Dronacharya Routh

Changing Pattern of Donor Selection Criteria in Deceased Donor Liver Transplant: A Review of Literature

During the last couple of decades, with standardization and progress in surgical techniques, immunosuppression and post liver transplantation patient care, the outcome of liver transplantation has been optimized. However, the principal limitation of transplantation remains access to an allograft. The number of patients who could derive benefit from liver transplantation markedly exceeds the number of available deceased donors. The large gap between the growing list of patients waiting for liver transplantation and the scarcity of donor organs has fueled efforts to maximize existing donor pool and identify new avenues. This article reviews the changing pattern of donor for liver transplantation using grafts from extended criteria donors (elderly donors, steatotic donors, donors with malignancies, donors with viral hepatitis), donation after cardiac death, use of partial grafts (split liver grafts) and other suboptimal donors (hypernatremia, infections, hypotension and inotropic support).

Donor outcome in live-related liver transplantation

BACKGROUND Live donor liver transplant has become an accepted, effective and lifesaving alternative to deceased donor transplant. The effect on donor and his safety remains a cause of concern. The donors are all in productive age and in our setting may have to go back to active service. This study is aimed at knowing the results of donor hepatectomies at our centre. METHODS Data of all donor hepatectomies done at our centre from Apr 2007 to Jun 2013 reviewed. This included the preoperative workup, operative details and postoperative follow-up. RESULTS 35 Donors of age between 20 and 50 years were taken up for procedure of which one was abandoned due to haemodynamic instability after intubation. In the 34 procedures done the percentage of the residual liver was at least 30%. No donor required blood transfusion. The overall complication rate was 26.5% which was stratified according to the modified Clavien classification of postoperative complications. There was transient rise of bilirubin and liver enzymes in all which returned back to normal with time. Infections were the most common cause of complication. All the donors had gone back to their work after a mean of 42 days after surgery. All donors were willing to donate again if needed. CONCLUSION Living donor liver transplant a widely practiced modality for end-stage liver disease. It is a safe procedure with good recovery and results. Our study shows that meticulous selection criteria and strict adherence to protocols leads to good outcome.

Simplifying minilap cholecystectomy.

Three to five centimeter midline incision is made (Fig. 1) and the peritoneal cavity is entered to the right of falciform ligament. Air is allowed to enter the supra-hepatic space to facilitate manipulation of liver/gallbladder. Gallbladder fundus is held up and an abdominal swab is pushed into the wound (Fig. 1). With the bladder retractor and tongue depressor in place, Hartmann’s pouch is pulled upward and laterally whilst the fundus is swept under the abdominal wall, away from operation site, to expose the Calot’s triangle optimally (Fig. 2). Two ligatures each, around cystic duct and artery, are tied sufficiently apart using fingers (Fig. 3). When space restricts tying sutures apart, then solitary ligatures are tied individually around cystic duct and artery. Hartmann’s pouch is then released and fundus is pulled back into operating field (Fig. 4). Gallbladder is sharply dissected off liver and excised by cutting between the ligatures (Figs. 4 and 5). When cystic duct and artery are secured using solitary ligatures, the gallbladder is excised by clamping its neck and cutting between the clamp and ligatures.

Primary non seminomatous germ cell tumour with liver metastasis

IntroductionCategorised as poor-risk disease, primary mediastinal non-seminomatous germ cell tumours (PMNSGCT) with metastasis have a dismal survival rate.Case ReportWe report herein a case of PMNSGCT with liver metastasis that underwent primary chemotherapy followed by staged resection of the mediastinal disease and resection of the liver metastasis from a difficult anatomical position, the caudate lobe.ConclusionPrimary mediastinal non-seminomatous germ cell tumour with metastasis has a poor prognosis. Recurrence is common in this group of patients even after chemotherapy and radical resection.

