National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma

A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.

Safety and efficacy of extended thrombophilia screening directed venous thromboembolic events (VTE) prophylaxis in live liver donors: do we really need extended thrombophilia screening routinely?

Background and aims

The study aimed to determine the prevalence of hereditary thrombophilia, and stratify its severity among live liver donors in Pakistan. Also, the authors evaluated the safety and efficacy of thrombophilia profile testing directed venous thromboembolic events (VTE) prophylaxis while balancing bleeding risk and the need for routine thrombophilia testing before live liver donation among living donor candidates.

Materials and methods

Protein S (PS), protein C (PC), anti-thrombin (AT) III, and anti-phospholipid antibody panel (APLA) levels were measured in 567 potential donor candidates. Donors were divided into normal, borderline and high-risk groups based on Caprini score. The safety endpoints were VTE occurrence, bleeding complications or mortality.

Results

Among 567 donors, 21 (3.7%) were deficient in protein C, and 14 (2.5%) were deficient in anti-thrombin-III. IgM and IgG. Anti-phospholipids antibodies were positive in 2/567 (0.4%) and 2/567 (0.4%), respectively. IgM and IgG lupus anticoagulant antibodies were positive in 3/567 (0.5%) and 3/567 (0.5%), respectively. VTE events, bleeding complications and postoperative living donors liver transplantation-related complications were comparable among the three donor groups (P>0.05). One donor in the normal donor group developed pulmonary embolism, but none of the donors in either borderline or high-risk group developed VTE. The mean length of ICU and total hospital stay were comparable. No donor mortality was observed in all donor groups.

Conclusions

Due to thrombophilia testing directed VTE prophylaxis, VTE events were comparable in normal, borderline and high-risk thrombophilia donor groups, but more evaluations are required to determine the lower safe levels for various thrombophilia parameters including PC, PS and AT-III before surgery among living donor candidates.

Obstacles to the deceased donor transplantation in Pakistan

INTRODUCTION

Transplantation in many Asian countries is moulded by socioeconomic, religious, cultural and health indicators. In most Asian countries, the living-related donation is the common most organ donation. Due to the limited deceased organ donation, live donor programmes flourished in many Asian countries. Another apparent reason for this tremendous growth of living-related programmes in Asian countries is their larger serving population. Several centres from Asia, including Pakistan and India from Southeast Asia and Egypt in Middle East Asia, on the one hand, have recently emerged as leading living donor transplant programmes. On the other hand, a few Asian countries, including Iran and China, have established some of the world's largest deceased donor programmes.

DISCUSSION

In Pakistan, thousands of patients die from end-stage organ failure annually, seeking organ transplants for survival. The exact statics are not available, but over 50 000 people are estimated to die each year as a result of end-stage organ failure without getting a transplant, about 15 000-18 000 from kidney failure, and 10 000 from liver failure and the National Centre for Health Statistics labelled organ failure as a leading cause of death. Despite all these efforts, the knowledge of organ donation among Pakistani people was determined to be around 60%. In Pakistan, the lack of deceased organ donation programmes and the unwillingness of people to deceased organ donation contributes to an increased demand for living organ donation and patients continue to rely on living donors. We discuss various obstacles to deceased organ donation comprising various challenges that form a unique combination, including religious, economic, social, demographic and political factors.Conclusion: Every single effort should be made to initiate and establish multiple deceased donor programmes in Pakistan. Developing the deceased donor programmes in the country will be vital to counter the countrywide increasing organ shortage. The mainstay transplant activities like organ procurement and distribution systems need to be adequately developed. It will help achieve national self-sufficiency and decrease living donors' burden. With education, the behaviour of healthcare professionals and common people can be changed and a positive attitude toward deceased organ donation can be obtained. As healthcare professionals, we should come forward and take responsibility by enrolling ourselves in deceased donors' registration. Public awareness, medical community interest and government support are essential in initiating and establishing deceased donor programmes in Pakistan.

