Orthotopic liver transplantation was first carried out by Thomas Starzl in 1963, and has become an established treatment for end-stage liver disease. About 11,000 transplants are done annually worldwide; the main source of donor organs is... more
Orthotopic liver transplantation was first carried out by Thomas Starzl in 1963, and has become an established treatment for end-stage liver disease. About 11,000 transplants are done annually worldwide; the main source of donor organs is the brainstem-dead, heart-beating donor. There are few absolute contraindications to organ donation but, with the increasing waiting list mortality and waiting times, donor acceptance
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BACKGROUND Pre-operative assessment of donor bile duct anatomy is important for planning donor hepatectomy. Rarely the anatomy may be such as to preclude donor hepatectomy. METHOD We retrospectively reviewed 501 cases of donor hepatectomy... more
BACKGROUND Pre-operative assessment of donor bile duct anatomy is important for planning donor hepatectomy. Rarely the anatomy may be such as to preclude donor hepatectomy. METHOD We retrospectively reviewed 501 cases of donor hepatectomy for Living donor liver transplantation ( LDLT) performed during 2004-2010. Preoperative evaluation of donor biliary anatomy was done using Magnetic resonance cholangiopancreatography (MRCP). MRCP included nonenhanced T1 and weighted T2 images obtained on a 1.5 T and later 3.0 T scanners (since April 2009). Intraoperative cholangiogram( IOC) was performed after cannulating the cystic duct and contrast injection. IOC images were used to classify bile duct anatomy at surgery and were considered to be the gold standard for comparison with MRCP. Huang’s classification for biliary anatomy was used to record our data. The accuracy, positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity of MRCP were calculated. RESULT...
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In patients with complete portal vein thrombosis, the main portal vein is obstructed, resulting in development of hepatopetal collateral vessels. In cases of complete portal vein thrombosis, interventional procedures are challenging, with... more
In patients with complete portal vein thrombosis, the main portal vein is obstructed, resulting in development of hepatopetal collateral vessels. In cases of complete portal vein thrombosis, interventional procedures are challenging, with the greatest difficulty in the form of passing the guide wire across the level of obstruction. A recognizable main portal vein remnant has been deemed as a mandatory criterion in previous reports. Here, we report a case of cavernous trans-formation of the portal vein in a pediatric patient after liver transplant who had no obvious detectable portal vein remnant on radiologic imaging. Using digital subtraction angiography, we were successful in passing a guide wire through the level of obstruction and placing a stent, thus causing successful recanalization of the occluded segment.
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Changing trends in Hepatic artery aneurysms - a single centre experience Nagaraja R , Varma V, Govindasamy M, Mehta N, Kumaran V, Gupta A, Nundy S Department of Surgical Gastroenterology and Liver Transplantation, Department of... more
Changing trends in Hepatic artery aneurysms - a single centre experience Nagaraja R , Varma V, Govindasamy M, Mehta N, Kumaran V, Gupta A, Nundy S Department of Surgical Gastroenterology and Liver Transplantation, Department of Interventional Radiology, Sir Ganga Ram Hospital, New Delhi Abstarct BACKGROUND : Hepatic artery aneurysms (HAAs) are rare and represent 20% to 40% of all visceral artery aneurysms. With time, there has been change in type, cause and presentation of HAAs as well as their management. Although there are many case reports on them, few are published from developing countries as well as few comparing patient outcomes after angioembolisation with surgery against surgery alone. PATIENTS AND METHODS : Retrospective analysis of prospectively maintained database was done for 27 patients admitted with the diagnosis of HAA between February 1999 to April 2011. We divided them into two groups, those who presented before 2007 (Surgery group) and after 2007 (angio-embolisat...
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While liver surgery has become safer with improvements in peri-operative management, parenchymal resection is the part of the procedure which is associated with major loss of blood and damage to important structures if not performed... more
While liver surgery has become safer with improvements in peri-operative management, parenchymal resection is the part of the procedure which is associated with major loss of blood and damage to important structures if not performed carefully. The ideal technique for hepatic parenchymal transection should be quick, easy to perform, reduce intra-operative blood loss and transfusion requirement, reduce post-operative bile leakage, and cause minimal damage to the surrounding hepatic parenchyma-- preferably at the lowest cost possible. This paper is a review of commonly used techniques for liver parenchymal transection during liver resections. According to the literature, there is little benefit of using the complicated and expensive devices over the simpler clamp crushing technique. We in our institution, who perform a large number of liver resections and living donor transplants, prefer to use the clamp crushing technique with a bipolar cautery for most resections and cavitron ultraso...
