Background: Donor safety is of paramount importance in living donor liver transplantation. In spite of adequate residual volumes some donors decompensate to a greater extent, the explanation for this probably lies in the variation in portal hemodynamic stresses. The changes in portal hemodynamics occurring during donor hepatectomy and their effect on remnant regeneration have not been studied previously. Aims: We aimed to study the alterations in portal hemodynamic that occur during partial donor hepatectomy and to analyze the effects of these changes on functional regeneration of the remnant liver. Methods: 50 healthy donors undergoing right lobe donor hepatectomy were enrolled for this study, only donors < 45 years, with remnant volume >30% of total liver volume and liver attenuation index of 5-15 HU on pre operative imaging were accepted. Corrected portal pressures (portal pressure - central venous pressure) were measures at; A- initiation of surgery; B- post clamping of rt. portal vein (for marking the line of demarcation); C- post completion of parenchymal transection, D- post explantation of graft. The evolution of changes in portal pressures were analyzed along with their significance to the trend of post operative biochemical parameters (S. Bilirubin, INR, ALT). Results: Mean Corrected portal pressures (C.P.P) at points A, B,C,and D were 4.07±2.05 mm hg, 6.47±2.52, 6.27±3.06 and 7.21±2.73 mm hg respectively (p< .05). The mean rise in CPP during the procedure was 3.24±2.88 mm hg. Mean serum bilirubin levels on day 3 and day 5 post operatively were 2.28±.99 mg/dl and 1.77±.82mg/dl respectively. Mean duration to normalization of serum bilirubin was 3.48±1.85 days. Mean INR and ALT levels on day 3 were 1.67±.38 and 67±22.3 IU/dl respectively. Regression analysis indicated that rise in corrected portal pressure was significantly associated with the day 3 bilirubin (p< .05), day 5 bilirubin (p< .05) day 3 ALT (p< .05), and duration to normalization of serum bilirubin (p< .05). Patients were divided into 3 groups on the basis of changes in CPP: group A- no rise/fall in CPP, group B- rise in CPP< 3 mmHg, group C- rise in CPP >3mmHg. Day 3, day 5 bilirubin, INR and ALT levels varied appreciably between these groups. Conclusions: Significant rise in portal pressures occurring following donor hepatectomy is a possible explanation for the delayed functional regeneration that occurs in a proportion of patients following partial donor hepatectomy. These findings could be a guide to formulate future protocols on donor/graft (with/without MHV) selection based on portal hemodynamics in the future.
Esophagogastric devascularization is an operation that can be performed for endoscopically uncontrolled variceal bleeding in hospitals having only basic surgical instruments and is therefore an appropriate procedure for small hospitals in developing countries. The aim of this study was to analyze one hospital's experience of this operation in consecutive patients with variceal bleeding.Between 1996 and 2003, 45 patients (30 male, 15 female) who had a mean age of 40 years (range 7-78 years) underwent devascularization procedures. Of the 45, 23 had cirrhosis and 22 had non-cirrhotic portal hypertension (11 extrahepatic portal venous obstruction, 11 non-cirrhotic portal fibrosis), and 18 patients had emergency procedures and 27 were elective. Mortality, morbidity, rebleeding rates and the prognostic factors for death were assessed.Elective and emergency mortality was one (3.7%) and 11 (61%) patients, respectively. There was no rebleeding in hospital. At follow up (mean 48 months, range 3-92 months) overall survival in patients with cirrhosis was 7 out of 20 and in patients with non-cirrhotic portal hypertension was 19 of 21. Five (17%) had recurrent variceal hemorrhage, of whom three, all cirrhotic patients, died. Preoperative prognostic indicators for death were emergency surgery, a Child-Pugh score >or=10, preoperative blood transfusion >or=20 units and renal failure.Gastroesophageal devascularization effectively controls variceal bleeding especially in non-cirrhotic patients with portal hypertension. In the elective situation it carries a low mortality and rebleed rate. In emergencies the prognosis is poor with advanced cirrhosis, following large quantities of blood transfusion and deranged renal function. It is suggested that this operation be offered especially to non-cirrhotic patients in hospitals in developing countries where facilities for more sophisticated procedures are not available.
INTRODUCTION Perioperative peroneal neuropathy is an uncommon complication following operations remote from the leg or in supine position including liver transplant. MATERIALS AND METHODS We retrospectively reviewed the medical records of 132 living-donor liver transplant recipients done at our center between September 2006 and December 2008. Various potential preoperative, intraoperative, and postoperative factors were studied in the cases that developed perioperative peroneal neuropathy. RESULTS Peroneal neuropathy was reported in 7 recipients (5.3%) following liver transplant. Apart from intraoperative positioning, other identifiable predisposing factors appear to be poor nutritional status, tall and slender body shape, alcoholic liver disease, and higher pretransplant model for endstage liver disease score. All patients were treated conservatively, including nutritionally balanced diet and vitamin supplements combined with physical rehabilitation therapy. The motor power returned to normal within 6 months in all 7 patients. CONCLUSIONS Perioperative peroneal neuropathy may be contributed by various preoperative factors apart from intraoperative nerve compression. It can be effectively prevented by being aware of the predisposing factors and implicating adequate precautions perioperatively.
Abstract Living donor liver transplantation is an effective, life sustaining surgical treatment in patients with end-stage liver disease and a successful liver transplant requires a close working relationship between the radiologist and the transplant surgeon. There is extreme variability in hepatic vascular anatomy; therefore, preoperative imaging of potential liver donors is crucial not only in donor selection but also helps the surgeons in planning their surgical approach. In this article, we elaborate important aspects in evaluation of potential liver donors on multi-detector computed tomography (MDCT) and the utility of MDCT in presurgical assessment of the hepatic parenchyma, relevant hepatic vascular anatomy and segmental liver volumes.
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.
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