Subash Gupta

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).

Living Donor Liver Transplant is a Transparent Activity in India

Living donor liver transplant (LDLT) has progressed rapidly in India with at least two major centers performing over 200 transplants annually. There have been concerns regarding donor safety as donor deaths have been reported worldwide. In India, there is a possible underreporting of donor complications and mortality leading to the allegation that LDLT is a clandestine activity. Deceased donor liver transplantation activity may be less transparent as there are no national guidelines for retrieval and allocation of organs. LDLT is for a named person and as the activity can only be conducted in major hospitals with involvement of over 100 medical personnel in each operation, it cannot be a clandestine operation. Government regulations require licensing of hospitals following inspection by senior doctors and reporting of transplant activity periodically. About 2500 living donor liver transplants have been conducted in India and there have been 7 donor deaths reported in India. Rather than not being transparent, donor morbidity and mortality has received excessive media attention. Most liver transplant activity in India is well organized with clearance from hepatologists and anesthetists. Unrelated donation needs to be cleared from a State appointed Authorization Committee. Foreigners cannot be transplanted without State clearance and approval of the concerned embassy. The donor risk is discussed and the success of the recipient operation is also explained to all patients. The ever-increasing popularity of the operation in spite of the high cost and the requirement for donation from a family member suggests that many patients are living healthy life after transplantation. Overall LDLT is a transparent activity in India.

Utility of Multidetector Computerized Tomography in Living Donor Liver Transplantation

Living donor liver transplantation (LDLT) has evolved as viable alternative to Cadaveric liver transplantation in the recent years. Major advantages of LDLT are reduction of waiting time, reduction of cold ischemia time and increase in the number of organs for transplantation. It is a radiology intensive procedure that requires specialized pre-operative assessment of donor as well as recipient for their suitability. The complex nature of the surgical procedure need detail understanding of hepatic angioarchitecture, biliary anatomy, extrahepatic vascular abnormalities and hepatic volumetry for a safe and successful transplantation. Multidetector CT (MDCT) has emerged as single most non-invasive imaging modality and permit comprehensive and accurate preoperative evaluation of clinically relevant information required to select suitable candidate and surgical technique for successful transplantation. It helps to evaluate liver parenchyma, hepatic vascular anatomy and predict adequacy of liver volume in prospective donor more efficiently. MR-Cholangiography is solely used for preoperative delineation of biliary anatomy for donor at our center. Recipients are better evaluated by MDCT for exclusion of advanced HCC and other malignancies, patency of venous system, presence of perihepatic varices and portosystemic shunts, patency of celiac artery and exclusion of splenic artery aneurysm. Complications peculiar to LDLT includes fluid collection along resection margin, bile leak, segmental biliary dilatation/narrowing, vascular occlusion/stenosis at anastomotic sites etc. and are better monitored by USG & MDCT.

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.

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.

Competitive ability of intercrops and herbicides for controlling weeds in maize (Zea mays L.)

ABSTRACT :A field experiment was conducted in the sandy loam soil of Kanke, Ranchi during Kharif seasons of 2004 and 2005, to find out most effective combinations of intercrops and herbicides for controlling weeds in Kharif maize. The experiment was laid out in Split Plot Design comprising five cropping systems, i.e., sole maize, sole soybean, sole groundnut, intercropping of maize+soybean (1:2) and intercropping of maize+groundnut (1:2) as main plots and five weed management practices, i.e., weedy check, weeding thrice at 15, 30 and 45 days after sowing, oxyfluorfen @ 0.2 kg a.i. ha-1 as pre-emergence, alachlor @ 2.0 kg a.i. ha-1 as preemergence and butachlor @ 1.5 kg a.i. ha-1 as pre-emergence + quizalofop-ethyl @ 100 ml ha-1 as post emergence, as sub plot treatments, replicated thrice. The result showed that maize intercropped with soybean and hand weeded thrice has lowest weed density and weed dry weight, which were statistically at par with that of maize intercropped with soybean and sprayed with oxyfluorfen @ 0.2 kg a.i. ha-1 as pre-emergence. The highest maize equivalent yield of 8039 kg ha-1 was recorded with maize+groundnut and hand weeded thrice, which was found to be statistically at par with maize+groundnut, treated with oxyfluorfen @ 0.2 kg a.i. ha-1 as preemergence and maize+soybean, treated with oxyfluorfen @ 0.2 kg a.i. ha-1 as pre-emergence, having maize equivalent yields of 7595 kg ha-1 and 7189 kg ha-1, respectively. The highest net return was recorded from the intercropping of maize+groundnut, treated with oxyfluorfen @ 0.2 kg a.i. ha-1 as pre-emergence, which can be used as the most effective and profitable combination in controlling weeds in Kharif maize.

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.

PREHOSPITAL THROMBOLYSIS-TIME IS MUSCLE AND MUSCLE IS TIME

Although the medical and technological revolution in the last three decades has improved clinical outcome in patients presenting with acute STEMI, residual morbidity and mortality are still high. It is widely acknowledged that the key factor in the successful treatment of AMI is the time elapsed between the onset of symptoms and initiation of therapy. The obvious step in the continuing effort to shorten time-to-treatment and thus to achieve maximal myocardial salvage is the use of prehospital thrombolysis. According to the mortality data, pre-hospital and also in-hospital thrombolysis has success rates comparable with Pri.PCI when initiated within the first 2–3 h after the onset of pain. Therefore, in these patients, thrombolytic therapy should not be withheld in favor of mechanical reperfusion if it cannot be offered within 90 min.