Singh Gagandeep

Expanding the Donor Kidney Pool: Utility of Renal Allografts Procured in a Setting of Uncontrolled Cardiac Death

The chronic shortage of deceased kidney donors has led to increased utilization of donation after cardiac death (DCD) kidneys, the majority of which are procured in a controlled setting. The objective of this study is to evaluate transplantation outcomes from uncontrolled DCD (uDCD) donors and evaluate their utility as a source of donor kidneys.

Live donor liver transplantation without blood products: strategies developed for Jehovah's Witnesses offer broad application.

Objective:Developing strategies for transfusion-free live donor liver transplantation in Jehovahs Witness patients. Summary Background Data:Liver transplantation is the standard of care for patients with end-stage liver disease. A disproportionate increase in transplant candidates and an allocation policy restructuring, favoring patients with advanced disease, have led to longer waiting time and increased medical acuity for transplant recipients. Consequently, Jehovahs Witness patients, who refuse blood product transfusion, are usually excluded from liver transplantation. We combined blood augmentation and conservation practices with live donor liver transplantation (LDLT) to accomplish successful LDLT in Jehovahs Witness patients without blood products. Our algorithm provides broad possibilities for blood conservation for all surgical patients. Methods:From September 1998 until June 2001, 38 LDLTs were performed at Keck USC School of Medicine: 8 in Jehovahs Witness patients (transfusion-free group) and 30 in non-Jehovahs Witness patients (transfusion-eligible group). All transfusion-free patients underwent preoperative blood augmentation with erythropoietin, intraoperative cell salvage, and acute normovolemic hemodilution. These techniques were used in only 7%, 80%, and 10%, respectively, in transfusion-eligible patients. Perioperative clinical data and outcomes were retrospectively reviewed. Data from both groups were statistically analyzed. Results:Preoperative liver disease severity was similar in both groups; however, transfusion-free patients had significantly higher hematocrit levels following erythropoietin augmentation. Operative time, blood loss, and postoperative hematocrits were similar in both groups. No blood products were used in transfusion-free patients while 80% of transfusion-eligible patients received a median of 4.5+/− 3.5 units of packed red cell. ICU and total hospital stay were similar in both groups. The survival rate was 100% in transfusion-free patients and 90% in transfusion-eligible patients. Conclusions:Timely LDLT can be done successfully without blood product transfusion in selected patients. Preoperative preparation, intraoperative cell salvage, and acute normovolemic hemodilution are essential. These techniques may be widely applied to all patients for several surgical procedures. Chronic blood product shortages, as well as the known and unknown risk of blood products, should serve as the driving force for development of transfusion-free technology.

A comparison of sirolimus vs. calcineurin inhibitor-based immunosuppressive therapies in liver transplantation

Background  Sirolimus is a potent immunosuppressive agent whose role in liver transplantation has not been well‐described.

Caval preservation with reconstruction of the hepatic veins using caval-common iliac bifurcation graft for domino liver transplantation

Domino liver transplantation has been performed routinely from livers procured from patients with Familial Amyloidosis (FA). Some technical modifications have been made on the recipient of Amyloid Hepatic Allograft (AHA) to overcome the cuff limitation such as the use of side to side cava-caval anastomosis with closure of the suprahepatic and infrahepatic cava. These technical innovations in the recipient AHA however have no benefit for the FA patient undergoing the hepatectomy and may in fact adversely affect the safety of the harvesting procedure by requiring high dissection of the IVC into the diaphragm. In addition the IVC is removed with the liver, therefore requiring complete supra-renal vena caval clamping and the use of veno-venous bypass. We describe a safe and simple technique to recover the AHA without the IVC.

Type VI biliary cyst: report of a case.

An isolated cyst of the cystic duct is an extremely rare lesion. Only single case reports are documented in the literature. The most accepted classification system of biliary cysts, the Todani classification, does not include this lesion. We report a case of isolated cyst of the cystic duct. The initial referral was for evaluation of a gallbladder mass discovered during evaluation of abdominal pain. Preoperative diagnosis was challenging as multiple imaging studies were unable to differentiate this lesion from a choledochal cyst. Surgical planning thus included cyst excision and biliary reconstruction. Operative exploration revealed a type VI biliary cyst and cholecystectomy with cystic duct ligation near the common bile duct was curative.

To Do or Not to Do Living Donor Hepatectomy in Jehovah's Witnesses: Single Institution Experience of the First 13 Resections

Living donor liver transplantation has come to be an acceptable alternative to deceased donor transplants. Several ethical issues related to living donation have been raised in the face of reported perioperative morbidity and mortality. We report our experience in 13 consecutive Jehovahs Witness (JW) donor hepatectomies. From June 1999 to April 2004, 13 adult JW donors underwent donor hepatectomies at the USC–University Hospital. Nine donors underwent right lobectomy with a 62% mean volume of the liver resected. Four donors underwent a left lateral segmentectomy with a mean volume of 17.8%. Cell scavenging techniques, acute normovolemic hemodilution and fractionated products were used. The mean hospital stay was 6.2 days. All donors are alive and well at a median follow‐up time of 3 years and 4 months. Live liver donation can be done safely in JW population if performed within a comprehensive bloodless surgery program.

