Optimal timing of endoscopic biliary drainage for bile duct leaks: A multicenter, retrospective, clinical study

BACKGROUND

Bile duct leaks (BDLs) are serious postsurgical adverse events. Typically, conservative management with abdominal drainage is the initial treatment option. However, prolonged abdominal drainage without improvement can lead to biliary stricture and delay the optimal timing of endoscopic retrograde cholangiopancreatography (ERCP).

AIM

To identify the optimal timing for ERCP and the period during which clinical observation with conservative management is acceptable, balancing ERCP success and the risk of biliary strictures.

METHODS

We conducted a multicenter retrospective study involving 448 patients with BDLs between November 2002 and November 2022. The patients were divided into four groups based on the timing of ERCP: 3 days, 7 days, 14 days, and 21 days. The primary outcome was clinical success, defined as the resolution of BDL and related symptoms within 6 months without additional percutaneous drainage, surgery, or death. The secondary outcome was incidence of biliary strictures. Univariate and multivariate logistic regression analyses were performed to identify factors associated with ERCP success and biliary stricture occurrence.

RESULTS

In a cohort of 448 consecutive patients diagnosed with BDLs, 354 were excluded, leaving 94 patients who underwent ERCP. Clinical success was achieved in 84% of cases (79/94), with a median ERCP timing of 20 days (9.5-35.3 days). Biliary strictures were identified in 29 (30.9%) patients. Performing ERCP within 3 weeks, compared to after 3 weeks, was associated with higher success rates [92.0% (46/50) vs 75.0% (33/44), P = 0.032] and a lower incidence of biliary stricture incidence [18.0% (9/50) vs 45.5% (20/44), P = 0.005]. Subsequent multivariate analysis confirmed the association with higher success rates (odds ratio = 4.168, P = 0.045) and lower biliary stricture rates (odds ratio = 0.256, P = 0.007).

CONCLUSION

Performing ERCP for BDLs within 3 weeks may be associated with a higher success rate and a lower biliary stricture rate. If patients with BDLs do not respond to conservative treatment, ERCP is suggested to be performed within 3 weeks.

Global transplantation: Lessons from organ transplantation organizations worldwide

Although national transplant organizations share common visions and goals, the creation of a unified global organization remains impractical. Differences in ethnicity, culture, religion, and education shape local practices and infrastructure, making the establishment of a single global entity unfeasible. Even with these social disparities aside, logistical factors such as time and distance between organ procurement and transplantation sites pose significant challenges. While technological advancements have extended organ preservation times, they have yet to support the demands of transcontinental transplantations effectively. This review presents a comparative analysis of the structures, operational frameworks, policies, and legislation governing various transplant organizations around the world. Key differences pertain to the administration of these organizations, trends in organ donation, and organ allocation policies, which reflect the financial, cultural, and religious diversity across different regions. While a global transplant organization may be out of reach, agreeing on best practices for the benefit of patients is essential.

Lesson learnt from 60 years of liver transplantation: Advancements, challenges, and future directions

Over the past six decades, liver transplantation (LT) has evolved from an experimental procedure into a standardized and life-saving intervention, reshaping the landscape of organ transplantation. Driven by pioneering breakthroughs, technological advancements, and a deepened understanding of immunology, LT has seen remarkable progress. Some of the most notable breakthroughs in the field include advances in immunosuppression, a revised model for end-stage liver disease, and artificial intelligence (AI)-integrated imaging modalities serving diagnostic and therapeutic roles in LT, paired with ever-evolving technological advances. Additionally, the refinement of transplantation procedures, resulting in the introduction of alternative transplantation methods, such as living donor LT, split LT, and the use of marginal grafts, has addressed the challenge of organ shortage. Moreover, precision medicine, guiding personalized immunosuppressive strategies, has significantly improved patient and graft survival rates while addressing emergent issues, such as short-term complications and early allograft dysfunction, leading to a more refined strategy and enhanced post-operative recovery. Looking ahead, ongoing research explores regenerative medicine, diagnostic tools, and AI to optimize organ allocation and post-transplantation car. In summary, the past six decades have marked a transformative journey in LT with a commitment to advancing science, medicine, and patient-centered care, offering hope and extending life to individuals worldwide.

