Single-Lobe Living Donor Liver Transplant in a Morbidly Obese Cirrhotic Patient Preceded by Laparoscopic Sleeve Gastrectomy

Nonalcoholic steatohepatitis (NASH) is a stage of nonalcoholic fatty liver disease (NAFLD), and, in most patients, it is associated with obesity and metabolic syndrome with progression to end-stage liver disease in about 20% of patients (McCullough (2004); Matteoni et al. (1999); Liou and Kowdley (2006)). It has been estimated that between 20 and 30% of patients with end-stage cirrhosis referred for liver transplantation (LT) evaluation and 30 to 70% of LT recipients exhibit some degree of obesity (Muñoz and ElGenaidi (2005)). Management of obesity in chronic liver disease patients is not only difficult but also preludes them from undergoing major bariatric surgery due to associated high morbidity and mortality. Here, we present a case report of a morbidly obese patient who underwent laparoscopic sleeve gastrectomy followed by single-lobe living donor liver transplantation (LDLT) with a successful outcome. We believe that this is the first report of successful LDLT following planned weight loss to facilitate LDLT

Perioperative monitoring of intracranial pressure using optic nerve sheath diameter in paediatric liver transplantation

An elevation of intracranial pressure (ICP) secondary to cerebral oedema is a major contributor to morbidity and mortality in acute liver failure (ALF). We present a case of ICP monitoring with ocular ultrasonography in a 2-year-old child with ALF for liver transplantation. Since invasive ICP monitoring was risky considering the level of coagulopathy, optic nerve sheath diameter (ONSD) monitoring was done by ultrasound. A value of 4.5 mm was chosen as the cut-off for an ICP >20 mmHg in this child and was checked at regular intervals during the surgery. Ultrasonographic ONSD assessment can be a useful modality in liver transplant recipients, with severe coagulopathy and high ICP. In our specific patient scenario, ocular ultrasound proved to be a valuable safe and noninvasive monitoring tool in this paediatric patient

Mechanisms of Resistance and Therapeutic Perspectives in Immunotherapy for Advanced Head and Neck Cancers

Immunotherapy is emerging as an effective treatment for advanced head and neck cancers and interest in this treatment modality has led to rapid expansion of this research. Pembrolizumab and nivolumab, monoclonal antibodies directed against the programmed cell death-1 (PD-1) receptor, are US Food and Drug Administration (FDA)- and European Medical Agency (EMA)-approved immunotherapies for head and neck squamous cell carcinoma (HNSCC). Resistance to immunotherapy is common, with about 60% of patients with recurrent or metastatic HNSCC not responding to immunotherapy and only 20–30% of patients without disease progression in the long term. Overcoming resistance to immunotherapy is therefore essential for augmenting the effectiveness of immunotherapy in HNSCC. This review details the innate and adaptive mechanisms by which head and neck cancers can become resistant to immunotherapeutic agents, biomarkers that can be used for immunotherapy patient selection, as well as other factors of the tumor microenvironment correlated with therapeutic response and prognosis. Numerous combinations and novel immunotherapies are currently being trialed, based on better understood immune evasion mechanisms. These potential treatments hold the promise of overcoming resistance to immunotherapy in head and neck cancers

Novel Immunotherapeutic Approaches for Head and Neck Squamous Cell Carcinoma

The immune system plays a key role in preventing tumor formation by recognizing and destroying malignant cells. For over a century, researchers have attempted to harness the immune response as a cancer treatment, although this approach has only recently achieved clinical success. Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer worldwide and is associated with cigarette smoking, alcohol consumption, betel nut use, and human papillomavirus infection. Unfortunately, worldwide mortality from HNSCC remains high, partially due to limits on therapy secondary to the significant morbidity associated with current treatments. Therefore, immunotherapeutic approaches to HNSCC treatment are attractive for their potential to reduce morbidity while improving survival. However, the application of immunotherapies to this disease has been challenging because HNSCC is profoundly immunosuppressive, resulting in decreased absolute lymphocyte counts, impaired natural killer cell function, reduced antigen-presenting cell function, and a tumor-permissive cytokine profile. Despite these challenges, numerous clinical trials testing the safety and efficacy of immunotherapeutic approaches to HNSCC treatment are currently underway, many of which have produced promising results. This review will summarize immunotherapeutic approaches to HNSCC that are currently undergoing clinical trials

Does situs inversus totalis preclude liver donation in living donor liver transplantation? A series of 3 cases from single institution

