Ashwin Rammohan

Dr. Rela Institute & Medical Centre · Institute of Liver Disease & Transplantation

Gastrointestinal stromal tumors (GISTs) have been recognized as a biologically distinctive tumor type, different from smooth muscle and neural tumors of the gastrointestinal tract (GIT). They constitute the majority of gastrointestinal mesenchymal tumors of the GIT and are known to be refractory to conventional chemotherapy or radiation. They are d...

Background: Postoperative infectious complications in patients undergoing pancreatic surgery are a significant cause for morbidity and mortality. While synbiotics have beneficial effects on human health, their clinical value in surgical patients remains unclear given a paucity of applicable clinical studies. Aim: To determine the impact of periope...

While statistics on the number of deceased are readily available during an epidemic, the grief of losing a loved one remains intangible. Strict regulations are in place for the management of the deceased and performance of last rites. Consequently, family members may not have the opportunity to achieve closure by resolving “unfinished business”. Th...

Acceptance of liver transplantation (LT) as an established treatment modality for end stage liver disease led an exponential increase in the demand for organs. This had a domino effect on the ever-increasing gap between availability of organs and the sick waiting for it. Interestingly, the west and the east influenced by cultural, socio-economic an...

Introduction: Suturing is an integral part of all surgeries. In minimal access surgery, the force exerted is based only on visual perception (tautness of the thread and degree of tissue deformation). An unbalanced suture force can cause tissue rupture or cut-through resulting in avoidable morbidity and mortality. There is a need to find ways of imp...

Introduction: Emerging evidence suggests that enhanced ribosome biogenesis, increased size, and quantitative distribution of nucleoli are associated with dysregulated transcription, which in turn drives a cell into aberrant cellular proliferation and malignancy. Nucleolar alterations have been considered a prognostic histological marker for aggres...

Anatomical variations of left hepatic vein (LHV) are observed in nearly a third of left lateral segment (LLS) donors in living donor liver transplantation (LDLT). There is paucity of studies and no structured algorithm for customised outflow reconstruction in LLS grafts with variant anatomy. Analysis of a prospectively collected database of 296 LLS...

There is much controversy regarding enhanced recovery for recipients of liver transplants from deceased and living donors. The objectives of this Review were to summarise current knowledge on individual enhanced recovery elements on short-term outcomes, identify key components for comprehensive pathways, and create internationally accepted guidelin...

Intermediate cell carcinoma is one of the rarest forms of primary liver cancer comprising relatively monomorphic populations of neoplastic epithelial cells demonstrating simultaneous positivity of both hepatocyte and cholangiocyte immunohistochemical markers. Here in, we describe an adult male patient who underwent left hepatectomy for a large live...

Background Failure to achieve a good arterial inflow to the graft in living donor liver transplantation (LDLT) has disastrous consequences to the graft and patient survival. Standard microvascular techniques of hepatic artery (HA) anastomosis used in deceased donor liver transplantation are not applicable in LDLT. We present the results of our uniq...

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index...

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index...

Background: The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel inde...

Background: The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel inde...

Background: Langerhans cell histiocytosis (LCH) is a rare but important cause of end-stage liver disease in children. Conventional chemotherapeutic agents that are otherwise the standard-of-care in LCH may be counterproductive in patients with hepatic decompensation. Furthermore, the precise role of liver transplantation (LT) in the management of...

Background The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index...

Background: The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel inde...

Acute graft-versus-host disease is an extremely rare complication after pediatric liver transplant. Despite a better prognosis in pediatric than in adult recipients, graft-versus-host disease is associated with high mortality. We report 2 cases of pediatric recipients with acute graft-versus-host disease; both had identical clinical presentation. R...

Background: Progressive familial intrahepatic cholestasis (PFIC) is a group of genetic disorders characterized by cholestasis, failure to thrive and cirrhosis and might require liver transplantation (LT). The outcomes of LT for this diverse group remains largely undefined. We present our data of LT for PFIC and compare their early, intermediate and...

Background: The art of immunosuppression consists of achieving a fine balance between rejection, infection and drug related adverse effects. Pharmacokinetics of Tacrolimus (expressed as blood concentration/dose ratio(C/D ratio)) & intra-patient variability (IPV) of the drug are known to play an important role in its efficacy. In addition, expressio...

Introduction Auxiliary partial orthotopic liver transplantation (APOLT) has been proposed as a treatment modality for certain types of non-cirrhotic metabolic liver disease (NCMLD). While the short-term outcomes of this operation have been comparable with orthotopic liver transplantation (LT), its long-term outcomes have sparsely been reported. We...

Liver transplantation (LT) is a life-saving surgical procedure and the current standard of care for most patients with end stage liver disease. With improvements in organ preservation techniques, perioperative care, and immunosuppression, there is better patient and graft survival following LT, and assessment of the liver allograft in long-term sur...