Prediction of higher ceftazidime-avibactam concentrations in the human renal interstitium compared with unbound plasma using a minimal physiologically based pharmacokinetic model developed in rats and pigs through microdialysis

Last resort antibiotics, like ceftazidime-avibactam (CZA), were used to treat urinary tract infections caused by multidrug-resistant bacteria. However, no data on tissue distribution were available. Our aim was to describe the in vivo kidney distribution of CZA in healthy rats and pigs using a physiologically based pharmacokinetic model (PBPK). Microdialysis probes were inserted into the blood, muscle, and kidney of both species. The experiment started with a retrodialysis by drug period. An i.v. single dose of CZA was administered. Samples were collected for 3 h in rats and 7 h in pigs. A PBPK model was developed to describe tissue and blood CZA pharmacokinetics in animals and to predict human concentrations. The PBPK model adequately described CZA rat and pig data in each tissue and blood. In both species, the concentration profiles of CZA in muscle and blood were almost superimposed, with muscle-to-plasma area under the curve (AUC) ratios close to one. However, kidney CZA concentrations were higher than those in blood, as indicated by kidney-to-plasma AUC ratios exceeding one (respectively 2.27 in rats and 2.63 in pigs for ceftazidime [CAZ]; 2.7 in rats and 4.5 in pigs for avibacam [AVI]). Prediction of human concentrations led to same observations. This study demonstrated an excellent penetration of CZA into the renal parenchyma of rats and pigs. Our PBPK model adequately described the data, and AUCs were higher in the renal cortex interstitium compared with unbound plasma. Our data suggested that the joint PK/PD target for CZA in humans could be attained with reduced CZA doses.

Barriers and willingness to express consent to organ donation among the Kazakhstani population

BACKGROUND

Organ donation is a critical component of healthcare, yet donation rates in Kazakhstan remain low. Understanding the socio-demographic factors, knowledge levels, and perceived barriers influencing individuals' willingness to consent to organ donation is essential for developing effective interventions.

METHODS

This cross-sectional study surveyed 1,294 participants across Kazakhstan. The sample was predominantly female (78.3%), urban (79.4%), and well-educated, with a significant proportion having medical backgrounds. Data were collected on socio-demographic characteristics, knowledge about organ donation, and perceived barriers. Comparison methods and binomial logistic regression analysis was used to identify significant predictors of willingness to express consent for organ donation.

RESULTS

Age, ethnicity, family status, and knowledge about organ donation were significant predictors of willingness to donate. Older participants and Russian ethnic group members were less likely to consent, while widowed individuals and those with higher knowledge levels were more likely to express consent. Although several factors did not have significant prediction with willingness to donate in the regression analysis, chi-square and U-tests revealed significant associations for residence, occupation, educational level, and religious affiliation. Key barriers to donation included distrust in the medical system, fears of organ trafficking, and insufficient awareness, particularly among non-medical participants. These barriers were significant deterrents and correlated with lower willingness to donate. However, due to the overrepresentation of urban, educated, and medical-affiliated participants in the sample, findings may not fully reflect the general population of Kazakhstan.

CONCLUSION

The findings highlight the need for targeted educational campaigns to increase public awareness and address misconceptions about organ donation. Building trust in the medical system and dispelling fears of unethical practices are essential for improving donation rates. The study underscores the complex interplay of socio-demographic factors, knowledge, and perceived barriers in shaping organ donation decisions in Kazakhstan, while also emphasizing the need for future research with a more representative sample.

Innovative strategies in bile duct repair: Assessing efficacy and safety across varied graft techniques - A systematic review

Bile duct injuries (BDI) from surgical procedures pose significant clinical challenges, requiring precise interventions for optimal outcomes. This systematic review explores the utilization of grafts in the repair of bile duct injuries, aiming to gain insights from existing literature. Graft-based techniques show promise in improving postoperative outcomes, but their efficacy varies. A systematic search was conducted across PubMed, Science Direct, and Scopus following the PRISMA 2020 Checklist, focusing on studies published until February 19, 2024. The inclusion criteria involved research using grafts to treat bile duct injuries in pig, swine, or mini-pig models. Out of 2231 studies identified, eleven met the inclusion criteria. These studies evaluated various graft techniques, including autologous tissue with biodegradable stents, decellularized grafts, patches, prosthetic grafts, bacterial cellulose film, and heterogeneous materials. Each method had distinct advantages and limitations, particularly regarding postoperative outcomes and histological findings. This review highlights the need for further research to determine the most effective graft-based strategies for BDI repair and improve patient care.

