Qualification: 
MS, DNB
dineshb@aims.amrita.edu

Dr. Dinesh Balakrishnan currently serves as Associate Professor at the Department of Gastrointestinal Surgery, School of Medicine, Kochi.

Qualification: MS (General Surgery) DNB (General Surgery) Fellow, Minimal Access Surgeons of India Senior Clinical Fellow, Department of Solid Organ Transplant Surgery, Addenbrooke's Hospital Cambridge.

Publications

Publication Type: Journal Article

Year of Publication Title

2019

J. Shaji Mathew, Kumar, K. Y. Santosh, Nair, K., Amma, B. Sivasankar, Krishnakumar, L., Dinesh Balakrishnan, Gopalakrishnan, U., Ramachandran Narayana Menon, Sunny, A., Dhar, P., Vayoth, S. Othiyil, and Surendran, S., “Antegrade Hepatic Artery and Portal Vein Perfusion Versus Portal Vein Perfusion Alone in live Donor Liver Transplantation: A Randomized Trial”, Liver Transpl, 2019.[Abstract]


BACKGROUND: Traditionally, deceased donor liver grafts receive dual perfusion through the portal vein and the hepatic artery(HA) either in-situ or on the back-table. Hepatic artery perfusion is avoided in live donor liver grafts for fear of damage to the intima and consequent risk of hepatic artery thrombosis(HAT). However, biliary vasculature is predominantly derived from the HA. We hypothesized that antegrade perfusion of the HA in addition to the portal vein on the back table could reduce the incidence of post-operative biliary complications.

METHODS: Consecutive adult patients undergoing live donor liver transplants (LDLT) were randomized after donor hepatectomy to receive graft perfusion of HTK (Histidine-tryptophan-ketoglutarate) solution either via both the hepatic artery and portal vein (dual perfusion group,n=62) or only through the portal vein (standard perfusion group,n=62). The primary endpoints were the occurrence of biliary complications (biliary leak/stricture). Secondary endpoints included hepatic artery thrombosis and patient survival.

RESULTS: The incidence of biliary stricture was significantly lower in the dual perfusion group 6.5% vs.19.4%[OR 0.29, 95%CI(0.09-0.95);P=0.04]. There was no significant reduction in the incidence of HAT, bile leak or hospital stay between the two groups. Three year patient and graft survival was significantly higher among patients who received dual perfusion compared to standard perfusion[P=0.004, P=0.003]. On multivariate analysis non perfusion of the hepatic artery and preceding bile leak were found to be risk factors for the development of biliary stricture(P=0.04 & P<0.001).

CONCLUSIONS: Dual perfusion of live donor liver grafts through both hepatic artery and portal vein on the back-table may protect against the development of biliary stricture. This could translate to improved patient survival in the short-term. This article is protected by copyright. All rights reserved.

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2019

J. Shaji Mathew, Menon, V. P., Menon, V. P., Mallick, S., Amma, B. Sivasankar, Dinesh Balakrishnan, Gopalakrishnan, U., Ramachandran Narayana Menon, Athira, P. P., Jagan, O. A., and Surendran, S., “Dengue virus transmission from live donor liver graft.”, Am J Transplant, 2019.[Abstract]


Arboviral transmission through transplanted organs is rare. We report a highly probable case of dengue viral transmission during live donor liver transplantation. Fever with severe thrombocytopenia was observed in the donor and recipient within 6 and 9 days after transplantation, respectively. Dengue diagnosis was confirmed by testing blood and explant tissue from donor and recipient using dengue specific NAT (nucleic acid testing) and serology. Serology indicated the donor to have secondary dengue infection that ran a mild course. However, the dengue illness in the recipient was severe and deteriorated rapidly, eventually proving fatal. The recipient's explant liver tissue tested negative for viral RNA indicative of a pre-transplant naïve status. The prM-Envelope gene sequence analysis of the donor and recipient viral RNA identified similar serotype (DENV1) with almost 100% sequence identity in the envelope region. Molecular phylogenetic analysis of donor and recipient viral envelope sequences with regional and local dengue strains further confirmed their molecular similarity, suggesting a probable donor to recipient transmission via organ transplantation. Screening of living donors for dengue virus may be considered in endemic regions. This article is protected by copyright. All rights reserved.