Management of acute mesenteric isxcaemia: A retrospective analysis

Aim-BackgroundAcute mesenteric ischaemia (AMI), although an uncommon condition with a difficult diagnosis, has a high rate of complications and is associated with a high mortality rate. We reviewed our experience of patients presenting with AMI in order to evaluate the current management and factors associated with survival in a tertiary care hospital.Material and MethodsClinical data of all patients who were diagnosed with AMI between 01 January 2012 and 30 June 2013 were retrospectively reviewed. Preoperative presentation, investigation, management and outcome in this group of patients were analyzed.ResultsThirteen patients were included in the study, of whom twelve were male and one female, mean age 44.5 years ranging from 35 to 78 years. The cause of AMI was embolism in three patients (23.1%), and thrombosis in ten patients (76.9%). Abdominal pain was the most common presenting symptom (100%). Four patients (30.8%) had previous symptoms of chronic mesenteric ischaemia in the form of postprandial pain. Nine patients (69.2%) had been exposed to high altitude for more than two weeks, four of whom displayed a procoagulant state. Eleven patients underwent abdominal exploration and endovascular treatment. Percutaneous transcatheter balloon angioplasty was performed in two (15.4%) cases. Eight out of eleven patients (72.7%) who underwent exploratory laparotomy had major small bowel resections involving more than 200 cms of small bowel. However, none of these patients underwent any reconstructive procedures due to extensive thrombus within the SMA and late presentation. Six patients were submitted to second-look exploration within 48 hours, all of whom underwent repeat resections of the bowel. Laparostomies were performed in two patients. None of these patients had a primary anastomosis. End jejunostomy/ileostomy was performed with mucous fistula in all 11 patients. Two patients died within a month, and the 30-day mortality rate was 15.4%; severe sepsis with multiorgan failure was the cause of death in both patients. Four patients (30.8%) had permanent intestinal failure without intestinal adaptation requiring permanent total parenteral nutrition (TPN) with indications for intestinal transplant. The survival rate at one year was 69.2%. Two late deaths occurred owing to complications of TPN.ConclusionA relatively uncommon diagnosis, AMI is often identified late and invariably with complications. Exploratory laparotomy with resection of the bowel is the most viable option in such a situation. The individuals exposed to high altitude and displaying a procoagulant state that present with AMI tend to belong to a much younger age group than that reported in the literature. Short bowel syndrome is a frequent long-term complication in surviving patients. Administration of TPN in strict aseptic conditions, control of sepsis, intestinal adaptation and intestinal transplant will increase the long-term survival of these patients.

A sporadic case of colorectal carcinoma with multiple polyps in a 16-year-old boy: An unusual presentation

Aim and BackgroundColorectal carcinoma associated with multiple colonic polyps is rare in children and adolescents without any previous family history of colorectal cancer/hereditary polyposis syndrome.Case ReportWe present the case of adenocarcinoma of the colon and rectum detected by biopsy in a 16-year-old boy with multiple polyps treated at our institution.ConclusionThough uncommon, sporadic cases of multiple polyps associated with colorectal carcinoma without any positive family history must always be considered in children with history of a colorectal polyp associated with bleeding. A high degree of suspicion is necessary to detect and treat such cases, thus preventing morbidity and mortality.

Mature teratoma of the pancreas: A rare entity

Aim and BackgroundPancreatic cystic lesions are being increasingly recognized and comprise different pathological entities. The management of these lesions is often challenging, because of inadequate preoperative diagnosis. Among this family of lesions, mature cystic teratomas are an extremely rare finding and are usually found in children.Case ReportWe present the rare case of a 60-year-old man being evaluated for melena. Preoperative investigation revealed a pancreatic mass. The patient underwent a Whipple pancreaticoduodenectomy. Surprisingly, histopathology revealed a mature teratoma of the pancreas.ConclusionThis case highlights the difficulty in establishing a preoperative diagnosis of this benign pathological entity. Though unusual in older patients, mature teratomas can present in this subgroup of patients. Mimicking malignancy, they warrant a radical surgical resection.