Splenic artery transposition for hepatic arterial supply in living donor liver transplantation

Objective

To determine the safety and outcome of splenic artery(SA) transposition in extra-anatomic hepatic arterial reconstruction (HAR) in living donor liver transplantation(LDLT).

Methods

We retrospectively compared the outcome of the ten liver recipients who underwent HAR with the transposed splenic artery (SA group) with a matched cohort of 40 recipients who underwent HAR with the standard hepatic artery (HA group) between March, 2019 and December, 2020 at liver transplantation department, Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences, Pakistan. The comparison of recipients' and donor demographics, operative and graft characteristics, post-operative labs, Doppler ultrasound(USG) findings, and complications, along with 30-day mortality, and 1-year survival were reported for both groups.

Results

The mean age of patients in the SA group was 42.80±7.510 and in the HA group was 43.73±8.171 years. The common indication of LDLT was viral hepatitis in both groups. The operative duration was longer in the SA group (597.50±41.3156 min) than in the HA group (530.75±66.502 min) with a significant p-value= 0.004. Similarly, blood loss was also more in the SA group (1635±226.139 ml) than in the HA group (1477.50±270.316 ml) (p-value= 0.096). The incidence of biliary and vascular complications, early allograft dysfunction, acute cellular rejection, 30-day mortality, and 1-year survival were comparable in both groups. Post-operatively splenectomy was not needed in any SA group recipients.

Conclusion

The SA is easily approachable, suitable, and safe for HAR in the difficult situation of hepatic arterial flow inadequacy during LDLT due to its appropriate length, and good blood flow.

Cerebral phaeohyphomycosis in liver transplant recipient: A case report

Cerebral phaeohyphomycosis is a fungal brain infection with a high fatality rate. It is caused by dematiaceous fungi and is increasingly recognized as a cause of serious illness in both immunocompetent and immunocompromised patients. We report cerebral phaeohyphomycosis in a liver transplant recipient. He was treated with multiple surgeries and antifungals and made a complete recovery. This report highlights that early and aggressive surgical intervention and extended antifungal coverage can have a positive outcome even in immunocompromised patients. The fungal infection in immunocompromised patients should be considered and treated aggressively.

Central Pancreatectomy for Solid Pseudopapillary Tumour of Pancreas in A 13-Year Girl

Solid Pseudopapillary Tumour (SPT) is a very rare tumour of the pancreas. A 13-year girl presented to us with the complaint of upper abdominal pain and non-bilious vomiting for 15 days. Preoperative diagnosis of SPT involving the body of the pancreas was made by CT scan and ultrasound- guided Trucut biopsy. A sparingly rare procedure of central pancreatectomy with distal pancreatico-jejunostomy was performed. This procedure offers excellent results in benign and low-grade malignant pancreatic neck and body tumours. In addition, it preserves functional elements of the pancreas and also eliminates the infective and haematological effects of splenectomy. Key Words: Solid pseudopapillary tumour, Central pancreatectomy, Pancreatic tumours.

Simultaneous Living Kidney And Liver Transplantation in a Young Male From Two Living Donors

Simultaneous kidney and liver transplantation (SKLT) is the surgical treatment modality for combined liver and kidney failure. Although it is a challenging procedure, but has got the added advantage of a single procedure and common immunosuppression therapy. Recently, the practice of deceased donors SKLT has increased dramatically in the West. However, it is less frequently performed with living donors. Here, we describe a successful SKLT procedure from two separate living donors in a 31-year male, who presented with end-stage renal disease secondary to hypertensive nephropathy and decompensated chronic liver disease secondary to hepatitis C infection. The patient had a smooth recovery and on 1-year follow-up, he is stable. Key Words: Simultaneous, Liver, Kidney, Transplantation.