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2018

C. Titus Varghese, Bharathan, V. Kumar, Gopalakrishnan, U., Dinesh Balakrishnan, Menon, R. N., Sudheer, O. Vayoth, Dhar, P., and Sudhindran, S., “Randomized trial on extended versus modified right lobe grafts in living donor liver transplantation.”, Liver Transpl, vol. 24, no. 7, pp. 888-896, 2018.[Abstract]


<p>Despite advances in the practice of living donor liver transplantation (LDLT), the optimum surgical approach with respect to the middle hepatic vein (MHV) in right lobe LDLT remains undefined. We designed a randomized trial to compare the early postoperative outcomes in recipients and donors between extended right lobe grafts (ERGs; transection plane was maintained to the left of MHV and division of MHV performed beyond the segment VIII vein) and modified right lobe grafts (MRGs; transection plane was maintained to the right of MHV; the segment V and VIII drainage was reconstructed using a conduit of recipient portal vein). Eligible patients (n = 86) were prospectively randomized into the ERG arm (n = 43) and the MRG arm (n = 43) at the beginning of donor hepatectomy. The primary endpoint considered in this equivalence trial was patency of the MHV or the reconstructed "neo-MHV" in the recipient. The secondary endpoints included biochemical parameters, postoperative complications, mortality in recipients as well as donors and volume regeneration of remnant liver in donors, measured at 2 months. The patency of the MHV was comparable in the ERG and MRG arms (90.7% versus 81.4%; difference, 9.3%; 95% confidence interval [CI], -5.8 to 24.4; z score, 1.245; P = 0.21). Volume regeneration of the remnant liver in donors was significantly better in the MRG arm (111.3% versus 87.3%; mean difference, 24%; 95% CI, 14.6-33.3; P < 0.001). The remaining secondary endpoints in donors and recipients were similar between the 2 arms. To conclude, MRG with reconstructed neo-MHV has comparable patency to native MHV in ERG and confers equivalent graft outflow in the recipient. Furthermore, it allows better remnant liver regeneration in the donor at 2 months. Liver Transplantation 24 888-896 2018 AASLD.</p>

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2018

J. Shaji Mathew, Manikandan, K., Kumar, K. Y. Santosh, Binoj, S. T., Dinesh Balakrishnan, Gopalakrishnan, U., Menon, R. Narayana, Dhar, P., Sudheer, O. V., Aneesh, S., and Sudhindran, S., “Biliary complications among live donors following live donor liver transplantation.”, Surgeon, vol. 16, no. 4, pp. 214-219, 2018.[Abstract]


<p><b>INTRODUCTION: </b>In live donor liver transplantation (LDLT), bile duct division is a critical step in donor hepatectomy. Biliary complications hence are a feared sequelae even among donors. Long term data on biliary complications in donors from India are sparse.</p><p><b>METHODS: </b>Prospective evaluation of 452 live donors over 10 years was performed to ascertain the incidence & risk factors of clinically significant biliary complications.</p><p><b>RESULTS: </b>Of the 452 donor hepatectomies (M: F = 114:338, median age = 38), 66.2% (299) were extended right lobe grafts, 24.1% (109) modified right lobe and 9.7% (44) were left lobe grafts. Portal vein anatomy was Type-I in 85% (386), Type-II in 7.5% (34) and Type-III in 7.1% (32). Following donor hepatectomy, a single bile duct opening occurred only in 46.5% (210) of the grafts. Of the remaining 53.5% grafts, 2 ductal openings were noted in 217 (48%) and three ductal openings in 25 (5.5%). Incidence of multiple openings in the duct were more commonly noted in Type II (70.6%) and III (75%) portal vein anatomy than in grafts with Type I (50.4%) portal anatomy (P = 0.001) Bile leak was noted in 15 (3.3%) donors which included one broncho-biliary fistula and bilio-pleural fistula. Analysis revealed no association between post-operative biliary complications and type of graft, portal vein anatomy or biliary anatomy. There was a single mortality in this series secondary to biliary sepsis. On long term follow, there were no biliary strictures in any of the patients.</p><p><b>CONCLUSIONS: </b>Biliary complications although rare (3.3%), present significant peri-operative morbidity to the donors.</p>

