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Pahari H, Chaudhary RJ, Thiagarajan S, Raut V, Babu R, Bhangui P, Goja S, Rastogi A, Vohra V, Soin AS. Hepatic Venous and Inferior Vena Cava Morphology No Longer a Barrier to Living Donor Liver Transplantation for Budd-Chiari Syndrome: Surgical Techniques and Outcomes. Transplant Proc 2017; 48:2732-2737. [PMID: 27788809 DOI: 10.1016/j.transproceed.2016.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 08/03/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Living donor liver transplantation (LDLT) for Budd-Chiari syndrome (BCS) has been reported with <10 inferior vena cava (IVC) replacements with vascular/synthetic graft. The goal of this study was to review outcomes of LDLT for BCS at our center, with an emphasis on surgical techniques and postoperative anticoagulation therapy. METHODS Between October 2011 and December 2015, a total of 1027 LDLTs were performed. Nine of these patients had BCS. We analyzed their etiologies, operative details, postoperative complications, and outcomes. RESULTS The indication was chronic liver disease for all patients. Two patients required retrohepatic IVC replacement with a polytetrafluoroethylene graft due to severe adhesions and thrombosis, respectively. One patient required V-Y plasty for suprahepatic IVC narrowing. Five patients had portal venous thrombosis, 3 treated by thrombectomy, and 1 by renoportal anastomosis. The mean follow-up time was 18 ± 16 months. Only 1 early death occurred due to sepsis. The anticoagulation therapy involved heparin infusion from postoperative day 1, conversion to low-molecular-weight-heparin on postoperative days 3 to 6, followed by warfarin (postoperative days 9-16 to maintain an international normalized ratio of 2-3 long term), along with low-dose aspirin for 6 months. There was no recurrence of thrombosis. CONCLUSIONS LDLT for BCS is well documented in literature. Prevention of recurrent thrombosis depends on meticulous surgical technique, perfect and wide outflow anastomoses, and a strict anticoagulation protocol. A synthetic (polytetrafluoroethylene) graft for IVC interposition is a safe and feasible option for reconstruction with good results. Low-dose aspirin with low-molecular-weight-heparin later converted to warfarin provides excellent results and prevents recurrence of thrombosis.
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Affiliation(s)
- H Pahari
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, India.
| | - R J Chaudhary
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, India
| | - S Thiagarajan
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, India
| | - V Raut
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, India
| | - R Babu
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, India
| | - P Bhangui
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, India
| | - S Goja
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, India
| | - A Rastogi
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, India
| | - V Vohra
- Department of Liver Transplant, GI Anaesthesia and Intensive Care, Medanta The Medicity, Gurgaon, India
| | - A S Soin
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, India
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Goja S, Singh MK, Soin AS. Robotics in hepatobiliary surgery-initial experience, first reported case series from India. Int J Surg Case Rep 2017; 33:16-20. [PMID: 28262591 PMCID: PMC5334495 DOI: 10.1016/j.ijscr.2017.02.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 02/13/2017] [Accepted: 02/13/2017] [Indexed: 01/01/2023] Open
Abstract
Utility of robotic system for heterogenous mix of hepatobiliary cases. Ability of robotic system to perform complex hepatobiliary cases. Advantages of minimal access surgery but at a higher cost.
Introduction Robotic surgical system's ability to perform complex hepatobiliary surgeries is gaining momentum with outcomes similar to open surgery and advantages of minimal access surgery. The authors present their initial experience of a heterogenous spectrum of robotic hepatobiliary cases and the first reported case series from India. Methods Retrospective review of hepatobiliary cases done robotically from February 2015 to January 2016 was done. Results The series has ten patients; with median age of 45 years (range 15–72). Etiologies were choledochal cyst type IVa, benign lower end common bile duct stricture (biliary reconstruction group); incidental gallbladder carcinoma, hepatocellular carcinoma, recurrent pyogenic cholangitis, polycystic liver disease, hemangioma, liver metastases, hydatid cyst (resection group). Median operative duration was 510 min; one patient needed intra-operative blood transfusion and there were no conversions to open surgery. One patient developed bile leak which was managed by biliary stenting and another thrombotic thrombocytopenic purpura during post-operative period. Median length of hospital stay was 6 days with average cost of robotic surgery being $1700 USD more for major hepatectomy and $900 USD more for biliary reconstruction compared to open procedure. Conclusion This initial series adds to existing data on the feasibility of robotic hepatobiliary cases with inherent advantages of minimal invasive surgery, however with limitation of availability and use of devices like cavitron ultrasonic surgical aspirator (CUSA) and higher operative cost.