Abdominal normothermic regional perfusion after donation after circulatory death improves pancreatic islet isolation yield

Abdominal normothermic regional perfusion (aNRP) is an in situ normothermic oxygenated donor perfusion technique before procurement during controlled donation after circulatory death (cDCD) procedures and allows for organ quality evaluation. There are few data on the effect of aNRP on pancreatic islet isolation and subsequent transplantation outcomes. We aim to evaluate the impact of aNRP on cDCD pancreatic islet isolation and transplantation. A retrospective analysis was performed on pancreatic islet isolation outcomes from aNRP, cDCD, and donation after brain death pancreases. Isolations were compared to previous donor age (60-75 years) matched isolations. Islet function was assessed by a dynamic glucose-stimulated insulin secretion. Donor baseline characteristics did not differ among groups. Isolations from aNRP pancreases (471 739 islet equivalents [IEQ] [655 435-244 851]) yielded more islets compared to cDCD (218 750 IEQ [375 951-112 364], P < .01) and to donation after brain death (206 522 IEQ [385 544-142 446], P = .03) pancreases. Dynamic glucose-stimulated insulin secretion tests in 7 aNRP islet preparations showed a mean stimulation index of 4.91, indicating good functionality. Bilirubin and alanine aminotransferase during aNRP correlated with islet yield (r2 = 0.685, P = .002; r2 = 0.491, P = .016, respectively). Islet isolation after aNRP in cDCD donors results in a high islet yield with viable functional islets. aNRP could increase the utilization of the pancreases for islet transplantation.

Dual organ transplantation: Pancreas and Liver in the kidney axis

PURPOSE OF REVIEW

This article explores the benefits and challenges of dual organ transplants.

RECENT FINDINGS

Simultaneous liver-kidney transplant has become a valuable option for patients with both liver and kidney failure, especially since the introduction of clearer eligibility guidelines in 2017. When done for the appropriate candidate, it can significantly improve survival and quality of life. Similarly, simultaneous pancreas-kidney transplantation provides significant advantages for patients with diabetes-related kidney failure by addressing both glycemic control and kidney function, with significant improvement in diabetes associated complications and survival.

SUMMARY

While these procedures are complex, they offer promising solutions for managing difficult multiorgan conditions. Ongoing research and personalized patient care will be key to maximizing their benefits.

Simultaneous en bloc kidney and pancreas transplantation from pediatric donors: Selection, surgical strategy, management, and outcomes

Pediatric donors are underutilized for simultaneous pancreas-kidney transplantation due to concerns about technical complications and inadequate islet and/or renal mass. We analyzed our experience with simultaneous en bloc kidney and pancreas transplantation using pediatric donors on 8 consecutive adult patients from 1997-2018. En bloc kidney transplants were implanted intraperitoneally and contralaterally to right-sided pancreas grafts. All patients became insulin-independent immediately; with 1 case of delayed kidney function and 1 case of insulin resistance; there were no graft thromboses. Donor age averaged 5.0 ± 1.7 years and weight 19.8 ± 4.8 kg; recipient age averaged 46.6 ± 12.8 years and body mass index 25.2 ± 3.8 kg/m2. Postoperative creatinine, glucose, and C-peptide reflected good graft function. Simultaneous en bloc kidney and pancreas transplantation is a safe technique providing excellent long-term glycemic control and kidney function to adult recipients.