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2017

L. Kumar, Dinesh Balakrishnan, Varghese, R., and Surendran, S., “Extracorporeal membrane oxygenation for post-transplant hypoxaemia following very severe hepatopulmonary syndrome.”, BMJ Case Rep, vol. 2017, 2017.[Abstract]


<p>Hepatopulmonary syndrome (HPS) associated with end-stage liver disease has a high morbidity when room air PaO is less than 50 mm Hg. Safe levels of oxygenation to facilitate transplantation have not been defined despite advancement in care. Postoperatively, hypoxaemia worsens due to ventilation perfusion mismatch contributed by postoperative pulmonary vasoconstriction and due to decrease in endogenous nitric oxide. A 16-year-old boy with cirrhosis presented with HPS and a PaO of 37 mm Hg on room air and underwent living donor liver transplant. Although stable intraoperatively, he desaturated on the second postoperative day. Despite a number of interventions, oxygenation remained critically low on 100% inspired oxygen. Extracorporeal membrane oxygenator (ECMO) was established with instant improvement in oxygenation (PaO68 mm Hg), and the patient was eventually salvaged. We suggest that ECMO could be a means of managing refractory post-transplant hypoxaemia in patients with HPS.</p>

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2017

S. Stephen, Markkassery, R., Sainudheen, B. Edathuruth, Merin Babu, Dinesh Balakrishnan, Sudhindran, S., and Padma, U. Devi, “A Comparative Study of Once Daily Versus Twice Daily Tacrolimus in Liver Transplantation”, Journal of Young Pharmacists, vol. 9, pp. 605-609, 2017.[Abstract]


Once daily (OD) tacrolimus, recently launched for post liver transplant immunosuppression might offer better compliance and efficacy compared to standard twice daily (BID) tacrolimus. Data from India, however is sparse. Aim: The aim of our study was to compare the efficacy and adverse effects of OD versus BID tacrolimus formulation in liver transplant recipients. Methods: This was a retrospective, observational, comparative study of 115 patients who were on tacrolimus based regimens (tacrolimus BID: 92; M: F-75:17 and tacrolimus OD: 23; M: F-22:1). Total daily dose and trough levels of tacrolimus were recorded at 1, 3, 6, 12 and 24 months after transplantation. Results: Median age in tacrolimus BID and OD groups were 45 years (6-64 years) and 50 years (1-70 years), respectively. The median tacrolimus dose was significantly lower in the tacrolimus OD arm at all the time points studied. Tacrolimus trough levels were significantly lower in the tacrolimus OD group at 3 and 6 months. The biopsy proven rejection rate was 15.2% and 0% in the tacrolimus BID and OD groups, respectively. Two year patient and graft survival rate was 89.4% in the tacrolimus BID and 87.5% in the tacrolimus OD group. The incidence of new onset diabetes, renal dysfunction, dyslipidemia, neurotoxicity, hyperkalemia and weight gain were comparable between the two arms. Conclusion: Tacrolimus OD has a lower rejection rate compared to its BID formulation. However, this does not translate into better patient or graft survival. Both the formulations appear to be comparable with respect to the adverse effect and tolerability profile.

