Vivek Vij

Successful living donor liver transplant in a child with Abernethy malformation with biliary atresia, ventricular septal defect and intrapulmonary shunting

Abstract:  Congenital portosystemic shunts are the anomalies in which the mesenteric venous drainage bypasses the liver and drains directly into the systemic circulation. This is a report of a rare case of LDLT in a four‐yr old male child suffering with biliary atresia (post‐failed Kasai procedure) associated with (i) a large congenital CEPSh from the spleno‐mesentric confluence to the LHV, (ii) intrapulmonary shunts, (iii) perimembranous VSD. The left lobe graft was procured from the mother of the child. Recipient IVC and the shunt vessel were preserved during the hepatectomy, and the caval and shunt clamping were remarkably short while performing the HV and portal anastomosis. Post‐operative course was uneventful; intrapulmonary shunts regressed within three months after transplantation and currently after 18 months following transplant child is doing well with normal liver functions. CEPSh has been extensively discussed and all the published cases of liver transplantation for CEPSh were reviewed.

Dengue Virus Transmission from Living Donor to Recipient in Liver Transplantation: A Case Report

Many infections are transmitted from a donor to a recipient through organ transplantations. The transmission of dengue virus from a donor to a recipient in liver transplantation is a rare entity, and currently, there is no recommendation for screening this virus prior to transplantation. We report a case of transmission of dengue virus from donor to recipient after liver transplantation. The recipient had a history of multiple admissions for hepatic encephalopathy and ascites. He was admitted in the ICU for 15 days for chronic liver disease, ascites, and acute kidney injury before transplantation. The donor was admitted 1 day before transplantation. The donor spiked fever on postoperative day 2 followed by thrombocytopenia and elevated liver enzymes. The donor blood test was positive for dengue NS1 antigen. The recipient also had a similar clinical picture on postoperative day 5 and his blood test was also positive for dengue NS1 antigen. Hence, the diagnosis for posttransplant donor-derived allograft-related transmission of dengue infection was made. Both recipient and donor were treated with supportive measures and discharged after their full recovery on postoperative days 9 and 18, respectively. The effect of immunosuppression on dengue presentation is still unclear and there is lack of literature available. In our case, the recipient developed dengue fever similar to general population without showing any feature of severe graft dysfunction. We have concluded that dengue virus can also be transmitted from donor to recipient, and immunosuppression did not have any adverse effect on the evolution of dengue fever within the recipient. Delhi being a hyperendemic zone, screening for donors (especially in season time) for dengue virus seems to be the best preventive method to control donor-derived transmission of dengue to recipient.

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).

Analysis of caudate lobe biliary anatomy and its implications in living donor liver transplantation - a single centre prospective study

Biliary complications are a significant cause of morbidity after living donor liver transplant (LDLT). Bile leak may occur from bile duct (anastomotic site in recipient and repaired bile duct stump in donor), cystic duct stump, cut surface pedicles or from divided caudate ducts. The first three sites are amenable to post‐operative endoscopic stenting as they are in continuation with biliary ductal system. However, leaks from divided isolated caudate ducts can be stubborn. To minimize caudate duct bile leaks, it is important to understand the anatomy of hilum with attention to the caudate lobe biliary drainage. This single‐centre prospective study of 500 consecutive LDLTs between December 2011 and December 2016 aims to define the biliary anatomy of the caudate lobe in liver donors based on intraoperative cholangiograms (IOCs) with special attention to crossover caudate ducts and to study their implications in LDLT. Caudate ducts were identified in 468 of the 500 IOCs. Incidence of left‐to‐right crossover drainage was 61.37% and right to left was 21.45%. Incidence of bile leak in donors was 0.8% and in recipients was 2.2%. Proper intraoperative identification and closure of divided isolated caudate ducts can prevent bile leak in donors as well as recipients.

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.

Need for Caudate duct classification: God is in the detail and so is the Devil!

Caudate duct classification is important not only in understanding the complex hilar anatomy intraoperatively but also in post-operative decision making in management of biliary complications. This article is protected by copyright. All rights reserved.

Hepatic Amyloidosis - When Looks are Deceptive!

The liver can be involved in many systemic diseases, including infectious, immunologic, metabolic, vascular, infiltrative, and neoplastic diseases. Amyloidosis is a rare systemic disorder characterized by the deposition of insoluble, fibril-forming amyloid proteins in the extracellular space of various organs and it is more frequently observed in the gastrointestinal tract, heart and kidney. Liver can also be involved but often remain clinically silent with abnormal liver function tests and organ enlargement. The clinical and imaging features of the disease are often nonspecific and a tissue biopsy is often required. Hepatic involvement of the systemic amyloidosis is usually presented as diffuse infiltration and hepatomegaly, but very rarely may appear as unusual focal mass. Hepatic dysfunction is usually subclinical, however, in some patients, there is massive involvement of the liver could lead to acute liver failure, acute on chronic liver failure and decompensated cirrhosis of liver. We present the two rare cases of hepatic involvement of systemic amyloidosis. First case is of primary AL-systemic amyloidosis that presented as hepatic lesions, in the setting of plasma cell dyscrasia. Second case is of secondary AA-systemic amyloidosis that presented as decompensated chronic liver disease reported first time in literature which required liver transplantation.

Graft versus host disease occurring in living donor liver transplant

Graft versus host disease (GVHD) is a serious disease occurring posttransplant. Most cases are seen after hematopoietic bone marrow/stem cell transplantation where the donor cells recognize host antigens and start reacting against them. The initial organs to be involved are skin, gut, and liver. Patients can present with maculopapular rashes, diarrhea, or jaundice. Early diagnosis and timely institution of therapy may salvage these patients. GVHD is rarely also identified in solid organ transplantation seen frequently with small bowel transplantation. Cases of GVHD after liver transplantation are very rare. We herein describe a case of GVHD following a deceased donor liver transplant with a review of pathophysiology of GVHD in liver transplant.

Retrospective analysis of explants liver pathology: Experience from a tertiary care center in India

Background: The histological spectrum of explant liver pathology and their prevalence has not previously been reported from the Indian subcontinent. (1) The study was performed to provide new insight into the prevalence of explant liver pathologies in this part of the world by retrospective analysis of the spectrum of histological changes, (2) to study the etiopathological association of cirrhosis, (3) to study the etiopathogenesis for development of hepatocellular carcinoma (HCC), and to analyze whether there is any association of macroregenerative and dysplastic nodule with HCC. Materials and Methods: Written records of all explant liver pathology service were entered into an electronic database. Retrospective analysis of the liver explants was performed from May 2015 to July 2016 at a tertiary-care center in India. Results: Maximum (97.2%) number of liver explants showed cirrhosis. Hepatitis C virus (HCV)-related chronic liver disease was the most common etiological factor for the development of cirrhosis in this part of the world followed by HBV and alcohol. The association between HCC and HBV was found to be statistically significant with a value of P = 0.009. The association between dysplastic nodules and HCC was also found to be significant. Conclusion: This is the first study to describe the histological spectrum of explant liver pathology from India. HCV forms the major disease burden for the chronic liver disease. There is a significant association of dysplastic nodules with HCC postulating their role as a precursor lesion in HCC.