Summary of the current guidelines for managing iatrogenic colorectal perforations and the evolving role of endoluminal vacuum therapy

Colonoscopy represents a safe procedure that is widely used in medical practice either to diagnose or treat various gastrointestinal diseases. During the last few years, the incidence rate of perforations in colonoscopic procedures has increased, especially in therapeutic colonoscopies. The recent advancements in endoscopic techniques and gastrointestinal tumoral resection procedures such as endoscopic mucosal resection, endoscopic full-thickness resection, and endoscopic submucosal dissection (ESD) could be a risk factor for this increased risk. The incidence rate of mortality of serious colonoscopic perforations is 7.1%. The management plan for these perforations starts with conservative treatment in mild cases, endoscopic closure, and surgical management in severe cases. Recently, endoluminal vacuum therapy was found to be effective in the management of colorectal perforations and this has been reported in multiple case reports. This editorial provides an overview of the current guidelines for the management of iatrogenic colorectal perforations. These insights are from the perspectives of endoscopists and gastroenterologists. We also present a management algorithm based on the guidelines of the European Society of Gastrointestinal Endoscopy, the American Gastroenterological Association, and the World Society of Emergency Surgery. We also discussed in brief the use of endoluminal vacuum therapy in colorectal perforations.

Novel minimally invasive strategies for achieving source control in intra-abdominal infections

PURPOSE OF REVIEW

To provide an overview of recent advancements in minimally invasive intra-abdominal source control techniques.

RECENT FINDINGS

There have been multiple recent advances in minimally invasive techniques for managing intra-abdominal infection or sepsis. Endoscopic based interventions include stenting, suturing, clip placement, and endoscopic vacuum therapy. Robotic surgery is becoming progressively more popular in emergency general surgery and offers comparable results compared to laparoscopic surgery with lower rates of conversion to open.

SUMMARY

Endoscopic based interventions and minimally invasive surgery offer comparable outcomes to more invasive interventions with less morbidity for patients, though the ability to perform these techniques may not be limited to tertiary and quaternary health centers. Providers must use their clinical judgment to determine the best course of action.

Everolimus Personalized Therapy: Second Consensus Report by the International Association of Therapeutic Drug Monitoring and Clinical Toxicology

ABSTRACT

The Immunosuppressive Drugs Scientific Committee of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology established the second consensus report to guide therapeutic drug monitoring (TDM) of everolimus (EVR) and its optimal use in clinical practice 7 years after the first version was published in 2016. This version provides information focused on new developments that have arisen in the last 7 years. For the general aspects of the pharmacology and TDM of EVR that have retained their relevance, readers can refer to the 2016 document. This edition includes new evidence from the literature, focusing on the topics updated during the last 7 years, including indirect pharmacological effects of EVR on the mammalian target of rapamycin complex 2 with the major mechanism of direct inhibition of the mammalian target of rapamycin complex 1. In addition, various concepts and technical options to monitor EVR concentrations, improve analytical performance, and increase the number of options available for immunochemical analytical methods have been included. Only limited new pharmacogenetic information regarding EVR has emerged; however, pharmacometrics and model-informed precision dosing have been constructed using physiological parameters as covariates, including pharmacogenetic information. In clinical settings, EVR is combined with a decreased dose of calcineurin inhibitors, such as tacrolimus and cyclosporine, instead of mycophenolic acid. The literature and recommendations for specific organ transplantations, such as that of the kidneys, liver, heart, and lungs, as well as for oncology and pediatrics have been updated. EVR TDM for pancreatic and islet transplantation has been added to this edition. The pharmacodynamic monitoring of EVR in organ transplantation has also been updated. These updates and additions, along with the previous version of this consensus document, will be helpful to clinicians and researchers treating patients receiving EVR.

Clinical application of indocyanine green fluorescence imaging in laparoscopic cholecystectomy with common bile duct exploration and J-Tube drainage

BACKGROUND

Intraoperative and postoperative biliary injuries remain significant complications of laparoscopic common bile duct exploration (LCBDE). Indocyanine green (ICG) has been shown to significantly reduce injuries caused by intraoperative operational errors. We found that the J-tube can reduce postoperative strictures and injuries to the common bile duct. At this moment, we aim to analyze and compare the complications, efficacy, short-term outcomes, and feasibility of these two adjunctive tools for LCBDE.

AIM

To evaluate the efficacy of ICG fluorescence imaging In LCBDE and J-tube drainage for patients with common bile duct stones.