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2017

K. Y. Santosh Kumar, Mathew, J. Shaji, Dinesh Balakrishnan, Bharathan, V. Kumar, Amma, B. Sivasankar, Gopalakrishnan, U., Menon, R. Narayana, Dhar, P., Vayoth, S. Othiyil, and Sudhindran, S., “Intraductal Transanastomotic Stenting in Duct-to-Duct Biliary Reconstruction after Living-Donor Liver Transplantation: A Randomized Trial.”, J Am Coll Surg, vol. 225, no. 6, pp. 747-754, 2017.[Abstract]


BACKGROUND: Biliary complications continue to be the "Achilles heel" of living-donor liver transplantation (LDLT). The use of biliary stents in LDLT to reduce biliary complications is a controversial issue. We performed a randomized trial to study the impact of intraductal biliary stents on postoperative biliary complications after LDLT.

STUDY DESIGN: Of the 94 LDLTs that were performed during a period of 16 months, ABO-incompatible transplants, left lobe grafts, 3 or more bile ducts on the graft, and those requiring bilioenteric drainage were excluded. Eligible patients were randomized to either a study arm (intraductal stent, n = 31) or a control arm (no stent, n = 33) by block randomization. Stratification was done, based on the number of ducts on the graft requiring anastomosis, into single (n = 20) or 2 ducts (n = 44). Ureteric stents of 3F to 5F placed across the biliary anastomosis and exiting into the duodenum for later endoscopic removal at 3 months were used. The primary end point was postoperative bile leak.

RESULTS: Bile leak occurred in 15 of 64 (23.4%), the incidence was higher in the stented group compared with the control group (35.5% vs 12.1%; p = 0.03). Multiplicity of bile ducts and stenting were identified as risk factors for bile leak on multivariate analysis (p = 0.031 and p = 0.032). During a median follow-up of 2 years, biliary stricture developed in 9 patients (14.1%). Postoperative bile leak is a significant risk factor for the development of biliary stricture (p = 0.003).

CONCLUSIONS: Intraductal transanastomotic biliary stenting and multiplicity of graft ducts were identified as independent risk factors for the development of postoperative biliary complications.

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2017

A. Vijay Kanetkar, Dinesh Balakrishnan, Sudhindran, S., Dhar, P., Gopalakrishnan, U., Menon, R., and Sudheer, O. Vayoth, “Is Portal Venous Pressure or Porto-systemic Gradient Really A Harbinger of Poor Outcomes After Living Donor Liver Transplantation?”, J Clin Exp Hepatol, vol. 7, no. 3, pp. 235-246, 2017.[Abstract]


<p><b>BACKGROUND: </b>Portal hyperperfusion as a cause of small for size syndrome (SFSS) after living donor liver transplantation (LDLT) remains controversial. Portal venous pressure (PVP) is often measured indirectly and may be confounded by central venous pressure (CVP).</p><p><b>METHODS: </b>In 42 adult cirrhotics undergoing elective LDLT, PVP was measured by direct canulation of portal vein and porto systemic gradient (PSG) was obtained after subtracting CVP from PVP. None underwent portal inflow modulation. SFSS was looked in 27 patients after excluding 15 with technical complications.</p><p><b>RESULTS: </b>Clinical features of SFSS found in 6 patients, 5 with graft recipient weight ratio (GRWR) > 0.8% and PVP < 20 mm of Hg. One with GRWR < 0.8% could truly be labeled as SFSS. Incidence of SFSS was not higher in patients with elevated PVP > 20 mm of Hg (14.3% vs 0%,  = 0.259) or PSG > 13 mm of Hg (33.3% vs 0%,  = 0.111). Intensive care unit (ICU) stay was longer in patients with elevated PVP (14.55 vs 9.13 days,  = 0.007) and PSG (16.8 vs 9.72 days,  = 0.009). There was no difference in graft functions, post-operative complications and mortality in first month post-LDLT.</p><p><b>CONCLUSION: </b>Elevated PVP or PSG increased morbidity but neither predicted SFSS nor affected survival.</p>

