Primary Liability under Excess Insurance Clauses: State Capital Insurance Co. v. Mutual Assurance Society Against Fire on Buildings

Insurance is a contract by which the insurer undertakes to indemnify the insured against loss arising from the destruction of or injury to the insured\u27s property as a result of certain causes. By its very nature an indemnity contract obligates the insurer to reimburse the insured for the amount of actual loss suffered by the insured. There are, however, situations in which multiple insurance coverage exists; that is, the same interest and the same risk are insured at the same time by more than one separate and distinct insurance contract, each presumably liable in the event of loss of or destruction to the insurable interest. Where multiple insurance exists, a loss occurs, and every policy meets its obligation to reimburse the insured for loss suffered, the insured gets a windfall, and the indemnity principle underlying the insurance concept is violated. A perplexing problem then arises in determining which insurer should be held primarily liable for reimbursing the insured for the loss suffered, and, if all insurers are primarily liable, how to apportion the loss among them

Combined Piggyback Technique and Cavoportal Hemitransposition for Liver Transplant

Portal Vein thrombosis (PVT) increases the difficulty of liver transplant; however, it is not an absolute contraindication. Cavoportal hemitransposition (CPH) is an option for patients with complete PVT and no alternative collateral vein. Our center often performs the piggyback technique for the hepatic vein reconstruction, which allows for great access to the recipient vena cava in patients with known complete PVT that may need a CPH preformed to successfully restore flow to the portal system of the donor liver. We describe the use of the piggy-back technique to prepare the vena cava for possible CPH in patients with known complete PVT

Direct Anastomosis of the Donor Hepatic Artery to the Supraceliac Aorta without Extension Graft during Adult Liver Transplant in the Era of Extended Criteria Donors: Report of a Case

Arguably, one of the most challenging aspects of liver transplant surgery is the hepatic artery reconstruction. When the donor and recipient arteries are normal, this anastomosis can still be difficult. However, when the recipient artery has been dissected or is small other alternative reconstructions must be considered. Routinely, the donor surgery includes removing the iliac artery and vein specifically to aid in alternative reconstruction techniques. With the increase use of extended criteria donors (i.e., specifically age >55) the iliac vessel may be unusable because of atherosclerotic disease. This paper describes revisiting an alternative technique for hepatic artery reconstruction during cadaveric liver transplant when the recipient artery has been dissected and the iliac vessels were unusable secondary to arterial plaque from a 75 yo donor. Herein, we describe the successful anastomosis of the celiac artery with aortic patch from the donor directly to the supraceliac aorta of the adult recipient

A Decade of Experience Using mTor Inhibitors in Liver Transplantation

Some studies suggest that Sirolimus (SRL) is associated with an increased risk of death in liver transplant recipients compared to treatment with calcineurin inhibitors (CNIs). We compared patients who received SRL or CNI in the first year after liver transplant. Our database included 688 patients who received a liver transplant. The patients were divided into groups. (1) CNI + MPS (mycophenolate sodium) at time of discharge. (2) CNI + MPS at time of discharge; SRL was added within the first 6 months and continued through the first year. (3) CNI + MPS at time of discharge; SRL was added within the first 6 months and discontinued before the first year. (4) SRL as primary immunosuppression. (5) SRL as primary immunosuppression and discontinued before the first year. We used mortality and graft loss as the primary measures of outcome. We also quantified renal function using the change in glomerular filtration rate (GFR), the presence of biopsy proven acute cellular reject (ACR), and steroid-resistant rejection (SRR). There were no significant differences in mortality or graft loss. There was no difference in patient or graft survival. Patients that received SRL as primary immunosuppression had 50% less rejection compared to controls

Judge Robert R. Merhige, Jr. - Strict Constructionist Weathers the Storm

On August 27, 1967, Robert R. Merhige, Jr., was commissioned as a United States District Court Judge for the Eastern District of Virginia, the embarkment upon what many members of the legal community have labeled a controversial judicial career. However, examination of Judge Merhige\u27s numerous decisions reveals that his image as a disputatius public figure has been more than a function of his flare for vehemently enforcing pronouncements and policies of the Supreme Court. The man, who created fervor throughout this state and the South with his publicly chastised busing decisions of the early 1970s, has been a victim of timing rather than an implementor of unprecedented legal reasoning. He was appointed to the bench amidst the turmoil of an emotionally charged social climate and at a time when the federal forum was beginning to expand and blossom for a host of grievances such as school busing, sexual discrimination and prisoners rights. Oddly, throughout his judicial career, Judge Merhige has perceived himself as a strict constructionist \u27 striving avidly to adhere to judicial precedents in decisions transcending the spectrum of constitutional issues. It is the intent of this note to examine Judge Merhige\u27s judicial philosophy in the areas of equal protection, the first amendment, due process and administrative law as compared to federal precedents and trends existing at the time of his opinions