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Affiliation(s)
- S Goja
- Medanta Institute of Liver Diseases and Transplantation, Medanta-The Medicity, Delhi, NCR, India.
| | - M K Singh
- Medanta Institute of Liver Diseases and Transplantation, Medanta-The Medicity, Delhi, NCR, India
| | - A S Soin
- Medanta Institute of Liver Diseases and Transplantation, Medanta-The Medicity, Delhi, NCR, India
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Choudhary NS, Saraf N, Saigal S, Mohanka R, Rastogi A, Goja S, Menon PB, Soin AS. Low-dose short-term hepatitis B immunoglobulin with high genetic barrier antivirals: the ideal post-transplant hepatitis B virus prophylaxis? Transpl Infect Dis 2015; 17:329-33. [PMID: 25682715 DOI: 10.1111/tid.12369] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 12/02/2014] [Accepted: 01/28/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Low-dose hepatitis B immunoglobulin (HBIG) and nucleos(t)ides analogs (lamivudine/adefovir) used for the prevention of hepatitis B virus (HBV) recurrence after liver transplantation (LT) are associated with some risk of HBV recurrence and antiviral resistance. METHODS The study cohort included 176 patients (at least >12 months follow-up) with HBV cirrhosis/hepatocellular carcinoma who received secondary prophylaxis with indefinite entecavir/tenofovir after living-donor LT (LDLT). All patients received 10,000 IU intravenous HBIG in anhepatic phase followed by 600-1000 IU intramuscularly daily for 7 days, weekly for 3 weeks, and then monthly, to keep antiHBs levels >100 mIU/mL for 1 year. Hepatitis B surface antigen (HBsAg) and HBV DNA were tested every 6 months. RESULTS The study cohort is composed of 157 men and 19 women, mean age 47.9 ± 10.1 years, all HBsAg positive, 35 (19.8%) had HBV DNA >2000 IU/mL before LT. After LT, patients received entecavir (n = 126, 71.5%), tenofovir (n = 20, 11.3%), or a combination of entecavir and tenofovir (n = 30, 17% for 3 months), followed by entecavir alone. During follow-up of 43 (12-117) months, 2 patients (including 1 with non-compliance) had HBV recurrence. CONCLUSION In a large cohort of LDLT recipients for HBV-related liver disease, use of low-dose short-term HBIG with high genetic barrier drugs results in a substantially lower incidence of HBV recurrence, even in high-risk patients.
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Affiliation(s)
- N S Choudhary
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, Haryana, India
| | - N Saraf
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, Haryana, India
| | - S Saigal
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, Haryana, India
| | - R Mohanka
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, Haryana, India
| | - A Rastogi
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, Haryana, India
| | - S Goja
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, Haryana, India
| | - P B Menon
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, Haryana, India
| | - A S Soin
- Medanta Liver Institute, Medanta The Medicity, Gurgaon, Haryana, India
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Soin AS, Mohanka R, Saraf N, Rastogi A, Goja S, Menon B, Vohra V, Saigal S, Sud R, Kumar D, Bhangui P, Ramachandra S, Singla P, Shetty G, Raghvendra K, Elmagd KMA. India's first successful intestinal transplant: the road traveled and the lessons learnt. Indian J Gastroenterol 2014; 33:104-13. [PMID: 24500752 DOI: 10.1007/s12664-013-0437-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 12/14/2013] [Indexed: 02/04/2023]
Abstract
Intestinal transplant is a therapeutic challenge not just surgically but also logistically because of the multidisciplinary expertise and resources required. A large proportion of patients who undergo massive bowel resection and develop intestinal failure have poor outcome, because of inability to sustain long-term parenteral nutrition and limited availability of intestinal and multi-visceral transplantation facilities. We report the first successful isolated intestinal transplant from India.
