Sudhindran Surendran

LAPAROSCOPY IN SUSPECTED ABDOMINAL TUBERCULOSIS IS USEFUL AS AN EARLY DIAGNOSTIC METHOD

Background:  Establishing a histological diagnosis in abdominal tuberculosis can be difficult, frequently delaying treatment. The aim of the study was to evaluate the role of laparoscopy for ascertaining the diagnosis in suspected abdominal tuberculosis.

Perioperative prostaglandin e1 infusion in living donor liver transplantation: A double‐blind, placebo‐controlled randomized trial

The role of prostaglandin E1 (PGE1) infusion in improving early graft function has not been well defined, especially in the scenario of living donor liver transplantation (LDLT). We designed a randomized, double‐blind, placebo‐controlled trial to evaluate the role of perioperative PGE1 infusion in LDLT. Patients in the study arm received PGE1 (alprostadil) at the rate of 0.25 μg/kg/hour, starting at 1 hour after portal venous reperfusion, and continued for 96 hours. The primary endpoint was early allograft dysfunction (EAD). We analyzed multiple secondary endpoints including postoperative liver function and renal function parameters, acute kidney injury (AKI), hepatic artery thrombosis (HAT), postoperative bleeding, overall mortality, and posttransplant hospital stay. The incidence of EAD was lower in the PGE1 arm, although the difference did not reach statistical significance (22.4% versus 36%; P = 0.21). Among the secondary endpoints, the incidence of AKI was significantly lower in the PGE1 arm (8.2% versus 28%; P = 0.02), as were the peak and mean postoperative creatinine levels. The need for renal replacement therapy was similar between the 2 groups. Among the postoperative graft function parameters, postoperative alanine aminotransferase level was significantly lower in the PGE1 arm (P = 0.04), whereas the remaining parameters including serum bilirubin, aspartate aminotransferase, and international normalized ratio were similar between the 2 arms. There was no difference in the incidence of HAT and postoperative bleeding, in‐hospital mortality, and posttransplant hospital stay between the 2 arms. Perioperative PGE1 infusion reduces the incidence of posttransplant renal dysfunction in patients undergoing LDLT. Liver Transplantation 22 1067–1074 2016 AASLD

Fulminant zygomycosis of graft liver following liver transplantation

A 44-year-old man with hepatitis B virus (HBV)-related cirrhosis underwent living donor liver transplantation at our institute. Induction of immunosuppression was achieved with basiliximab, due to deranged renal function, and maintained with prednisolone, tacrolimus and mycophenolate mofetil. The intraoperative and immediate postoperative periods were fairly uneventful. A duplex scan, taken during the third week post-transplantation due to sudden rise in liver enzymes, revealed multifocal hypoechoic lesions in the graft liver with normal Doppler parameters. Multidetecor computed tomography (MDCT) showed multiple hypodense vessel-sparing lesions in the graft liver. Cultures from the aspirate grew filamentous fungi identified as Basidiobolus ranarum species. Despite multiple broad spectrum antifungal infusions including liposomal amphotericin, itraconazole, caspofungin and posaconazole, serial sonography showed the hepatic lesions increasing in size, and involving segments V, VI and VII. The patient developed severe liver dysfunction ultimately progressing to sepsis, multiorgan dysfunction and death.

Extracorporeal membrane oxygenation for post-transplant hypoxaemia following very severe hepatopulmonary syndrome.

Hepatopulmonary syndrome (HPS) associated with end-stage liver disease has a high morbidity when room air PaO2 is less than 50 mm Hg. Safe levels of oxygenation to facilitate transplantation have not been defined despite advancement in care. Postoperatively, hypoxaemia worsens due to ventilation perfusion mismatch contributed by postoperative pulmonary vasoconstriction and due to decrease in endogenous nitric oxide. A 16-year-old boy with cirrhosis presented with HPS and a PaO2 of 37 mm Hg on room air and underwent living donor liver transplant. Although stable intraoperatively, he desaturated on the second postoperative day. Despite a number of interventions, oxygenation remained critically low on 100% inspired oxygen. Extracorporeal membrane oxygenator (ECMO) was established with instant improvement in oxygenation (PaO268 mm Hg), and the patient was eventually salvaged. We suggest that ECMO could be a means of managing refractory post-transplant hypoxaemia in patients with HPS.

A New Score to Predict Recipient Mortality from Preoperative Donor and Recipient Characteristics in Living Donor Liver Transplantation (DORMAT Score).