Liver Transplantation in HIV-Infected Patient

HIV infections have always been a stigma, and the majority of transplant centres avoid liver transplantation in patients having end-stage liver disease patients with HIV coinfection. HIV patients with end-stage liver disease having undetectable HIV viral load, CD4+ cell count of >100/ml, and negative history of AIDS-specific opportunistic infections are considered suitable candidates for liver transplantation. Fulfilling the above-mentioned criteria, we performed successful living donor liver transplantation (LDLT) procedure on a 58-year-old gentleman who presented with end-stage liver disease and HIV coinfection. Key Words: HIV, Living donor, Liver transplantation.

Simultaneous Living Kidney And Liver Transplantation in a Young Male From Two Living Donors

Simultaneous kidney and liver transplantation (SKLT) is the surgical treatment modality for combined liver and kidney failure. Although it is a challenging procedure, but has got the added advantage of a single procedure and common immunosuppression therapy. Recently, the practice of deceased donors SKLT has increased dramatically in the West. However, it is less frequently performed with living donors. Here, we describe a successful SKLT procedure from two separate living donors in a 31-year male, who presented with end-stage renal disease secondary to hypertensive nephropathy and decompensated chronic liver disease secondary to hepatitis C infection. The patient had a smooth recovery and on 1-year follow-up, he is stable. Key Words: Simultaneous, Liver, Kidney, Transplantation.

ABO incompatible living donor liver transplant with antibody titer of 1:4: First case report from Pakistan

Introduction and importance

The most common reason for live liver donor rejection is ABO incompatibility. With breaching this incompatibility barrier, probably an additional 25%–35% of liver transplantation (LT) procedures would become possible. Also, ABOi-LT can be lifesaving in acute settings. Initially, ABOi-LT reported a poor prognosis secondary to antibody-mediated rejection (AMR) which is more common in ABOi allograft recipients. AMR may be avoided by desensitization. Various desensitization protocols are practiced globally, however, there is no consensus available on the optimal desensitization protocol for the ABOi-LT. The ABO-incompatible (ABOi) can expand the liver donor pool tremendously. We report the first case of ABO incompatible-liver transplantation (ABOi-LT) from Pakistan.

Case presentation

A 48 years old male, presented with decompensated liver diseaseand hepatocellular carcinoma secondary to HCV infection. LT was advised as the optimal modality of treatment. Due to the non-availability of a compatible donor, ABOi-LT was planned.His daughter agreed to donate.Pre-LT desensitization was started on the 23rd-day pre-LT with intravenous (I/V) rituximab 700 mg/body (375 mg/m²) along with I/V Bortezomib 2mg (1.3 mg/m²⁾. Bortezomib was repeated subcutaneously (S/C) on the 20th, 16th, and 13th days pre-LT. One week before LT oral Mycophenolate mofetil 500 mg and Tacrolimus 1 mg were started twice daily. Therapeutic plasmapheresis was done on the 5th, 3rd, and 1st-day pre-LT. Per-operatively, Basiliximab was administeredI/V with a dose of 0.8 gm/kg during the anhepatic phase. Anti-A & Anti-B titer level was determined on the 5th day before plasmapheresis and repeated on the 2nd and 1st-day pre-LT. Then post-LT plasmapheresis was done onthe 15th day and at 3 months. The CD 19 activity was determined one day before LT and on the 15th-day post-LT. His LT was performed uneventfully and was discharged on the 15th postoperative day (POD). However, on the 26th POD, he was diagnosed with left subclavian vein thrombosis which was treated successfully with anticoagulation therapy for 6 months. Till the last follow up patient is doing well.

Clinical discussion

Desensitization is the removal of preformed anti-ABO antibodies and depleting serum B cells production. Antibody-mediated rejection irreversibly damages the graft and predisposes it to graft failure. The prognosis of ABOi-LT has dramatically improved since the introduction of desensitization protocols.

Conclusion

Antibody-mediated rejection may be avoided by desensitization. The intravascular infusion therapies and splenectomy can be omitted from the desensitization protocol. ABO-i LT can tremendously increase the liver donor pool.

•

Antibody-mediated rejection could be avoided by desensitization.

•

There is no consensus available on a standardized ABOi-LDLT desensitization protocol.