Transfusion-free techniques in pediatric live donor liver transplantation

Patients of the Jehovah’s Witness faith are unwilling for religious reasons to accept transfusion with blood or blood products. In pediatric patients of the Jehovah’s Witness faith, blood products can be used under court mandate if deemed medically imperative. However, transfusion under court order is obviously fraught with concerns for physicians and parents. This report describes medical and surgical techniques that have been used to avoid transfusion in adult Jehovah’s Witness patients and their successful use in two pediatric patients undergoing liver transplantation (1).

Left Extended Hepatectomy for a Metastatic Gastrointestinal Stromal Tumor After a Disease-Free Interval of 17 Years: Report of a Case

Gastrointestinal stromal tumors (GISTs), although rare, are frequently diagnosed with liver metastasis. These metastatic GISTs are poorly responsive to conventional chemotherapy; however, recent studies report improved survival after complete surgical resection of liver metastases. On the other hand, few reports describe the treatment of delayed liver metastasis after resection of a primary GIST. We report the case of a 55-year-old woman found to have liver metastasis from a GIST after a 17-year disease-free interval. The patient underwent a left extended hepatectomy for a complete resection of the metastatic GIST and is alive and well 30 months later. To our knowledge, this is the longest disease-free interval reported in the literature, and emphasizes the importance of considering late metastasis when evaluating patients with a history of GIST. Thus, surgical resection of delayed liver metastasis from a GIST should be considered as primary therapy.

Laparoscopic liver resections: extent of resection defines length of stay.

NAL SURGERY issue, titled: ‘‘Laparoscopic Hepatic Resection using, Saline-Enhanced Electrocautery Permits Short Hospital Stays. We at the University of Southern California University Hospital are currently doing over 100 liver resections a year and are one of the leading centers in the country for living donor liver transplantation. To say that salineenhanced electrocautery reduces the hospital stay delivers the wrong message to the reader base. This is just another technique of cutting the liver and has nothing to do with decreasing the hospital stay. The question this paper should really address is the selection of the patients for laparoscopic liver resection (LLR). How many patients who are seen for resection really lend themselves to a laparoscopic resection? What precludes the remaining patients from being done laproscopically? As proponents of LLRs ourselves, whether one uses the stapler, harmonic, or saline-enhanced electrocautery, there should be no difference as long as it pertains to wedge or small resections. To say that this is true for all resections is unsafe. Learn et al. state that ‘‘no association was found with respect to location or size of the mass.’’ Well, this case series is too small to make such a profound statement. What truly determines hospital stay is the extent of surgery. Even if one does a laparoscopic right lobectomy uneventfully with minimal blood loss, it is ethically and medically unsafe to send this patient home on postoperative day 1. In fact, there is a dramatic drop in the phosphorus levels, which directly correlate to postoperative complications. Clinical consequences of severe hypophosphatemia include impaired diaphragmatic contractility, ventricular irritability, myocardial depression, and insulin depression. Pomposelli et al. observed lifethreatening hypophosphatemia in liver donors, which was managed by replacing the phosphate intravenously. On an average, the inorganic phosphate begins to drop on the second postoperative day and ends around the fifth postoperative day. Moreover, at the present time there is no literature that correlates specifically the extent of the resection and the degree of hypophosphatemia, but the fact is that it occurs with major liver resections. Whether this electrolyte disturbance is a function of increased metabolic and synthetic demands of the regenerating liver or whether this is secondary to renal hypophosphaturia is a moot point. However, this in itself should be caution enough to not send the patient home prematurely. Laparoscopic liver resections are rapidly coming to be a way of main stream practice, and a plethora of papers are beginning to flood the literature; however, length of stay needs to be weighed in perspective to the extent of resection and not the modality used to cut the liver. Discharging patients in 24 hours after doing a LLR can sometimes be inappropriate and may even be fatal; therefore, caution needs to be exercised with the authors’ recommendations.

Living related donor nephrectomy in transfusion refusing donors.

Many transplant programs are averse to evaluate potential kidney donors with preferences against accepting human blood products. We examined the donor and graft outcomes between our transfusion‐consenting (TC) and transfusion‐refusing (TR) live kidney donors to determine whether a functional or survival disadvantage resulted from the disallowance of blood product transfusion during live donor (LD) nephrectomy. From July, 1999 to August, 2005, 82 live donor nephrectomies were performed, eight of who were TR donors (10%). Blood conservation techniques were utilized in TR donors. Demographics, surgical and functional outcomes, admission and discharge hematocrit, and creatinine were compared between TC and TR donors. No donor mortalities occurred. Two TC donors received blood transfusions (2.7%), and each study group experienced a single, <1‐year graft loss. Intra‐operative blood losses were significantly less in TR donors (298 ± 412 vs. 121 ± 91 ml, P < 0.03). No differences were noted between donor demographics, intra‐operative events, and graft and patient survival. Successful donor nephrectomy from TR patients has the potential to expand the kidney allograft pool to include the TR donor population. Precautionary blood conservation methods allow the informed and consenting TR individual to donate a kidney with acceptable risk and without compromise to donor or graft outcomes.