Neerav Goyal

Intraoperative No Go Donor Hepatectomy in Living Donor Liver Transplantation

We read the article titled ‘No Go Donor Hepatectomy in Living Donor Liver Transplantation’ by Guba et al. in the March 2010 issue of AJT with great interest (1). Twelve donor procedures (4.7%) were aborted in their series of 257 transplants. Reasons for aborting the donor procedures were unsuitable biliary or vascular anatomy (seven), poor graft quality (three) and unexpected intraoperative events (two). Incidence of 4.7% was slightly higher than incidence of 3.2% in A2ALL multicenter group trial (2).

Liver Transplantation: Experience with Last 50 Cases at Our Centre

Objectives To evaluate the results of the last 50 liver transplants performed in our institution. Methods We analyzed the 53 liver transplants performed at our institution from September 2006 to November 25, 2007. Results 53 OLTs were performed on 52 patients (46 adults, 7 children, 48 elective for end stage liver disease, 5 acute liver failure, one early retransplant). Two patients had Hepatic artery thrombosis (HAT), none had portal or hepatic venous complications. Eleven patients had bile leaks (3 cut surface, 8 anastomotic leaks). Five patients required ERCP + stenting and 3 underwent reexploration and hepaticojejunostomy. Overall patient survival rate was 87%. Patients transplanted for acute liver failure (n = 5) and pediatric transplants (n = 7) had 100% survival. Conclusions Our results are similar to what is reported from established liver transplant centres worldwide.

Current Status of Pediatric Liver Transplantation in India

Liver transplantation is now an established mode of therapy in children with fulminant hepatic failure and end stage liver disease due to various causes. The indications have evolved over the last few years to include various metabolic disorders. A thorough pre transplant evaluation followed by pre-emptive identification and management of anticipated complications is essential for the success of a liver transplant. Low socioeconomic and educational levels and insufficient social assistance have a considerable impact on practicality of a transplant taking place, the follow up and overall outcome of patients undergoing transplantation in India. Nevertheless, the liver transplant programme in India has come a long way over the past ten years with patient survival rates comparable to the best centers in the world. The improvements in surgical and medical expertise have contributed in a big way to this achievement.

In Situ Splitting of the Cadaver Liver for Two Adult Recipients by LDLT Technique

BACKGROUND To expand the donor pool, split liver transplantation is conventionally performed for one adult and one pediatric recipient. Application of this technique for two adult recipients can produce remarkable impact on the waiting list. Proper donor and recipient selection is crucial for the favorable outcome following full-right and full-left liver split. Right lobe adult to adult living donor liver transplantation (LDLT) is essentially a full right and full left split. However, LDLT techniques have not been used for full right and left split. METHODS We performed in situ splitting of the whole liver using LDLT techniques from a hemodynamically stable young deceased donor and transplanted into two adult recipients, both with model for end-stage liver disease score of 17. The transection was carried out through the midplane of liver, generating a right lobe and a left lobe graft. RESULTS Both the recipients had uneventful postoperative recovery. At ten months of follow up, both the recipients are doing well with good liver function. CONCLUSION Based on the concept of living related liver transplantation, our case explores the technical feasibility of full-right and full-left in situ liver split.

Does situs inversus totalis preclude liver donation in living donor liver transplantation? A series of 3 cases from single institution

Highlights • Largest case series with situs inversus totalis.• Technique was simple.• The critical part of anastomosis was biliary.• We have demonstrated all 3 possible biliary anastomosis with technical ease.• Outcomes are comparable to the normal right lobes.

Hepatic artery thrombosis versus neurological complications – Role of antiplatelet medications in adult living donor liver transplantation

Aspirin used in the post-operative period as prophylaxis for hepatic artery thrombosis (HAT) increases the risk of neurological complications (NC) in adult living donor liver transplantation (LDLT) recipients was the hypothesis. Case control study was done on 1400 cases operated in our institute. Pediatric transplants, combined liver kidney, cadaver transplants, dual lobe transplants, preexisting organic neurological dysfunction and patients whose records were missing were excluded from the study. There were effectively 880 cases in non-aspirin group (NAG) and 440 cases in aspirin group (AG). The groups were matched for various factors. There were more alcoholics in AG and more ALFs in NAG. On subgroup analysis these two etiological factors were found to be statistically insignificant P > 0.05. So the prophylactic protocol was aspirin 75 mg once daily in all adults (age >12 years) once the platelet counts have reached 50,000 and there is no evidence of bleeding elsewhere. In pediatric population our protocol is use of aspirin 75 mg and clopidogrel 75 mg once daily once the platelet counts have reached 50,000 and there is no evidence of bleeding anywhere else.

Management of chronic hepatitis C before and after liver transplant

Abstract Hepatitis C infection is the most common cause of cirrhosis worldwide. Management of chronic hepatitis C in peri-transplant period is challenging. Patients with compensated/Childs A cirrhosis due to hepatitis C virus (HCV) infection are treated like noncirrhotics, with peginterferon (PEG-IFN) and ribavirin, albeit with a higher incidence of complications. Treatment is not recommended for decompensated cirrhotics due to higher complication rate including the risk of death. After liver transplant, immunosuppression should be adjusted to prevent/delay recurrent HCV disease. Incidence and severity of recurrent HCV disease as well as patient and graft survival is similar between living donor and deceased donor liver transplants. It is currently recommended to treat established recurrent hepatitis C, that is raised alanine aminotransferase (ALT) with HAI >4 and/or F >1. Pre-emptive/prophylactic antiviral therapy is poorly tolerated and has low efficacy. Standard dose regimen (PEG-IFN 1.5 μg/Kg or 180 μg weekly + ribavirin 800–1200 mg/day) for 48 weeks irrespective of the genotype is the recommended treatment protocol. Therapy poses significant problems in the form of anemia, neutropenia, higher risk of rejection, and so on.

Cavoportal Hemitransposition for Post Living Related Liver Transplant Portal Vein Thrombosis: A Valid Option

Portal Vein Thrombosis post liver transplant is a dreaded complication as it carries a high morbidity and mortality. In infants this is more so as they have a small calibre portal vein and portal flow itself is low. Thrombectomy is an option but in infants rethrombosis rate is high with consequent graft loss. Cavoportal hemitransposition is a novel though rarely tried option and we share our experience with this procedure in an infant.

Liver Transplantation–Indian Scenario

Liver transplant is an accepted modality of treatment for end stage liver disease. In India, living donor liver transplantation (LDLT) is more common than cadaveric liver transplants. Live donation has advantages like optimization of the timing of transplantation better quality liver due to less cold ischemic time and also as live donors are healthy individuals. The problem of living donor program is ethical, that a healthy volunteer faces unequivocal risks of morbidity and mortality. The major indications for OLT in adults are end stage cirrhosis due to any etiology, most common being chronic hepatitis C, chronic hepatitis B and alcoholic liver disease, fulminant hepatic failure and hepatocelllular carcinoma. The major indications for pediatric OLT are biliary atresia, neonatal hepatitis and other metabolic disorders. Minimal listing criteria for liver transplant are a Child-Turcotte-Pugh (CTP) score of at least 7and/or a MELD score > 10. We use triple immunosuppression with Tacrolimus, mycophenolate mofetil and prednisolone for post transplant immunosuppression. In last two years, we have performed 122 OLTs on 120 patients at our centre. Overall patient survival rate was 87%. Patients transplanted for acute liver failure (n=7) and pediatric transplants (n=13) had 100% survival.