METHODS

We retrospectively collected the clinical case data of patients who were treated at the Hepatobiliary Surgery Department of the Third People's Hospital of Nantong, affiliated with Nantong University, from January 2016 to January 2021 due to gallbladder stones with choledocholithiasis and who underwent LCBDE combined with a primary suture and either J-tube or T-tube drainage. The patients were divided into groups: Traditional white-light laparoscopy + T-tube group (WL + T-tube), traditional WL + J-tube group, fluorescent laparoscopy + T-tube group (ICG + T-tube) and fluorescent laparoscopy + J-tube group (ICG + J-tube). The preoperative and postoperative clinical case data, laboratory examination data, and intraoperative and postoperative complications (including postoperative bile leakage, electrolyte disturbances, biliary peritonitis, and postoperative infections) and other relevant indicators were compared.

RESULTS

A total of 198 patients (112 males and 86 females) were included in the study, with 74 patients in the WL + T-tube, 47 in the WL + J-tube, 42 in the ICG + T-tube, and 35 in the ICG + J-tube. Compared with the other groups, the ICG + J had significantly shorter operation time (114 minutes, P = 0.001), less blood loss (42 mL, P = 0.02), shorter postoperative hospital stays (7 days, P = 0.038), and lower surgical costs (China yuan 30178, P = 0.001). Furthermore, patients were subdivided into two groups based on whether a T-tube or J-tube was placed during the surgery. By the third postoperative day, the aspartate transaminase, glutamic pyruvic transaminase, total bilirubin, and direct bilirubin levels were lower in the J-tube group than in the T-tube group (P < 0.001). At last, follow-up observations showed that the incidence of biliary strictures at three months postoperatively was significantly lower in the J-tube group than in the T-tube group (P = 0.002).

CONCLUSION

ICG fluorescence imaging in laparoscopic cholecystectomy with common bile duct exploration and J-tube drainage facilitates rapid identification of biliary anatomy and variations, reducing intraoperative bile duct injury, blood loss, surgery duration, and postoperative bile duct stenosis rates, supporting its clinical adoption.

Nurse Specialist in the Organ and Tissue Donation Process with Coordination Role: A Scoping Review

Background/Objectives: In recent years, the introduction of specialist nurses, such as donation coordinator nurses, has been proposed as a potentially effective strategy to increase the number of donations and improve the quality of the process. However, experiences in this field are still limited. The aim of this study was to evaluate the impact of the inclusion of this professional in health systems, both in quantitative and qualitative terms. Methods: A scoping review was performed. Studies published from 1990 to 2024 were included regardless of the study design. The bibliographic search was performed on the databases MedLine, Web of Science, Scopus, CINAHL, and PsycInfo and on the search engines EBSCOhost, ProQuest, and Google Scholar. The search strings included keywords such as organ donation, transplant, procurement, and nursing role. The extraction and selection of articles were conducted in accordance with the PRISMA-ScR guidelines and with the methodology of the Joanna Briggs Institute for scoping reviews. The protocol study was prospectively registered with the Open Science Framework database on 3 December 2023, with registration number osf.io/wzxr3. Results: From the included studies, it emerged that the involvement of a nurse coordinator in the donation process is significantly associated with an increase in the number of organ donors and higher rates of family consent to donation. Additionally, the studies highlighted enhanced effectiveness in identifying potential donors and improvements in the training and preparedness of healthcare staff. Conclusions: The nurse coordinator in the donation process can have positive effects both on the management of the process and on the increase in the number of organ and tissue donations.

Indocyanine green fluorescence improves safety in laparoscopic cholecystectomy using the Fundus First technique: a retrospective study

Introduction

As one of the most commonly performed surgeries in the world, safety during laparoscopic cholecystectomy (LC) is of utmost importance. Indocyanine green (ICG) has been used for different medical purposes including assessment of liver function since the 1950s. Its use during LC was first described in 2009 by Ishizawa. Since ICG is excreted in the bile, its fluorescent properties can be used to illuminate the bile ducts, and may reduce the risk for bile duct injury and other complications. Previous studies have compared ICG with conventional visualization showing shorter operation time and lower conversion rates during LC performed with traditional operation techniques. Results from LC performed with the Fundus First method (FF-LC) and ICG fluorescence has not been previously reported. The aim of this retrospective study was to compare LC with and without the aid of ICG fluorescence at a Swedish hospital routinely performing FF-LC.