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2017

R. Babu, Sethi, P., Surendran, S., Dhar, P., Gopalakrishnan, U., Dinesh Balakrishnan, Ramachandran Narayana Menon, Thankamonyamma, B. Sivasankar, Vayoth, S. Othiyil, and Thillai, M., “A New Score to Predict Recipient Mortality from Preoperative Donor and Recipient Characteristics in Living Donor Liver Transplantation (DORMAT Score).”, Ann Transplant, vol. 22, pp. 499-506, 2017.[Abstract]


<p>BACKGROUND Recipient outcomes in adult living donor liver transplantation depend on various characteristics in both recipient and donor. We aimed to derive a score based upon preoperative characteristics in donor and recipient that could predict the recipient mortality in adult living donor liver transplantation. MATERIAL AND METHODS Retrospective data of 100 living donor liver transplantation recipients and their respective donors were analyzed for preoperative factors that correlated with recipient mortality. Statistically significant factors were weighted appropriately to derive a regression equation to obtain a donor-to-recipient match (DORMAT) score. This score was applied to 71 patients prospectively and their outcome was analyzed. RESULTS Donor-recipient match (DORMAT) score, derived using regression analysis of the significant variables was [0.002 (Recipient age) + 0.013 (Recipient BMI) + 0.055 (SBP) + 0.344 (HRS) + 0.022 (Pre-op culture positivity) + 0.01 (Donor age) - 0.639]×100. DORMAT score, when validated to a prospective cohort of 71 adult-to-adult LDLT patients, had a C-statistic (area under ROC curve) of 0.712. The mortality rate was seen to increase with increasing DORMAT score. CONCLUSIONS DORMAT score is a useful clinical decision-making tool to predict recipient mortality in adult living donor liver transplantation.</p>

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2017

B. Chandran, Bharathan, V. Kumar, Mathew, J. Shaji, Amma, B. Sivasankar, Gopalakrishnan, U., Dinesh Balakrishnan, Ramachandran Narayana Menon, Dhar, P., Vayoth, S. Othiyil, and Surendran, S., “Quality of life of liver donors following donor hepatectomy.”, Indian J Gastroenterol, vol. 36, no. 2, pp. 92-98, 2017.[Abstract]


<p><b>BACKGROUND: </b>Although morbidity following living liver donation is well characterized, there is sparse data regarding health-related quality of life (HRQOL) of donors.</p><p><b>METHODS: </b>HRQOL of 200 consecutive live liver donors from 2011-2014 performed at an Indian center were prospectively collected using the SF-36 version 2, 1 year after surgery. The effect of donor demographics, operative details, post-operative complications (Clavien-Dindo and 50-50 criteria), and recipient mortality on the quality-of-life (QOL) scoring was analyzed.</p><p><b>RESULTS: </b>Among 200 donors (female/male=141:59), 77 (38.5%) had complications (14.5%, 16.5%, 4.5%, and 3.5%, Clavien-Dindo grades I-IV, respectively). The physical composite score (PCS) of donors 1 year after surgery was less than ideal (48.75±9.5) while the mental composite score (MCS) was good (53.37±6.16). Recipient death was the only factor that showed a statistically significant correlation with both PCS (p<0.001) and MCS (p=0.05). Age above 50 years (p<0.001), increasing body mass index (BMI) (p=0.026), and hospital stay more than 14 days ( p= 0.042) negatively affected the physical scores while emergency surgery (p<0.001) resulted in lower mental scores. Gender, postoperative complications, type of graft, or fulfillment of 50-50 criteria did not influence HRQOL. On asking the hypothetical question whether the donors would be willing to donate again, 99% reiterated there will be no change in their decision.</p><p><b>CONCLUSION: </b>Recipient death, donation in emergency setting, age above 50, higher BMI, and prolonged hospital stay are factors that lead to impaired HRQOL following live liver donation. Despite this, 99% donors did not repent the decision to donate.</p>

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