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Introduction. Duodenal perforation is a common surgical emergency and carries mortality ranging from 4% to 30% reported in Western countries, but there is a paucity of reports from India. We aimed to determine the factors which influence... more
Introduction. Duodenal perforation is a common surgical emergency and carries mortality ranging from 4% to 30% reported in Western countries, but there is a paucity of reports from India. We aimed to determine the factors which influence the surgical outcomes in patients with duodenal perforation. Methods. We retrospectively analyzed prospectively collected data from January 2010 to December 2018. Results. A total of 55 patients were included in the study of which 69% (38) were males and 31% (17) were females (M : F = 4.5 : 2). The mean age was 52.3 years. The cause for duodenal perforation was duodenal ulcer (n = 25, 45.5%), followed by post-ERCP complications (n = 15, 27.3%), surgery (n = 11, 20%), and blunt trauma (n = 4, 7.2%) with perforations localized at D2 (n = 28, 51%) and at D1 (n = 27, 49%). Patients underwent primary repair with an additional diversion procedure (n = 28, 51%) and repair only in 18 (32.8%). There were 21 (38%) deaths. Patients with ERCP-associated duodena...
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Research Interests: Surgery, Medicine, Clinical Sciences, Survival Rate, Bile Duct, and 4 moreResection, Portal vein, hpb, and Hepatectomy
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Background: Despite the high morbidity following Whipple‟s pancreatoduodenectomy operations, there is still a lack of an objective pre-operative tool, based only on clinical and biochemical parameters to predict the outcome following the... more
Background: Despite the high morbidity following Whipple‟s pancreatoduodenectomy operations, there is still a lack of an objective pre-operative tool, based only on clinical and biochemical parameters to predict the outcome following the procedure that might be implemented. Materials and Methods: Using a multivariate regression model, the significant predictors of post-operative outcome were identified in a set of retrospective database of patients (2006-2017), and a risk score developed by binary logistic regression method. This was validated in a set of prospective patients (2017-2020). The model‟s predictive accuracy and discriminative ability were assessed using the receiver operating characteristics (ROC) analysis. Results: On multivariate analysis in the retrospective cohort (n=442), the significant predictors of post-operative outcome were identified as peak bilirubin levels, pre-operative stenting and nature of the disease (Benign/Malignant). A risk score was derived and validated on the prospective cohort (n=182). The mean risk for an unfavourable outcome was 24% for a score of </=7, 44% for a score of 8-14 and 70% for a score of >/=15. This was further tested on the validation cohort for individual risk scores (AUC=0.793). There was no significant difference between observed and expected risk of major complications (p=0.31). Conclusion: The risk score showed a fair accuracy in predicting post-operative morbidity in the prospective cohort. Therefore, we propose this to be used as a quick aid to predict the operative outcome in patients posted for pancreatoduodenectomy on an outpatient basis using simple pre-operative clinical and laboratory variables.
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Introduction. Whipple’s pancreatoduodenectomy (PD) is a formidable operation, associated with a high risk of morbidity and mortality. In the setting of an underlying chronic liver disease, the incidence of complications and mortality... more
Introduction. Whipple’s pancreatoduodenectomy (PD) is a formidable operation, associated with a high risk of morbidity and mortality. In the setting of an underlying chronic liver disease, the incidence of complications and mortality increases manifold. Patients and Outcomes. Of the 112 Whipple’s PD performed between 2018 to 2020 at a high-volume HPB and liver transplant centre, 4 patients underwent the surgery in the background of an underlying chronic liver disease (CLD). All except one were performed in Child’s A cirrhotics. There was a single 30-day mortality in this series of 4 patients that occurred in the background of Child’s B cirrhosis. On follow-up at 1 year, there was one more mortality in the series, owing to liver decompensation following chemotherapy. Conclusion. Judicious preoperative selection criteria, adequate preoperative nutritional and physiological optimisation, and prudent weighing of risk vs. benefit of undergoing Whipple’s PD in periampullary malignancies i...