Langerhans cell histiocytosis (LCH) is a malignant disease of the histiocytes involving various organ systems. The spectrum of liver involvement in LCH ranges from mild transaminitis to end-stage liver disease. The hallmark of hepatic LCH is secondary sclerosing cholangitis, which manifests due to a progressive destruction of the biliary tree by ma...

Introduction: There are unique technical and management challenges associated with living donor liver transplantation (LDLT) for Budd-Chiari Syndrome (BCS). The outcomes of LDLT for BCS in comparison to other indications remain unclear and warrant elucidation. Methods: Data of 24 BCS patients who underwent LDLT between January 2012 and June 2019 we...

Introduction There is paucity of data on neurological complications (NCs) and its predisposing factors, in pediatric liver transplant (PLT) recipients. Methods Records of seventy-one children who underwent LT between October 2018 and November 2019 were reviewed. Patients were categorized into group A: with NC and group B: without NC in the post-LT...

Post-coronavirus disease 2019 (COVID-19) cholangiopathy (PCC) is a new entity observed in patients recovering from severe COVID-19 pneumonia. Most patients recover with cholestasis improving over a period of time. In some patients cholestasis is severe and persists or progresses to liver failure necessitating liver transplant. We present a previous...

Background: Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multi- centre studies. Methods: A 34-question online sur...

This paper reports the application of a low-cost diagnostic modality for fat analysis in a liver phantom as well as human liver donors. The device works on the principle of diffuse reflectance spectroscopy, which absorbs and/or scatters depending upon the molecules that compose a tissue. Here, we describe the development of liver phantom of varying...

After a 1-y absence due to the coronavirus disease 2019 pandemic, the 26th Annual Congress of the International Liver Transplantation Society was held from May 15 to 18, 2021, in a virtual format. Clinicians and researchers from all over the world came together to share their knowledge on all the aspects of liver transplantation (LT). Apart from a...

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and proces...

Objective : Spectrum of hepatic presentation in Langerhans cell histiocytosis (LCH) varies from asymptomatic hepatomegaly to secondary sclerosing cholangitis leading to cirrhosis with or without decompensation. Conventional chemotherapy may be counterproductive in a patient with LCH and hepatic decompensation. We analysed the outcomes of our patien...

Detecting macrovesicular steatosis (MS) in from live and deceased donor livers is crucial. Studies have unequivocally shown that the severity of MS correlates with adverse post-LT outcomes, and the degree of MS is intimately related to the viability of the liver graft, which in turn is crucial to the success of the operation. A conventional liver b...

Cholangiocarcinomas are a heterogeneous group of highly aggressive cancers that may arise anywhere within the biliary tree. There is a wide geographical variation with regards to its incidence, and risk-factor associations which may include liver fluke infection, primary sclerosing cholangitis, and hepatolithiasis amongst others. These tumours are...

Background The effect of SARS-CoV-2 infection upon HPB cancer surgery perioperative outcomes is unclear. Establishing risk is key to individualising treatment pathways. Aim Identify the mortality rate and complications risk for HPB cancer elective surgery during the pandemic. Methods International, prospective, multicentre study of consecutive ad...

Background: Portal inflow modulation (PIM) aimed at reducing portal hyperperfusion is commonly used in in living donor liver transplantation (LDLT) to reduce the risk of small-for-size syndrome (SFSS). Many different techniques, both pharmacological and surgical have been used for this purpose. There is however, little consensus on the best method...

Objectives: The outcomes of emergency general surgery (EGS) patients with concomitant COVID-19 infection remain unknown. With a multicenter study in 361 hospitals from 52 countries, we sought to study the mortality and pulmonary complications of COVID-19 patients undergoing EGS. Methods: All patients aged ≥17 years and diagnosed preoperatively w...

Purpose of review: Preoperative optimization and structured evidence-based perioperative care of a patient undergoing complex hepatobiliary (HPB) surgery are essential components in their management. Apart from advances in surgical technique, these perioperative measures have resulted in substantial reductions in morbidity and mortality. There hen...

Liver anatomy has been extensively studied throughout the evolution of surgical techniques for the liver including transplantation. With the advent of split and living donor transplantation, there has been an obligation for a more detailed re-evaluation of liver anatomy. Though the anatomy of individual lobes of the liver has been described meticul...

Alagille syndrome (ALGS) is an autosomal dominant disorder characterized by involvement of various organ systems. It predominantly affects the liver, skeleton, heart, kidneys, eyes and major blood vessels. With myriads of presentations across different age groups, ALGS is usually suspected in infants presenting with high gamma glutamyl transpeptida...

Members of the COVIDSurg Collaborative are co-authors of this study and are listed under the heading Collaborators. For details of role see Appendix S1. Dear Editor During the COVID-19 pandemic, multiple theories were proposed based on the observation that countries with an ongoing national Bacillus Calmette-Gué rin (BCG) immunization programme had...

SARS‐CoV‐2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri‐operative or prior SARS‐CoV‐2 were at further increased risk of venous thromboembolism....

