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BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic has led to deferral of elective transplants and proactive pretransplant testing of the donor/recipient. The impact of these on living-donor liver transplantation (LDLT) activity and outcome is not known. We performed LDLT only for sick patients or patients with advanced hepatocellular carcinoma in this period, with special COVID protocols. METHODS: Patients undergoing LDLT counseling, evaluation, and transplant in the period March to June 2020 (group A) under COVID-19 restrictions and special protocols were included. LDLT activity and outcomes among these patients were compared with those in the same period in 2019 (group B). RESULTS: In the period March 15-June 10, we performed 39 and 23 (59%) LDLTs in 2019 and 2020, respectively. The adult patients with cirrhosis in group A (n = 20) had a significantly higher MELD score, 19.8 ± 7.0 versus 16.1 ± 5.6 in group B (n = 36), p = 0.034. Early recipient mortality was similar in 2019 (2/39) and 2020 (2/23). One of 23 post-transplant recipients, 3/71 recipients and donors during evaluation, and 8/125 healthcare workers (HCWs) developed COVID-19, all of whom recovered uneventfully. CONCLUSION: LDLT activity substantially reduced during the COVID era. The incidence and outcome of COVID-19 among the waiting or transplanted patients and HCWs were similar to those of the general population. The outcome after LDLT in the COVID era was similar to that in non-COVID times. These data suggest that LDLT may be extended to more stable patients with strict protocols.
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Although the well-accepted lower limit of the graft-to-recipient weight ratio (GRWR) for successful living donor liver transplantation (LDLT) remains 0.80%, many believe grafts with lower GRWR may suffice with portal inflow modulation (PIM), resulting in equally good recipient outcomes. This study was done to evaluate the outcomes of LDLT with small-for-size grafts (GRWR <0.80%). Of 1321 consecutive adult LDLTs from January 2012 to December 2017, 287 (21.7%) had GRWR <0.80%. PIM was performed (hemiportocaval shunt [HPCS], n = 109; splenic artery ligation [SAL], n = 14) in 42.9% patients. No PIM was done if portal pressure (PP) in the dissection phase was <16 mm Hg. Mean age of the cohort was 49.3 ± 9.1 years. Median Model for End-Stage Liver Disease score was 14, and the lowest GRWR was 0.54%. A total of 72 recipients had a GRWR <0.70%, of whom 58 underwent HPCS (1 of whom underwent HPCS + SAL) and 14 underwent no PIM, whereas 215 had GRWR between 0.70% and 0.79%, of whom 51 and 14 underwent HPCS and SAL, respectively. During the same period, 1034 had GRWR ≥0.80% and did not undergo PIM. Small-for-size syndrome developed in 2.8% patients. Three patients needed shunt closure at 1 and 4 weeks and 60 months. The 1-year patient survival rates were comparable. In conclusion, with PIM protocol that optimizes postperfusion PP, low-GRWR grafts can be used for appropriately selected LDLT recipients with acceptable outcomes.
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Enfermedad Hepática en Estado Terminal/cirugía , Rechazo de Injerto/epidemiología , Trasplante de Hígado/métodos , Sistema Porta/cirugía , Complicaciones Posoperatorias/epidemiología , Adulto , Aloinjertos/anatomía & histología , Aloinjertos/irrigación sanguínea , Enfermedad Hepática en Estado Terminal/mortalidad , Femenino , Rechazo de Injerto/etiología , Rechazo de Injerto/fisiopatología , Rechazo de Injerto/prevención & control , Supervivencia de Injerto , Humanos , Ligadura/efectos adversos , Ligadura/estadística & datos numéricos , Hígado/anatomía & histología , Hígado/irrigación sanguínea , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/estadística & datos numéricos , Donadores Vivos , Masculino , Persona de Mediana Edad , Tamaño de los Órganos , Selección de Paciente , Derivación Portocava Quirúrgica/efectos adversos , Derivación Portocava Quirúrgica/estadística & datos numéricos , Presión Portal/fisiología , Sistema Porta/fisiopatología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/prevención & control , Estudios Retrospectivos , Arteria Esplénica/cirugía , Resultado del TratamientoRESUMEN
INTRODUCTION: Most western patients who have not had a previous operation and present with biliary obstruction are thought to have a malignant lesion. However in our country where the disease is common, we found that some of these patients had a tuberculous cause which considerably altered their management as well as their prognosis. We herein present our experience of these patients whom we had operated with a preoperative diagnosis of biliary tract malignancy and discuss, retrospectively, how they might have been detected before operation to have tuberculosis. METHODS: Between August 1996 and June 2010, we operated on 209 patients with a preoperative diagnosis of carcinoma of the gallbladder and common bile duct. Seven out of these 209 patients had biliary tuberculosis. We retrospectively analyzed the clinical features of these patients from our prospectively maintained database. RESULTS: There were four males and three females who had a mean age of 54 (32-65) years. The bile duct was involved in four and gallbladder in three patients. In contrast to those with malignancy, patients with tuberculosis had a longer history (122 vs 44 days), an abdominal mass was present less frequently (28% vs 57%), the serum bilirubin was lower (1.6 vs 6 mg/dl), and they also had evidence of tuberculosis elsewhere in the body (28.5%). There was no operative mortality in biliary tract tuberculosis in contrast to 7.5% in biliary tract malignancy. CONCLUSION: Though tuberculosis of the biliary tract is rare, it needs to be considered in the differential diagnosis of patients with biliary obstruction especially in countries where the disease is endemic.
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Enfermedades de las Vías Biliares/diagnóstico , Tuberculosis Gastrointestinal/diagnóstico , Adulto , Anciano , Enfermedades de las Vías Biliares/patología , Enfermedades de las Vías Biliares/cirugía , Neoplasias del Sistema Biliar/diagnóstico , Diagnóstico Diferencial , Femenino , Humanos , India , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tuberculosis Gastrointestinal/patología , Tuberculosis Gastrointestinal/cirugíaRESUMEN
BACKGROUND: Nonoperative management is being increasingly employed in the management of blunt hepatic injuries. PATIENTS AND METHODS: We analyzed patients with complex hepatic injuries over a period of 10 years (1996-2006). RESULTS: Two hundred and ten patients with blunt hepatic injury were admitted and 103 patients had complex liver injuries. The predominant mode of injury was road traffic accidents in 91.2%. The grade distribution of liver injuries was grade III (72.8%), grade IV (23.3%) and grade V (4.9%). Twenty-four patients (23.3%) underwent surgery for persistent hemodynamic instability, persistent fall in hemoglobin level, bile leaks and intra-abdominal collection with sepsis. Associated intra-abdominal injuries were present in 19.4%, and 58.4% had associated extra-abdominal injuries. The operative procedures included hepatectomy (1), suture hepatorraphy (12), T-tube drainage for bile duct injuries (5), perihepatic sponge and gel foam packing (9), liver abscess drainage (3), and resection and debridement of liver tissue in six patients. The mortality and morbidity in this series was 10.7 and 56.4%, respectively. Multiorgan failure was present in 5, single organ failure in 37, sepsis in 24, biliary complications in 16 and intra-abdominal collection in 17 patients. Endoscopic management for bile leaks was performed in five patients, image-guided pig-tail drainage for abscesses in 11 patients, while angioembolization was done in two patients for right hepatic artery bleed. The mortality was not significantly different in surgical and nonoperative groups but operated patients had significantly higher morbidity. CONCLUSIONS: Complex liver injuries can be managed successfully with conservative treatment in majority, with low mortality and acceptable morbidity. Surgery is reserved for selected indications.