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Background: The operative mortality after pancreaticoduodenectomy (PD) has declined but morbidity still remains considerable. Post pancreaticoduodenectomy hemorrhage (PPH) occurs in 3-13% of patients following PD. We studied the incidence... more
Background: The operative mortality after pancreaticoduodenectomy (PD) has declined but morbidity still remains considerable. Post pancreaticoduodenectomy hemorrhage (PPH) occurs in 3-13% of patients following PD. We studied the incidence and outcomes of patients with PPH after PD to determine the associated risk factors and effect on hospital stay. Methods: We retrospectively analyzed from a prospectively collected data of patients developing PPH following PD between January 2007 and May 2018. ISGPS definition and grading system were used. By using univariate and multivariate analyses, independent predictors of PPH were identified. Results: Of the 340 patients undergoing PD, PPH occurred in 39 patients (11.5%), of whom 5 (12.8%) had Grade A, 22 (56.4%) had Grade B and 12 (30.8%) had Grade C PPH. Six (15.4%) of the 39 patients with PPH died against an overall mortality in the study population of 16 out of 340 patients (4.7%), reflecting higher mortality (P = 0.019) in patients with PPH . The independent risk factors for PPH were a high pre-operative bilirubin (mean 4.7 vs. 7.4 mg/dl, P = 0.01) and INR (mean 1.2 vs. 1.72, P = 0.024), whereas it was closely followed by but, but not significantly associated with pre-operative biliary stent placement (P = 0.09). Pancreatico-jejunostomy (PJ) leak was seen in 20.7% in non-hemorrhage group vs. 41% in hemorrhage group (P = 0.008) and was an independent risk factor for PPH. Conclusion: PPH occurred in 11.5% of patients and resulted in a mortality four times greater than those without a PPH. It occurred more frequently in patents with a high pre-operative serum bilirubin, INR, biliary stenting or those with a PJ leak.
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Introduction and importance Among the various causes for lower gastrointestinal bleeding, ectopic varices constitute a small chunk. Though rare, these can pose a diagnostic challenge with recurrent bleed leading to multiple admission and... more
Introduction and importance Among the various causes for lower gastrointestinal bleeding, ectopic varices constitute a small chunk. Though rare, these can pose a diagnostic challenge with recurrent bleed leading to multiple admission and blood transfusions. Case presentation A 41-year-old male presented to our department with multiple episodes of melena. On further evaluation with CT angiography, a diagnosis of extrahepatic portal vein obstruction with moderate splenomegaly and ectopic jejunal varix was made. He underwent splenectomy with resection of involved jejunal segment with side to side anastomosis. Clinical discussion The diagnosis of ectopic varices remains elusive in a large number of cases in view of the varied etiology. Various newer endoscopic and imaging modalities can play a diagnostic as well as therapeutic role but this also further complicates the management as there is a lack of substantial guidelines directing the treatment protocol. As a result, we have to resort to a case by case approach for the optimal management in these cases. Conclusion The main modality of management for bleeding ectopic varices is percutaneous or endoscopic. Surgery is reserved for refractory cases, with decompressive shunts combined with segmental resection of involved intestine being at the forefront of surgical options.
Research Interests: Surgery, Medicine, Portal hypertension, Clinical Sciences, Varices, and 3 moreBleed, Anastomosis, and Melena
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BACKGROUND The Clavien-Dindo (CD) grading system reports the most severe of all the postoperative complications. The comprehensive complication index (CCI) sums up all the complications in postoperative period. We compared the CCI and CD... more
BACKGROUND The Clavien-Dindo (CD) grading system reports the most severe of all the postoperative complications. The comprehensive complication index (CCI) sums up all the complications in postoperative period. We compared the CCI and CD to assess which of the two was a better measure of postoperative outcomes. MATERIALS AND METHODS Between June 2015 and December 2016, we recorded the complications using CD grading and CCI in 1000 consecutive patients in our gastrointestinal and hepatopancreaticobiliary surgery unit. The outcome variables studied were postoperative length of hospital stay (LOS), postoperative intensive care unit (ICU) stay, and time to normal activity. The results were expressed as strength of correlation and predictive accuracy of the outcome variables. RESULTS There were 600 males and 400 female patients, with a mean age of 50.3 y. A total of 788 (78.8%) elective and 212(21.2%) emergency procedures were performed. The overall 90-day/in-hospital mortality was 7.9%. Both CD and CCI showed a good correlation with LOS (r = 0.58; P = 0.001, r = 0.57; P = 0.001), ICU stay (r = 0.62; P = 0.002, r = 0.62; P = 0.001), and time to normal activity (r = 0.48; P = 0.01; r = 0.49; P = 0.01). The accuracy of CCI to predict the LOS (area under the curve [AUC] = 0.89; P < 0.001), ICU stay (AUC = 0.85; P < 0.001), and time to normal activity (AUC = 0.76; P < 0.001) was comparable to that of CD (AUC = 0.90; P < 0.001, AUC = 0.87; P < 0.001, AUC = 0.77; P < 0.001). CONCLUSIONS Both CD and CCI were equally accurate in measuring the postoperative outcomes and in their ability to predict the same in patients undergoing gastrointestinal and hepatopancreaticobiliary surgeries. Considering the relative ease of determination of CD, it remains a more commonly used measure for assessing the severity of complications and outcomes compared to CCI.