Introduction: Liver transplantation (LT) is the gold standard for decompensated Chronic Liver Disease (CLD) in individuals satisfying the selection criteria. Organ scarcity is the rate limiting step in liver transplantation across the globe. Expanding the donor pool is practiced by transplant surgeons across the globe in view of perennial donor organ scarcity and ever increasing organ demand. Presentation of case: We have presented series of 3 cases of liver transplantation (LT) with modified left lobe (conventional right) graft from a situs inversus donor and implanting it as a conventional right lobe with a modified technique. The grafts had Type 1, Type 2 and Type 3 biliary anatomies. One graft had inferior hepatic veins also. All three patients had uneventful recoveries. The follow up period range is 4 years to 8 months. Discussion: There are multiple case reports in the literature involving situs inversus donors in liver transplantation. Various techniques have also been described. We describe simple and effective technique which has proved successful to our patients. Conclusion: SIT donors can be safely accepted for living donor liver transplantation. It is a technically challenging procedure both for donor liver harvesting and implantation in recipient. This is the first case series of LT using modified left lobe graft (conventional right) from a SIT donor with 2 different techniques. Biliary anastomosis is the tricky part of the operation

Precholecystectomy ERCP in follow up cases of gallstone pancreatitis. Is it necessary?

Background/Objective: The need for a routine ERCP prior to cholecystectomy in all follow up cases of gallstone pancreatitis; the incidence of choledocholithiasis in these cases and to define radiological and biochemical criteria that would necessitate a precholecystectomy ERCP. Materials and Methods: 42 patients of severe gallstone pancreatitis were treated in the hospital during the period 1st January - December 31st 2001. The severity of acute pancreatitis was based on Ranson's scoring system. All were conservatively managed during the initial phase of hospitalization, which ranged from 11-31 days. Standard radiological and biochemical investigations for acute pancreatitis were done in all cases. They were advised to undergo ERCP followed by cholecystectomy within 3-4 weeks. However only 36 patients came back for follow up and they form the study group. Ultrasound of abdomen and liver function tests were repeated in all of them prior to ERCP. All of them subsequently underwent cholecystectomy, 34 of them laparoscopically. Results: Only 3(8.3%) had choledocholithiasis on ERCP. The CBD was cleared of stones during the same procedure and patients underwent cholecystectomy subsequently. Ultrasound showed choledocholithiasis in 2 and the alkaline phosphatase (AKP) and aspartate transaminases (AST) were raised in 2 patients. Conclusion: A precholecystectomy ERCP should be performed in follow up cases of gallstone pancreatitis only if there are sonological features suggestive of choledocholithiasis and/or an elevation specifically of alkaline phosphatase and aspartate transaminase in the liver function tests

Letter to the Editor of Journal of Otolaryngology regarding “Risk of diabetes in patients with sleep apnea: comparison of surgery versus CPAP in a long-term follow-up study”

Abstract Obstructive sleep apnea (OSA) is associated with multiple chronic comorbidities with treatments including continuous positive airway pressure (CPAP), upper airway surgery (UAS), and hypoglossal nerve stimulation (HNS). Given the complexity of the condition and multiple treatment options, there is an ongoing debate to determine the best management. O’Connor-Reina et al. recently published a paper titled “Risk of diabetes in patients with sleep apnea: comparison of surgery versus CPAP in a long-term follow-up study.” In their study, the authors stated that OSA patients who received surgery had a 50% less chance of developing diabetes compared to patients who only received CPAP treatment. However, we would like to point out some limitations that warrant attention and caution interpretation of the findings by physicians and patients

Precholecystectomy ERCP in follow up cases of gallstone pancreatitis. Is it necessary?

Background/Objective: The need for a routine ERCP prior to cholecystectomy in all follow up cases of gallstone pancreatitis; the incidence of choledocholithiasis in these cases and to define radiological and biochemical criteria that would necessitate a precholecystectomy ERCP. Materials and Methods: 42 patients of severe gallstone pancreatitis were treated in the hospital during the period 1st January - December 31st 2001. The severity of acute pancreatitis was based on Ranson's scoring system. All were conservatively managed during the initial phase of hospitalization, which ranged from 11-31 days. Standard radiological and biochemical investigations for acute pancreatitis were done in all cases. They were advised to undergo ERCP followed by cholecystectomy within 3-4 weeks. However only 36 patients came back for follow up and they form the study group. Ultrasound of abdomen and liver function tests were repeated in all of them prior to ERCP. All of them subsequently underwent cholecystectomy, 34 of them laparoscopically. Results: Only 3(8.3%) had choledocholithiasis on ERCP. The CBD was cleared of stones during the same procedure and patients underwent cholecystectomy subsequently. Ultrasound showed choledocholithiasis in 2 and the alkaline phosphatase (AKP) and aspartate transaminases (AST) were raised in 2 patients. Conclusion: A precholecystectomy ERCP should be performed in follow up cases of gallstone pancreatitis only if there are sonological features suggestive of choledocholithiasis and/or an elevation specifically of alkaline phosphatase and aspartate transaminase in the liver function tests