Background This study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Methods This was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January–October 201...

SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients.Since surgical patients are already at higher risk of venous thromboembolism than general populations, thisstudy aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk ofvenous thromboembolism. We...

There is little evidence around the potentially protective role of previous Bacillus Calmette-Guerin (BCG) vaccination on postoperative mortality in patients with perioperative SARS-CoV-2 vaccination. Prior BCG vaccination did not protect SARS-CoV-2 infected patients against postoperative pulmonary complications and 30-day mortality.

We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which pati...

Macrovesicular Steatosis (MS) is an independent risk factor for adverse post-liver transplant (LT) outcomes. The degree of MS is intimately related to the viability of the liver graft, which in turn is crucial to the success of the operation. An ideal liver graft should have no MS and most centres would find it unacceptable to use a donor liver wit...

Standardization of immunomodulation protocols has enabled ABO-incompatible liver transplants with outcomes similar to those of ABO-compatible liver transplants. Patients with the A2 blood group are unique because they have a diminished expression of the A antigen. Despite rare immune complications, this phenomenon of diminished expression has led t...

The incidence and geographical distribution of cancers in children are dramatically different from the adult population. Consequent to improvements in postcancer survival, there is a progressive increase in the number of patients requiring liver transplantation (LT) who are in remission from pretransplant malignancy (PTM). Conventionally, however,...

Background and Aims The global impact of SARS-CoV-2 on liver transplantation (LT) practices across the world is unknown. The goal of this survey was to assess the impact of the pandemic on global LT practices. Method A prospective web-based survey (available online from 7th September 2020 to 31st December 2020) was proposed to the active members of...

Background Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction. Methods This internati...

Introduction: There are unique technical and management challenges associated with living donor liver transplantation (LDLT) for Budd-Chiari Syndrome (BCS). The outcomes of LDLT for BCS in comparison to other indications remains unclear and warrants elucidation. Methods: Data of 24 BCS patients who underwent LDLT between January 2012 and June 2019...

We thank the authors for their viewpoints regarding extra‐anatomic arterial inflow in living donor liver transplantation (LDLT). They challenge the premise of our technique of using the distal gastroduodenal artery (GDA) with retrograde flow via the pancreaticoduodenal arterial (PDA) arcades for graft arterialization in extensive subintimal dissect...

Background Need for routine reconstruction of all arteries in grafts with multiple arterial inflows remains an unsettled debate. The aim of following article is to review an anatomical basis of a decision-making strategy to deal with multiple arteries in living donor liver transplantation (LDLT).MethodsLDLT performed between August 2009–2019 were i...

Background and Aims Recently, there has been a considerable increase in patients with Non-alcoholic fatty liver disease (NAFLD/NASH). Availability of high-efficacy drugs for Hepatitis B and Hepatitis C infection may have changed the disease prevalence. We aimed to study the impact of this changing epidemiology in patients undergoing Liver Transplan...

Background: Liver involvement in Langerhans cell histiocytosis (LCH) can be spectrum varying from asymptomatic hepatomegaly to secondary sclerosing cholangitis with cirrhosis, with or without decompensation and portal hypertension (PHTN). Modification of conventional approach is required for treating these subset of patients with LCH having advance...

We thank Varghese et al. for the interest shown in our article. Their assumptions are nonetheless fractious and factually erroneous, necessitating clarification. The findings of post-liver transplant (LT) allograft biopsies in our cohort of yellow phosphorus (YP) toxin-related liver injury (TLI) was unlike anything observed in other causes of post-...

Background: LT for infants less than 5 kg remains a challenge with high technical complication rates, which is further compounded by large-for-size grafts requiring hyper-reduction. The benefits of MIDH especially for standard left lateral segment (LLS) resection have been unequivocally demonstrated. However, given the fine margins of error, the h...

In living donor liver transplantation (LDLT) the safety of the live donor (LD) is of paramount importance. Despite all efforts, the morbidity rates approach 25%-40% with conventional open donor hepatectomy (DH) operations. However, most of these complications are related to the operative wound and despite increased self- esteem and satisfaction in...

Advances in surgical technique, perioperative care and immunosuppression along with a better understanding of the pathology have dramatically improved the outcomes of liver transplantation (LT). Historically, post-LT recurrent viral hepatitis (rVH) were a major cause for graft loss. More recently with elucidation of viral pathogenesis, genomic anal...

To support the global restart of elective surgery, data from an international prospective cohort study of 8492 patients (69 countries) was analysed using artificial intelligence (machine learning techniques) to develop a predictive score for mortality in surgical patients with SARS-CoV-2. We found that patient rather than operation factors were the...

To support the global restart of elective surgery, data from an international prospective cohort study of 8492 patients (69 countries) was analysed using artificial intelligence (machine learning techniques) to develop a predictive score for mortality in surgical patients with SARS-CoV-2. We found that patient rather than operation factors were the...