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OBJECTIVE Evidence favors apolipoprotein B (apoB) over LDL cholesterol as a predictor of cardiovascular events, but data are lacking on coronary artery calcification (CAC), especially in type 2 diabetes, where LDL cholesterol may... more
OBJECTIVE Evidence favors apolipoprotein B (apoB) over LDL cholesterol as a predictor of cardiovascular events, but data are lacking on coronary artery calcification (CAC), especially in type 2 diabetes, where LDL cholesterol may underestimate atherosclerotic burden. We investigated the hypothesis that apoB is a superior marker of CAC relative to LDL cholesterol. RESEARCH DESIGN AND METHODS We performed cross-sectional analyses of white subjects in two community-based studies: the Penn Diabetes Heart Study (N = 611 type 2 diabetic subjects, 71.4% men) and the Study of Inherited Risk of Coronary Atherosclerosis (N = 803 nondiabetic subjects, 52.8% men) using multivariate analysis of apoB and LDL cholesterol stratified by diabetes status. RESULTS In type 2 diabetes, apoB was associated with CAC after adjusting for age, sex, and medications [Tobit regression ratio of increased CAC for 1-SD increase in apoB; 1.36 (95% CI 1.06–1.75), P = 0.016] whereas LDL cholesterol was not [1.09 (0.85...
Research Interests: Endocrinology, Diabetes, Medicine, Multivariate Analysis, Humans, and 15 moreInternal Medicine, Female, Male, Apolipoprotein B, LDL-cholesterol, Aged, Middle Aged, Calcinosis, Adult, European Continental Ancestry Group, Biological markers, Coronary Artery Disease, Reference Values, Cross Sectional Studies, and Medical and Health Sciences
Background: Patients with intestinal obstruction consist of a major proportion of emergency room visits and the complication is associated with significant morbidity and mortality. It has a diverse etiology and varies from region to... more
Background: Patients with intestinal obstruction consist of a major proportion of emergency room visits and the complication is associated with significant morbidity and mortality. It has a diverse etiology and varies from region to country. In developed countries it is mainly due to adhesions and in developing countries due to obstructed hernias. Although there are numerous studies from the western world there have been few recent publications from the developing world. Method: We retrospectively analyzed all the patients admitted for intestinal obstruction to our department from January 1996 to December 2019. Their demographic data, duration of symptoms before presenting to the hospital and duration of stay before surgery in the hospital were noted along with cause and level of obstruction. The type of procedure, any post-operative complications, mortality or re-exploration were also noted. Post-operative complications were graded as per Clavien Dindo classification. Results: A to...
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Introduction: The mortality rates for various non-transplant surgical procedures in patients with cirrhosis generally range from 8.3% to 25%. In some reports, the mortality was as high as 70% in patients with poor liver function (high... more
Introduction: The mortality rates for various non-transplant surgical procedures in patients with cirrhosis generally range from 8.3% to 25%. In some reports, the mortality was as high as 70% in patients with poor liver function (high Child’s or model for end-stage liver disease (MELD) scores). Since data are limited, we analyzed our recent experience with cirrhotic patients undergoing emergent or elective non-hepatic gastrointestinal surgery at Sir Ganga Ram Hospital, New Delhi. METHODS: We retrospectively analysed, from a prospectively maintained database the records of all our patients with cirrhosis who underwent non-hepatic gastrointestinal surgery between June 2010 and May 2015. Our main objective was to study their outcome and predictors of mortality RESULTS: 54 non-hepatic gastrointestinal surgical procedures (44 intra-abdominal, 10 abdominal wall) were performed in these patients. Liver cirrhosis was classified according to the Child’s (7 Child’s A, 27 B, 20 C) and ME...
