Post hepatectomy liver failure (PHLF) comprises of a conundrum of symptoms and signs following major hepatic resections. The pathophysiology essentially revolves around disruption of the normal hepatocyte regeneration and disturbed liver homeostasis. Prompt identification of the pre-operative predictors of PHLF in the form of biochemical parameters and imaging features are of paramount importance for any hepatic surgeon and forms the cornerstone of its management. Treatment revolves around a goal-directed resuscitation of the systemic organ failure. Auxiliary support systems such as liver dialysis devices and stem cell therapy are still under investigational trials for treatment of the same. Orthotopic liver transplantation (OLT) is the last resort in most cases not responding to other measures.

Background: Accidental or suicidal poisoning with yellow phosphorus or metal phosphides (YPMP) such as aluminum (AlP) zinc phosphide (Zn 3 P 2) commonly causes acute liver failure (ALF) and cardiotoxicity. These are used as household, agricultural, and industrial rodenticides and in production of ammunitions, firecrackers, and fertilizers. In absence of a clinically available laboratory test for diagnosis or toxin measurement or an antidote, managing their poisoning is challenging even at a tertiary-care center with a dedicated liver intensive care unit (LICU) and liver transplant facility. Methods: Patients with YPMP-related ALF were monitored using standardized clinical, hemodynamic, biochemical, metabolic, neurological, electrocardiography (ECG), and sequential organ failure assessment (SOFA) score and managed using uniform intensive care, treatment, and transplant protocols in LICU. Sociodemographic characteristics, clinical and biochemical parameters, and scores were summarized and compared between 3 groups i.e. spontaneous survivors, transplanted patients, and non-survivors. Predictors of spontaneous survival and the need for liver transplant are also evaluated. Results: Nineteen patients with YPMP-related ALF were about 32 years old (63.2% females) and presented to us at a median of 3 (0-10) days after poisoning. YPMP-related cardiotoxicity was rapidly progressive and fatal, whereas liver transplant was therapeutic for ALF. Spontaneous survivors had lower-dose ingestion (<17.5 g), absence of cardiotoxicity, < grade 3 hepatic encephalopathy (HE), lactate < 5.8, SOFA score < 14.5, and increase in SOFA score by < 5.5. Patients with renal failure need for continuous veno-venous hemodiafiltration (CVVHDF) and King College criteria positivity on account of prothrombin time and international normalized ratio (PT-INR) > 6.5 had higher mortality risk. Patients undergoing liver transplant and with spontaneous recovery required longer intensive care unit and hospital stay. At median follow-up of 3.4 (2.6-5.5) years, all spontaneous survivors and transplanted patients are well with normal liver function. Conclusions: Early transfer to a specialized center, preemptive close monitoring, and intensive care and organ support with ventilation, CVVHDF, plasmapheresis, and others may maximize their chances of spontaneous recovery, allowing accurate prognostication and a timely liver transplant. (J CLIN EXP HEPATOL xxxx;xxx:xxx)

Ewing's sarcoma is a highly aggressive malignant tumour most commonly affecting long bones in children and adolescents. It is part of the Ewing's sarcoma family of tumours (ESFTs) that also include peripheral primitive neuroectodermal tumour and Askin's tumours. ESFTs share common cytogenetic aberrations, antigenic profiles and proto-oncogene expression with an overall similar clinical course. In 99% of ESFTs, genetic translocation with molecular fusion involves the EWSR1 gene on 22q12. Approximately 30% of ESFTs are extraosseous, most commonly occurring in the soft tissues of extremities, pelvis, retroperitoneum and chest wall. Primary presentation in solid organs is very rare but has been described in multiple sites including the pancreas. Accurate diagnosis of a Ewing's sarcoma in a solid organ is critical in facilitating correct treatment. We report the case of a 17-year-old girl with cytogenetically confirmed primary pancreatic Ewing's sarcoma and provide a brief review of the published literature.

IntroductionTumours involving the duodenum are usually treated with pancreaticoduodenectomy, which may be associated with considerable morbidity. Limited distal duodenal resection, a relatively smaller procedure, can be done in some of these patients. We describe our experience with this operation for such lesions.MethodsWe retrospectively analyzed, from prospectively collected data 10 consecutive patients who underwent limited duodenal and proximal jejunal resection between March 2011 and Nov 2015.ResultsThere were 8 males and 2 females who had a median age of 47 years. Their common presentations were abdominal pain (50%) and upper gastrointestinal bleeding (40%). Five had malignancy (adenocarcinoma: 2, neuroendocrine tumours: 2, non Hodgkin's lymphoma 1). Three had gastrointestinal stromal tumours (GISTs) and 2 had other benign tumours (lipoma 1, ectopic pancreas 1). The 30-day post-operative morbidity rate was 60% (n = 6) with mostly minor complications (Clavien grade 1 or 2). Median post-operative stay was 9 (range, 6–13) days. All ten patients were alive without recurrence after a median follow up of 26.5 months.ConclusionLimited distal duodenal resection is a feasible surgical alternative to a pancreaticoduodenectomy in carefully selected patients with benign and some malignant tumours of the third and fourth part of the duodenum.

BackgroundLiving donor liver transplantation (LDLT) has emerged as an equally viable option to deceased donor liver transplant for treating end stage liver disease patients. Optimising the recipient outcome without compromising donor safety is the primary goal of LDLT. Achieving the adequate graft to recipient weight ratio (GRWR) is important to prevent small for size syndrome which is an uncommon but potentially lethal complication of LDLT.Case presentationHere we describe a case of successful dual lobe liver transplant for a 32 years old patient with ethanol related end stage liver disease. A right lobe graft without middle hepatic vein and another left lateral sector graft were transplanted successfully. Recipient and both donors recovered uneventfully.ConclusionDual lobe liver transplant is a feasible strategy to achieve adequate GRWR without compromising donor safety.