•

We report the first case of ABOi-LDLT from Pakistan with an antibody titer of 1:4.

•

We used bortezomib along with rituximab and plasmapheresis as a desensitization protocol.

•

In our case, we managed to reduce the anti-body titer to as low as 1:4 before the transplant.

Expanding the living liver donor pool in countries having limited deceased donor activity: Pakistani perspective

Over the last decades, liver transplantation (LT) has evolved into a life-saving procedure. Due to limited deceased donor activities in the eastern world, living donor liver transplantation (LDLT) had flourished tremendously in most Asian countries. Yet, these LDLT activities fall short of meeting the expected demands. Pakistan, a developing country, bears a major burden of liver diseases. Currently, only few centers offer LDLT services in the country. On the other hand, deceased donor liver transplantation (DDLT) activities have not started due to social, cultural, and religious beliefs. Various strategies can be adopted successfully to overcome the scarcity of live liver donors (LLDs) and to expand the donor pool, keeping in view donor safety and recipient outcome. These include consideration of LLDs with underlying clinical conditions like G6PD deficiency and Hepatitis B core positivity. Extended donor criteria can also be utilized and relaxation can be made in various donors' parameters including upper age and body mass index after approval from the multidisciplinary board. Also, left lobe grafts, grafts with various anatomical variations, and a low graft-to-recipient ratio can be considered in appropriate situations. ABO-incompatible LT and donor swapping at times may help in expanding the LLDs pool. Similarly, legislation is needed to allow live non-blood-related donors for organ donations. Finally, community education and awareness through various social media flat forms are needed to promote deceased organ donation.

An Innovation in the Technique of Recipient Hepatectomy in Living Donor Liver Transplantation

Recipient hepatectomy is a challenging surgical procedure. Coagulopathy, multiple collaterals, and dense adhesions secondary to previous spontaneous bacterial peritonitis in cirrhotics are the major contributing factors. However, the appropriate recipient hepatectomy technique can limit the massive blood loss and minimize the operative time. The hepatoduodenal dissection has a key role in recipient hepatectomy. The hilar structures of partial graft in live donor liver transplantation (LDLT) usually have a short length and a small caliber. The concerning task in LDLT recipient hepatectomy is to preserve the integrity, quality, and adequacy of hilar structures for successful implantation. The high hilar dissection technique is usually practiced for getting the adequate length of hilar structures. However, the problems with high hilar dissection inducted the authors to tailor the technique over time. In this report, a modified technique of recipient hepatectomy characterised by the artery-first approach is described. This technique is good in terms of preventing arterial dissection and minimising the anhepatic phase. Key Words: Recipient hepatectomy, Hepatoduodenal dissection, Liver transplantation, Technique.

DRCNNTLe: A deep recurrent convolutional neural network with transfer learning through pre-trained embeddings for automated ICD coding

The International Classification of Diseases (ICD), which is endorsed by the World Health Organization, is a diagnostic classification standard. ICD codes store, retrieve, and analyze health information to make clinical decisions. Currently, ICD coding has been adopted by more than 137 countries. However, in Pakistan, very few hospitals have implemented ICD coding and conducted different epidemiological studies. Moreover, none of them have reported the spectrum of liver disease burden based on ICD coding, nor implemented automated ICD coding. In this study, we annotated ICD codes for the database of the liver transplant unit of the Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences. We named this database Medical Information Mart for Liver Transplantation (MIMLT). The results revealed that the database contains 34 ICD codes, of which V70.8 is the most frequent code. Furthermore, we determined the spectrum of liver disease burden in liver recipients based on ICD coding. We found that chronic hepatitis C (070.54) is the most frequent indication for liver transplantation. Additionally, we implemented automated ICD coding utilizing the MIMLT database and proposed a novel Deep Recurrent Convolutional Neural Network with Transfer Learning through pre-trained Embeddings (DRCNN_TLe) model, which is an extended version of our DRCNN-HP model. DRCNN_TLe extracts robust text representations from its pre-trained embedding layer, which is trained on a large domain-specific MIMIC III database corpus. The results indicate that utilizing pre-trained word embeddings, which are trained on large domain-specific corpora can significantly improve the performance of the DRCNN_TLe model and provide state-of-the-art results when the target database is small.

