty-five voluntary liver donors were enrolled. Peripheral blood samples were taken a day before the operation and on postoperative days (PODs) 1, 3, 7, 14, and 42. Levels of hepatocyte growth factor (HGF), interleukin (IL) 6, tumor necrosis factor α (TNF-α), thrombopoietin (TPO), transforming growth factor β1 (TGF-β1), interferon (IFN) α, and IFNγ were monitored. The remnant liver volume (RLV) before surgery and regeneration liver volume (RgV) on POD 14 were calculated on computed tomography (CT). RgV/RLV ratio was correlated with the remnant-liver-volume-to-body-weight ratio (RLVBWR). Inverse correlation was observed between RgV/RLV and RLVBWR (r(2) = 0.61; P < 0.001). There was a significant rise of HGF on POD 1 (P = 0.001), POD 7 (P = 0.049), and POD 14 (P = 0.04). TNF-α was elevated on POD 1 (P = 0.004). The levels of IL 6 (P < 0.001) and TPO (P < 0.001) were higher from POD 1 to POD 42. IFNα was higher on POD 14 (P = 0.003) and POD 42 (P = 0.001). There was a significant fall of IFNγ on POD 1 (P = 0.01) and increase on POD 14 (P = 0.04). The levels of TGF-β1 were higher on POD 14 (P = 0.008) and on POD 42 (P = 0.002). In conclusion, HGF, IL 6, TNF-α, and TPO are involved in the early phase, whereas TGF-β1 and IFN are involved in the termination phase of liver regeneration. Liver regeneration was observed to be higher in donors with low RLVBWR.