Methods

Data from all patients operated with LC at Sundsvall General Hospital before and after the implementation of routine ICG between 2016 and 2023 were analyzed.

Results

The study included 2,009 patients; 1,455 operated with ICG (ICG-group) and 549 without (comparison group). FF-LC was used in 94.9% of all operations. The groups were comparable regarding gender, BMI, age, presence of acute cholecystitis and proportion urgent/elective surgery. ICG was found to be safe, with similar 30-day complication rates between study groups. A lower conversion rate was seen in the ICG-group (1.2% vs. 3.3%, p = 0.001) and there was a non-significant reduction in readmissions (p = 0.054). In univariate analysis, ICG was associated with prolonged operation time, but this was not supported in multivariate analysis. Time to cholangiography was prolonged in the ICG-group in both univariate and multivariate analyses.

Discussion

ICG fluorescence is an adjunct that could improve the operative safety. Implementation of routine ICG fluorescence at this Swedish hospital was found to be safe and efficient, suggesting improvement in safety during FF-LC. Further studies are needed to see if ICG increases safety in LC.

The utilisation of biliary organoids for biomedical applications

Biliary duct injury, biliary atresia (BA), biliary tract tumors, primary sclerosing cholangitis (PSC), and other diseases are commonly encountered in clinical practice within the digestive system. To gain a better understanding of the pathogenesis and development of these diseases and explore more effective treatment methods, organoid technology has recently garnered significant attention. Organoids are three-dimensional structures derived from stem/progenitor cells that can faithfully mimic the intricate structure and physiological function of tissues or organs in vitro. They provide a valuable platform for studying the pathogenesis of biliary tract diseases and offer novel possibilities for repairing and regenerating biliary tract injuries. The main seed cells used to construct biliary tract organoids include primary human biliary tract epithelial cells as well as pluripotent stem cells. The construction of these organoids involves various techniques such as traditional embedding technology, rotary culture technology, hanging drop culture technology, along with emerging approaches like organ chip technology, three-dimensional (3D) printing technology, and four-dimensional (4D) printing technology. This article comprehensively reviews the construction methods of biliary tract organoids while discussing their applications in disease modeling research on disease mechanisms drug screening tissue/organ repair; it also highlights current challenges and suggests future research directions regarding biliary tract organoids which will serve as references for treating common refractory digestive system diseases in clinical practice.

Outcomes after index cholecystectomy: a UK longitudinal multi-centre cohort Study

PURPOSE

International guidelines for management of acute biliary pathology recommend emergency cholecystectomy (EmC), citing improved outcomes compared to elective cholecystectomy (ElC) based on trials which may not reflect the capacity constraints in clinical practice, nor selection based on multiple prior attendances with emergency biliary pathology or attendances following a decision for ElC. We therefore conducted a longitudinal retrospective study evaluating all attendances with biliary pathology prior to cholecystectomy with the aim of assessing whether EmC is justified in this context.

METHODS

Data was collected on patients undergoing cholecystectomy between 2016 and 2021 at four centres. Patients who had an emergency presentation with a biliary pathology prior to cholecystectomy up to 2010 were included. Patients were divided into EmC and ElC groups, EmC was defined as cholecystectomy occurring during an emergency admission with biliary pathology. Multilevel regression modelling was used to identify independent predictors for time to surgery from index presentation, number of re-attendances and length of stay (LoS).

RESULTS

2,056 patients were included: 1,786 (86.9%) had ElC and 270 (13.1%) EmC. EmC was independently associated with a reduction in time to surgery (-112.32 days [95% CI -140.22 to -84.42]). However, there was a significant increase in both post-operative and overall LoS (+ 3.34 days [95% CI 1.81-4.86]) across all admissions with EmC. EmC did not significantly reduce rates of emergency re-attendance prior to surgery overall.