Role of antibiotic prophylaxis on surgical site infection prevention in a low-risk population undergoing laparoscopic cholecystectomy: A randomized controlled study

Objective

Study design

Setting

Methods

Results

Conclusion

•

One of the postoperative complications following cholecystectomy is surgical site infections (SSIs).

•

This study aimed to determine the effectiveness of preoperative antibiotic prophylaxis in preventing SSIs.

•

We found that prophylactic antibiotics have no impact in preventing SSIs in low-risk individuals undergoing laparoscopic cholecystectomy.

Small-for-Size <em>versus</em> Standard-Size Graft in Living Donor Liver Transplantation

OBJECTIVE

To compare the outcome of small-for-size grafts versus standard-size grafts regarding the frequency of postoperative complications, early graft dysfunction, and 1-year survival.

STUDY DESIGN

Retrospective cohort study.

PLACE AND DURATION OF STUDY

Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences (PAQSJIMS) Hospital, Gambat, Sindh, Pakistan from March 2019 to April 2020.

METHODOLOGY

A total of 147 living donor liver transplant recipients' data were retrospectively evaluated. Study participants were divided into two groups; small-for-size graft (GRWR <0.8%) and standard-size graft (GRWR >0.8%). Recipients' demographics, graft characteristics, operative parameters, postoperative complications, and graft survival were compared in both groups.

RESULTS

Out of 147 recipients, 21 were found to have small-for-size graft, while 126 patients had the standard-size graft. Mean GRWR in small-for-size graft group was 0.73 + 0.4 (0.63-0.79), while 0.93 + 0.82 (0.81-3.0) in standard-size graft group. A statistically significant difference was found while comparing body mass index (p <0.001), hepatic venous reconstruction (p = 0.013), and liver attenuation index (p <0.001) between both study groups. While all other recipient and donor characteristics, demographical data, operative variables, postoperative lab, and complications were comparable in both groups (p >0.05). Kaplan-Meier analysis showed that 1-year survival rate for small-for-size graft recipients was 90.5%, while the survival rate for the standard-size graft was 96.0% (p = 0.272).

CONCLUSION

Frequency of post-op complications was comparable in both groups. The graft survival in small-for-size grafts was as good as for standard-size grafts. Key Words: Living donor liver transplantation, GRWR, Small-for-size graft, Standard-size graft.

Median Arcuate Ligament Compression on Celiac Trunk during Liver Transplantation Procedure

Low insertion of median arcuate ligament (MAL) can cause compression over the celiac trunk with subsequent complications. During liver transplantation procedure, the graft artery is usually anastomosed with the hepatic artery of the recipient, which arises from the celiac trunk. MAL compression might reduce hepatic arterial blood flow to the graft, which can induce postoperative hepatic arterial thrombosis, causing graft failure. Here, we report a case of liver transplant procedure, during which pulsation of hepatic artery of the recipient diminished dramatically, after ligation of gastro-duodenal artery. However, dissection and division of MAL restored excellent hepatic arterial blood flow. This case highlights the significance of prompt diagnosis and management of MAL compression syndrome in liver transplant recipients during transplant surgery. Key Words: Celiac trunk, Median arcuate ligament, Liver transplant.

Challenges of continuation of live liver donor programme during COVID-19 pandemic in Pakistan: outcomes and lessons learned

Background

COVID-19 pandemic has globally affected healthcare including the transplantation programmes.

Materials and methods

We retrospectively studied the impact of COVID-19 on live liver donor (LLD) programme at liver transplant centre in Gambat, Pakistan. Standard operative procedures (SOPs) including COVID-19 nasopharyngeal swab PCR, CT scans, personal protective equipment use, 6-feet distancing were developed for LLD and transplant team to mitigate COVID-19 exposure. We compared the complications, healthcare utilisation (hospital stay, readmission) and mortality between two LLD cohorts—before and during COVID-19 pandemic from March 2019 to December 2020.