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Introduction. The solid pseudopapillary epithelial neoplasm (SPN) is a rare form of pancreatic neoplasm with an incidence of 2-3% of all pancreatic tumours. The recent increase in incidence is attributed to the increasing use of imaging... more
Introduction. The solid pseudopapillary epithelial neoplasm (SPN) is a rare form of pancreatic neoplasm with an incidence of 2-3% of all pancreatic tumours. The recent increase in incidence is attributed to the increasing use of imaging techniques for nonspecific abdominal complaints. We report our institutional experience in the management of this tumour over the last decade. Method. We retrospectively analyzed from a prospectively maintained database of patients from January 2011 to December 2020 who were operated upon for SPN. All the patients were followed till date. Results. Of 479 patients operated on for various types of pancreatic tumours during this period, 15 (3.1%) had SPN. The mean age of presentation was 28 years with a female preponderance (12/15, 80%). The most common location was the body and tail of the pancreas (66%), and the mean size was 6.4 cm (2–15 cm). The tumour extent was defined as ‘borderline resectable’ in 20% of cases. Distal pancreatectomy was done in 1...
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Minimizing the incidence of hepatic artery thrombosis in living donor liver transplantation Naimish Mehta, Vivek Mangla, Vibha Varma, Shailendra Lalwani, Deepak Chawla, Samiran Nundy Department of Surgical Gastroenterology and Liver... more
Minimizing the incidence of hepatic artery thrombosis in living donor liver transplantation Naimish Mehta, Vivek Mangla, Vibha Varma, Shailendra Lalwani, Deepak Chawla, Samiran Nundy Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi. Background Hepatic artery thrombosis (HAT) following liver transplantation (LT), a major source of morbidity and mortality, is more common in children and after living donor liver transplantation (LDLT). We analyzed the results of our arterial anastomotic technique. Methods Between July 2010 and April 2014, we performed 181 LT procedures (177 Living donor and 4 Deceased donor liver transplants). Out of these, three patients underwent simultaneous liver and kidney transplantation for co-existing chronic kidney disease. Hepatic artery (HA) anastomosis was performed with interrupted 7-0 prolene sutures using a 2.5x loupe magnification in 177 (97.8%) with ‘W’ tecjnique and in 4 (2.2%) patients under ope...
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Background : Progressive familial intrahepatic cholestasis (PFIC) is a rare genetic disease with progressive hepatic fibrosis and eventually leads to liver failure from intrahepatic retention of bile acids. It occurs more frequently in... more
Background : Progressive familial intrahepatic cholestasis (PFIC) is a rare genetic disease with progressive hepatic fibrosis and eventually leads to liver failure from intrahepatic retention of bile acids. It occurs more frequently in consanguineous marriages and it presents in early infancy. Surgical biliary-diversion procedures in patients without cirrhosis have been infrequently described in literature with varying results. We describe our experience with 2 patients who underwent partial biliary diversions - one external and one internal biliary diversion. Case series : An 18 month boy was on follow up since two months of age having presented with hypocalcaemic seizures and icterus. Investigations revealed cholestasis with normal gamma glutamyl transferase levels and DNA defects consistent with PFIC 2. A partial internal biliary diversion (cholecystojejunocolostomy) was done . He had postoperative choleric diarrhea which resolved gradually within two months. At a followup of 4 m...
Research Interests: Medicine and cholestasis
Indications and outcome of urgent redo-laparotomy in a Surgical Gastroenterology Unit. Koirala R, Mehta N, Thiagrajan S, Mahendran G, Chattopadhyay S, Varma V, Kumaran V, Nundy S Department of Surgical Gastroenterology and Liver... more
Indications and outcome of urgent redo-laparotomy in a Surgical Gastroenterology Unit. Koirala R, Mehta N, Thiagrajan S, Mahendran G, Chattopadhyay S, Varma V, Kumaran V, Nundy S Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India ABSTRACT BACKGROUND: A proportion of operations performed in a surgical gastroenterology department are unplanned repeat laparotomies for complications of the original procedure. We examined why these 'redo' laparotomies were performed and what was their outcome. METHOD: We retrospectively analysed, from a prospectively maintained database, the details of 6530 patients who underwent abdominal surgery from September 1996 till December 2009. Of these we focused on the 257 redo laparotomies. RESULTS: In this series gender distribution was 4928 males and 1602 females with a mean age of 48 yrs. Redo-laparotomies were conducted in 193 (2.95%) patients, with 49 patients undergoing more than one re-ex...