BACKGROUND Recipient outcomes in adult living donor liver transplantation depend on various characteristics in both recipient and donor. We aimed to derive a score based upon preoperative characteristics in donor and recipient that could predict the recipient mortality in adult living donor liver transplantation. MATERIAL AND METHODS Retrospective data of 100 living donor liver transplantation recipients and their respective donors were analyzed for preoperative factors that correlated with recipient mortality. Statistically significant factors were weighted appropriately to derive a regression equation to obtain a donor-to-recipient match (DORMAT) score. This score was applied to 71 patients prospectively and their outcome was analyzed. RESULTS Donor-recipient match (DORMAT) score, derived using regression analysis of the significant variables was [0.002 (Recipient age) + 0.013 (Recipient BMI) + 0.055 (SBP) + 0.344 (HRS) + 0.022 (Pre-op culture positivity) + 0.01 (Donor age) - 0.639]×100. DORMAT score, when validated to a prospective cohort of 71 adult-to-adult LDLT patients, had a C-statistic (area under ROC curve) of 0.712. The mortality rate was seen to increase with increasing DORMAT score. CONCLUSIONS DORMAT score is a useful clinical decision-making tool to predict recipient mortality in adult living donor liver transplantation.

Post-operative myocardial infarction complicating donor hepatectomy: Implications for donor safety.

Sir, A 56-year-old post-menopausal lady was evaluated as a liver donor for her daughter who had fulminant liver failure. Her medical history was unremarkable, and post-menopausal state and age above 50 years were the only associated risks. A 12-lead electrocardiogram and two-dimensional echocardiography were both normal. We identified her as intermediate surgical risk[1] with clinical cardiopulmonary reserve of six metabolic equivalents. Standard protocols for anaesthesia for hepatectomy were performed; however, an epidural catheter was abandoned in view of technical difficulty and analgesia was provided with an intravenous fentanyl infusion. The procedure lasted for 6.5 h with blood loss of 600 ml and the patient was extubated at the end of procedure. Continuous analgesia was provided with an intravenous infusion of fentanyl targeting a pain score <4 on the visual analogue scale. On the 1st post-operative day (POD), the patient was pain-free, ambulant and haemodynamically stable. Her heart rate averaged 65/min, central venous pressure 7–8 mmHg, haemoglobin 10.8 g/dL, serum aspartate aminotransferase 684 IU/L, serum alanine aminotransferase 565 IU/L and international normalised ratio (INR) 1.46. On the second POD, the patient developed sudden hypotension with cardiac arrest. There was no evidence of hypovolaemia or bleeding at the surgical site. Standard cardiopulmonary resuscitation was initiated with successful return of spontaneous circulation after two cycles. The blood pressure was then maintained with infusions of adrenaline and dopamine. A 12-lead electrocardiogram suggested an inferolateral wall ST-elevation myocardial infarction [STEMI, Figure 1]. A coronary angiogram showed 80% stenosis of the distal right coronary artery with normal flow in all other vessels. Percutaneous coronary intervention was performed with a bare metal stent that was exchanged for a covered stent following perforation at the site of stenting. A pigtail catheter was inserted into the pericardial sac [Figure 2]. Infusion of eptifibatide and intravenous heparin were administered at the time of intervention. The patient bled 1.8 L from the abdominal drain and 330 ml from the pericardial sac, for which she was transfused two units of packed red blood cells and two units of fresh frozen plasma (INR was 4.23). She was weaned off the ventilator on the 4th day following intervention and was discharged on the 16th POD. Figure 1 Electrocardiogram showing inferolateral wall ST-elevation myocardial infarction Figure 2 Pigtail catheter in the pericardial sac Despite guidelines for donor selection,[2] emotional factors and donor availability confound the selection in life-threatening situations. Donor deaths range from 0.5% to 2% in right hepatectomy, and myocardial infarction has also been one of the causes.[3] As history suggested a good cardiopulmonary reserve with a revised cardiac risk index[1] score of 0.9%, we did not consider the need for stress testing. An exercise stress testing, dobutamine echocardiogram or assessment of anaerobic threshold may have been predictive of major adverse cardiac events (MACE) in this patient.[1] In contrast to the American College of Cardiology guidelines,[1] the European Society of Cardiology[4] guidelines classify liver resection surgery as high surgical risk for MACE. It is possible that stress of surgery pre-disposed the STEMI following plaque rupture.[4] Percutaneous intervention was the treatment of choice as surgical revascularisation or thrombolysis is associated with increased bleeding post-operatively.[1] Although coagulation disturbances are known after major hepatectomy, epidural analgesia is considered acceptable if performed judiciously.[5] Living donation is a viable option for fulminant liver failure, and marginal donors are accepted in the background of restricted donor availability as a life-saving measure. As the donor undergoes surgery that is not indicated for his well-being, rigorous adherence to standard protocols in donor evaluation[6] even in emergent situations and communication of potential life-threatening complications is necessary for living donor transplants. In the light of our report, exercise stress testing or pharmacological stress testing for prediction of MACE should be considered in high surgical risk procedures including donor hepatectomy. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Simultaneous pancreas–kidney transplant for type I diabetes with renal failure: Anaesthetic considerations

Pancreatic grafts have been successfully used in patients with diabetes and are combined with kidney transplantation in patients with renal failure. The propagation of awareness in organ donation in India has increased the donor pool of transplantable organs in the last few years making multi visceral transplants feasible in our country. We present the anaesthetic management of a 32-year-old male with diabetes mellitus and end-stage renal failure who was successfully managed with a combined pancreas and kidney transplantation.