Results

During study period 300 LLD surgeries were performed. There was an increase in rate of LLDs from 132 (44%) in pre-COVID to 168 (56%) during COVID-19 era. Average numbers of transplants per month performed during pre-COVID and during COVID-19 era were 10.1 and 14, respectively. No donor has developed COVID-19 infection during hospitalisation. Rate of all LLD complications (32 (21.47%) and 49 (29.16%), p=0.43), uneventful discharges (120/168 (71.4%) and 88/132 (66.6%), p<0.05), mean hospital stay (6±2 days and 5±2 days, p=0.17) and readmission (5 (4%) and 3 (1.8%), p=0.43) were similar during the pre-COVID and COVID-19 era. No donor mortality was observed during study period.

Conclusion

With the implementation of mindful SOPs, rate of LLD increased without any case of COVID-19 infection. Our SOPs were helpful in continuation of LLD programme in a developing country during COVID-19 pandemic.

Frequency and Outcome of Hepatic Arterial Thrombosis in Recipients of Living Donor Liver Transplantation

ABASTRACT Objective: To determine the frequency, risk factors, and management of hepatic arterial thrombosis (HAT) in recipients of living donor living transplantation.

STUDY DESIGN

Cohort study.

PLACE AND DURATION OF STUDY

Department of Liver Transplant, Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences, Gambat, Sindh, Pakistan, from 1st January 2019 to 31st July 2020.

METHODOLOGY

Two hundred and forty living donor liver transplants (LDLT) recipients' data were evaluated. Frequencies of HAT were recorded, and various risk factors for the development of HAT were analysed by comparing HAT group (n = 12) and non-HAT group (n = 228). Management and outcome of HAT cases were also reviewed. Statistical analysis of this study was done with SPSS software version 21.

RESULTS

Out of 240 patients, 212 (88.3%) were males. Overall mean age was 39.40 ± 12.14 years. Mean model for end-stage liver disease (MELD) score was 18.70 ± 4.98. Overall male to female ratio was 7.5:1. The common indication for LDLT in these patients was chronic liver disease secondary to hepatitis B and C virus infection in 85% of patients. Postoperative HAT incidence was found as 5%.  Risk factor found statistically significant was intraoperative platelet transfusion.

CONCLUSION

HAT is a deadly complication and needs early detection to avoid graft loss. The risk factor documented in this study should be avoided, if possible. Moreover, prompt and quick action is necessary for re-vascularisation to avoid re-transplantation. Key Words: Living donor, Hepatic arterial thrombosis, Liver transplantation.

Primary biliary cirrhosis in early childhood - A rare case report

INTRODUCTION AND IMPORTANCE

Primary biliary cirrhosis (PBC) is a chronic and progressive autoimmune liver disease with no known etiology. This disease is mainly characterized by granulomatous destruction of intrahepatic biliary ducts, severe peri-portal inflammation, and ultimate progress to liver fibrosis and cirrhosis. Here, we report a five-year-old girl diagnosed with PBC, presented to us with end-stage liver disease for liver transplantation. Our patient successfully underwent liver transplantation with an uneventful recovery. This case highlights the need for awareness to report further PBC cases in the pediatric age group.

CASE PRESENTATION

A five-year old female child presented with a 6 months history of progressive jaundice. She had multiple admissions for hepatic encephalopathy and this time she was admitted for hepatic transplantation. On examination, she was icteric and had hepatomegaly. After thorough workup, she underwent successful hepatic transplantation and was alright post-operatively. At 6 months follow up, she is doing well.

CONCLUSION

PBC is rare in childhood. The natural history and exact incidence of PBC in childhood are not known. Hence, there is a need for awareness to report further PBC cases in the pediatric age group.