Donor Complications Following Laparoscopic Compared to Hand-Assisted Living Donor Nephrectomy: An Analysis of the Literature

There are two approaches to laparoscopic donor nephrectomy: standard laparoscopic donor nephrectomy (LDN) and hand-assisted laparoscopic donor nephrectomy (HALDN). In this study we report the operative statistics and donor complications associated with LDN and HALDN from large-center peer-reviewed publications. Methods. We conducted PubMed and Ovid searches to identify LDN and HALDN outcome studies that were published after 2004. Results. There were 37 peer-reviewed studies, each with more than 150 patients. Cumulatively, over 9000 patients were included in this study. LDN donors experienced a higher rate of intraoperative complications than HALDN donors (5.2% versus. 2.0%, P < .001). Investigators did not report a significant difference in the rate of major postoperative complications between the two groups (LDN 0.5% versus HALDN 0.7%, P = .111). However, conversion to open procedures from vascular injury was reported more frequently in LDN procedures (0.8% versus 0.4%, P = .047). Conclusion. At present there is no evidence to support the use of one laparoscopic approach in preference to the other. There are trends in the data suggesting that intraoperative injuries are more common in LDN while minor postoperative complications are more common in HALDN

Liver and Intestine Transplantation in the United States 1998–2007

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75730/1/j.1600-6143.2009.02567.x.pd

Biliary reconstruction in liver transplant patients with primary sclerosing cholangitis, duct‐to‐duct or Roux‐en‐Y?

IntroductionRoux‐en‐Y choledochojejunostomy and duct‐to‐duct (D‐D) anastomosis are biliary reconstruction methods for liver transplantation. However, there is a controversy over which method produces better results. We have compared the outcome of D‐D anastomosis vs. Roux‐en‐Y hepaticojejunostomy in patients with primary sclerosing cholangitis who had undergone liver transplant in Shiraz Organ Transplant Center.MaterialsThe medical records of 405 patients with primary sclerosing cholangitis (PSC) who had undergone liver transplant from 1996 to 2015 were reviewed. Patients were divided into two groups: Roux‐en‐Y group and D‐D group. Morbidity, disease recurrence, and graft and patient survival rates were compared between the two groups.ResultsTotal of 143 patients underwent a D‐D biliary reconstruction, and 260 patients had a Roux‐en‐Y loop. Biliary complication involved 4.2% of patients from the D‐D group, and 3.9% from the Roux‐en‐Y group (P=. 863). Actuarial 1‐, 3‐, and 5‐year patient survival for D‐D and Roux‐en‐Y group was 92%, 85%, and 74%; and 87%, 83%, and 79%, respectively (P=.384). The corresponding 1‐, 3‐, and 5‐year probability of biliary complication was 97%, 95%, and 92%; and 98%, 97%, and 94%, respectively (P=.61).ConclusionDuct‐to‐duct biliary reconstruction in liver transplantation for selected patients with PSC is a good alternative instead of Roux‐en‐Y biliary reconstruction.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/137583/1/ctr12964.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/137583/2/ctr12964_am.pd

Complications of right lobe living donor liver transplantation

Background/Aims: Right lobar living donor liver transplantation (LDLT) has been controversial because of donor deaths and widely variable reports of recipient and donor morbidity. Our aims were to ensure full disclosure to donors and recipients of the risks and benefits of this procedure in a large University center and to help explain reporting inconsistencies. Methods: The Clavien 5-tier grading system was applied retrospectively in 121 consecutive adult right lobe recipients and their donors. The incidence was determined of potentially (Grade III), actually (Grade IV), or ultimately fatal (Grade V) complications during the first post-transplant year. When patients had more than one complication, only the seminal one was counted, or the most serious one if complications occurred contemporaneously. Results: One year recipient/graft survival was 91%/84%. Within the year, 80 (66%) of the 121 recipients had Grade III (n = 54) Grade IV (n = 16), or Grade V (n = 10) complications. The complications involved the graft's biliary tract (42% incidence), graft vasculature (15%), or non-graft locations (9%). Complications during the first year did not decline with increased team experience, and adversely affected survival out to 5 years. All 121 donors survive. However, 13 donors (10.7%) had Grade III (n = 9) or IV (n = 4) complications of which five were graft-related. Conclusions: Despite the satisfactory recipient and graft survival at our and selected other institutions, and although we have not had a donor mortality to date, the role of right lobar LDLT is not clear because of the recipient morbidity and risk to the donors. © 2009 European Association for the Study of the Liver