Haseeb Zia

The travails of setting up a living donor liver transplant program: Experience from Pakistan and lessons learned

Living donor liver transplantation (LDLT) is the only treatment option for patients with end‐stage liver disease (ESLD) where cadaveric donors are not available. In developing countries, the inception of LDLT programs remains a challenge. The first successful liver transplantation program in Pakistan started transplantation in 2012. The objective of this study was to report outcomes of 100 LDLT recipients in a developing country and to highlight the challenges encountered by a new LDLT program in a resource‐limited setting. We retrospectively reviewed recipients who underwent LDLT between April 2012 and August 2014. Demographics, etiology, graft characteristics, and operative variables were assessed. Outcome was assessed on the basis of morbidity and mortality. All complications of ≥ 3 on the Clavien‐Dindo grading system were included as morbidity. Estimated 1‐year survival was calculated using Kaplan‐Meier curves, and a Log‐rank test was used to determine the significance. Outcomes between the first 50 LDLTs (group 1) and latter 50 LDLTs (group 2) were also compared. Median age was 46.5 (0.5‐72) years, whereas the median MELD score was 15.5 (7‐37). The male to female ratio was 4:1. ESLD secondary to hepatitis C virus was the most common indication (73% patients). There were 52 (52%) significant (≥ grade 3) complications. The most common morbidities were bile leaks in 9 (9%) and biliary strictures in 14 (14%) patients. Overall mortality in patients who underwent LDLT for ESLD was 10.6%. Estimated 1‐year survival was 87%. Patients who underwent transplantation in the latter period had a significantly lower overall complication rate (36% versus 68%; P = 0.01). Comparable outcomes can be achieved in a new LDLT program in a developing country. Outcomes improve as experience increases. Liver Transpl 21:982‐990, 2015.

Is pancreaticodoudenectomy with vascular resection a safe procedure in developing country? Early outcomes and review of national literature.

INTRODUCTION Safety of extended lymphadenectomy (EL) ± vascular resection in patients undergoing pancreaticoduodenectomy (PD) in resource limited settings is not well established. The objective of this study was to report outcomes of PD resection with EL ± vascular resection from Pakistan and review national literature. METHODS Data of patients who underwent PD between 2011 and 2014 was reviewed. A total of 66 patients were included in the study. Primary outcome was 90 day morbidity and mortality. Secondary objective was 2 year overall survival. RESULTS Median age was 57 (32-82) years. Majority patients had locally advanced (pT3/T4) tumors and nodal involvement i.e. 44 (71%) and 42 (67.8%). Mean number of excised lymph nodes and positive lymph nodes was 28.2 ± 12.8 (range 3-62) and 4.8 ± 6.9 (range 0-27) respectively. There were 13 vascular resections including 3 arterial resections. Overall 90 day morbidity was 31.8% and mortality was 3%. No difference in complication rate was observed in patients who did and did not undergo vascular resection i.e. 18% versus 34.5% (P = 0.1). Similarly, median survival was 11 (3-24) months and 11 (1-36) months and not significantly different (P = 0.5). CONCLUSION In developing countries, extended lymphadenectomy with vascular resection can be safely performed with pancreaticoduodenectomy in specialized hepatobiliary units.

Prognostication of Learning Curve on Surgical Management of Vasculobiliary Injuries after Cholecystectomy

Background. Concomitant vascular injury might adversely impact outcomes after iatrogenic bile duct injury (IBDI). Whether a new HPB center should embark upon repair of complex biliary injuries with associated vascular injuries during learning curve is unknown. The objective of this study was to determine outcome of surgical management of IBDI with and without vascular injuries in a new HPB center during its learning curve. Methods. We retrospectively reviewed patients who underwent surgical management of IBDI at our center. A total of 39 patients were included. Patients without (Group 1) and with vascular injuries (Group 2) were compared. Outcome was defined as 90-day morbidity and mortality. Results. Median age was 39 (20–80) years. There were 10 (25.6%) vascular injuries. E2 injuries were associated significantly with high frequency of vascular injuries (66% versus 15.1%) (P = 0.01). Right hepatectomy was performed in three patients. Out of these, two had a right hepatic duct stricture and one patient had combined right arterial and portal venous injury. The number of patients who developed postoperative complications was not significantly different between the two groups (11.1% versus 23.4%) (P = 0.6). Conclusion. Learning curve is not a negative prognostic variable in the surgical management of iatrogenic vasculobiliary injuries after cholecystectomy.

Where angels fear to tread: donor bile duct division in living donor liver transplant.

Dear Sir, Conventional arterial and biliary anatomy is encountered in 65–70% cases of liver transplantation with preponderance in females [1,2]. In LDLT, reported rate of aborted donor hepatectomy is 1.2% and one-third of these are attributable to biliary and vascular variations [3]. Here, we discuss a living donor with a unique vasculobiliary anatomy that required common hepatic duct (CHD) division. A 24-year-old healthy female underwent right hepatectomy as voluntary right liver lobe donor to her father. She was the only child and sole right lobe donor. She had nonconventional arterial anatomy on CT angiography as demonstrated in Fig. 1 while MRCP was normal. Intraoperatively, not only CT findings were confirmed, but also CHD was found sandwiched between superior seg-