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Affiliation(s)
- A S Soin
- Medanta Institute of Liver Diseases and Transplantation, Medanta-The Medicity, Sector 38, Gurgaon, Haryana, 122 001, India,
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Soin AS, Raut V, Mohanka R, Rastogi A, Goja S, Balachandran M, Saigal S, Saraf N, Bhangui P, Sumana KR, Singla P, Srinivasan T, Choudhary N, Tiwari A, Raina V, Govil D, Mohan N, Vohra V. Use of ABO-incompatible grafts in living donor liver transplantation--first report from India. Indian J Gastroenterol 2014; 33:72-6. [PMID: 24369388 DOI: 10.1007/s12664-013-0424-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 10/13/2013] [Indexed: 02/04/2023]
Abstract
ABO incompatibility is the commonest reason for rejection of donors in living donor liver transplantation (LDLT). The donor pool could be expanded by 25 % to 35 % if the ABO barrier is overcome. In the absence of pre-conditioning, transplantation across the blood groups is fraught with the almost universal risk of antibody-mediated rejection (AMR) that rapidly leads to graft loss. However, AMR can be prevented by removal of preformed antibodies and reducing their production by B cells. We describe our initial experience of three cases of ABO-incompatible (ABO-i) LDLT: a 42-year-old male, an 8-month-old male and a 28-month-old female, all of blood group O+ who received blood group B + right lobe, B + left lateral segment, and A + left lateral segment liver grafts, respectively. Pre-LDLT conditioning included administration of anti-CD20 antibody (Rituximab(®)) to the adult 4 weeks prior, and four to seven sessions of double-filtration plasmapheresis to all, to remove preformed antibodies and achieve anti-donor blood group antibody (ADA) titers of ≤ 1:16 IgG and ≤ 1:8 IgM, respectively. In addition, cases 1 and 3 received mycophenolate mofetil for 7 days prior to LDLT. After LDLT, all three patients achieved normal graft function over 8-17 days with no evidence of AMR and without the need for further plasmapheresis. Postoperative complications included portal vein thrombosis (one successfully re-explored), CMV (one), Pseudomonas and Klebsiella sepsis (one each), and abdominal collection (one treated with percutaneous drainage). All are currently well with normal graft function and low ADA titers at 8, 16, and 19 months after ABO-i LDLT.
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Affiliation(s)
- A S Soin
- Medanta Institute of Liver Diseases and Transplantation, Medanta-The Medicity, Gurgaon, Haryana, 122 001, India,
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Saigal S, Saraf N, Ragesh B, Mohanka R, Kakodkar R, Rastogi A, Goja S, Balachandran P, Soin A. 30 excellent outcome of living donor liver transplantation in patients with hepatopulmonary syndrome-a single center experience. J Clin Exp Hepatol 2011; 1:146. [PMID: 25755358 PMCID: PMC3940397 DOI: 10.1016/s0973-6883(11)60167-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Bhangui P, Mohanka R, Saigal S, Kakodkar R, Rastogi A, Goja S, Menon B, Saraf N, Mohan N, Soin A. 6 tuberculosis and living donor liver transplantation-a 7-year experience from India. J Clin Exp Hepatol 2011; 1:135-6. [PMID: 25755334 PMCID: PMC3940131 DOI: 10.1016/s0973-6883(11)60143-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Ramachandra S, Saigal S, Saraf N, Kakodkar R, Mohanka R, Goja S, Rastogi A, Menon B, Baijal S, Soin A. 23 postliver biopsy arterioportal fistula in living donor liver transplant-a case report. J Clin Exp Hepatol 2011; 1:143-4. [PMID: 25755352 PMCID: PMC3940248 DOI: 10.1016/s0973-6883(11)60160-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Soin AS, Kakodkar R, Mohanka R, Rastogi A, Balachandran M, Goja S, Mohan N. 11 reduced left lateral sector liver transplantation in children under 10 kg-less is better. J Clin Exp Hepatol 2011; 1:138. [PMID: 25755340 PMCID: PMC3940185 DOI: 10.1016/s0973-6883(11)60148-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Vij V, Ramaswamy VK, Goja S, Dargan P, Mallya A, Goyal N, Gupta S. Intraoperative no go donor hepatectomy in living donor liver transplantation. Am J Transplant 2010; 10:2181-2; author reply 2183. [PMID: 20883553 DOI: 10.1111/j.1600-6143.2010.03155.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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