CONCLUSION

Although EmC reduces time to surgery, it does not reduce the number of emergency re-attendances and increases LoS. In the context of limited emergency theatre capacity, it may be beneficial to prioritise those who benefit most from EmC.

Imaging and management of complications post biliary-enteric anastomosis

Biliary-enteric anastomosis is a common surgical procedure for benign and malignant pathologies involving bile ducts, pancreas and duodenum, as well as during liver transplantation. Imaging is key in detecting potential complications. Ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and nuclear scintigraphy provide complementary information. Ultrasound offers real-time assessment of bile duct dilation and fluid collection. CT scan, due to its wide availability, is often performed first and provides detailed cross-sectional anatomy. MRI, including MR cholangiography, excels in visualizing bile ducts and detecting subtle changes in anastomosis integrity. Common complications of BEA include bile leak, biliary anastomotic stricture, and cholangitis, each presenting with distinct imaging features. Effective imaging allows for early detection and management of these complications, improving patient outcomes. This review discusses the role of imaging in assessing post-BEA complications and emphasizes the importance of multimodal imaging approaches in the comprehensive evaluation of BEA and its complications.

Making organ donation after circulatory death routine: Preserving patienthood and reproducing ways of dying in the intensive care unit

Controlled organ donation after circulatory death (DCD) was re-introduced in the UK in 2008, in efforts to increase rates of organs for transplant. Following reintroduction, there were debates about the ethics of DCD, including whether potential DCD donors receive end-of-life care which is in their best interests. Since this time, DCD has become a routine donor pathway in the NHS. In this article, we present findings from an ethnographic study examining the everyday practices of DCD in two English Trusts. Drawing on the concept of death brokering and Bea's (2020) call to consider organ donation as embedded and routine practice within health care, we look at how DCD is integrated into end-of-life care in intensive care units. We show how DCD is made routine at the end-of-life via the practices of health professionals who create an active separation between discussions about death and donation; reproduce usual ways of doing things in end-of-life care; and respect the distinction between patient/donor, dying and death. In doing so, we argue these function to preserve the patienthood of the potential donor, ensuring DCD operates as an integrated part, and culturally accepted form of, good end-of-life care for potential donors, their relatives, and health professionals alike.

Post-operative complications of cholecystectomy: what the radiologist needs to know

Cholecystectomy is one of the most performed surgical procedures. The safety of this surgery notwithstanding, the sheer volume of operations results in a notable incidence of post-cholecystectomy complications. Early and accurate diagnosis of such complications is essential for timely and effective management. Imaging techniques are critical for this purpose, aiding in distinguishing between expected postsurgical changes and true complications. This review highlights current knowledge on the indications for cholecystectomy, pertinent surgical anatomy and surgical technique, and the recognition of anatomical variants that may complicate surgery. The article also outlines the roles of various imaging modalities in identifying complications, the spectrum of possible postsurgical anatomical changes, and the implications of such findings. Furthermore, we explore the array of complications that can arise post-cholecystectomy, such as biliary system injuries, gallstone-related issues, vascular complications, and the formation of postsurgical collections. Radiologists should be adept at identifying normal and abnormal postoperative findings to guide patient management effectively.

Clinical outcomes and risk factors of post-polypectomy microperforation in patients with colorectal neoplasia: a case-control study

Background

Colonoscopic polypectomy significantly reduces the incidence of colorectal cancer, but it carries potential risks, with colonic perforation being the most common and associated with significant morbidity.

Objectives

This study evaluated the clinical outcomes and risk factors of microperforation during colonoscopic polypectomy.

Design

A retrospective cohort study.

Methods

We retrospectively reviewed the patients' records who underwent colonoscopic polypectomy and subsequent plain radiographic examination to monitor perforation. Patients with pneumoperitoneum detected on plain radiography were enrolled. Patients who underwent adverse event-free colonoscopic polypectomies within 1 week of each case and were matched 2:1 by age and sex to the cases were selected as controls.

Results

Microperforations occurred in 12 patients (8 males; age: median 64.5 years). Polyps with microperforations were more frequent in the right colon (83.3% vs 33.3%). Endoscopic mucosal resection with precutting (EMR-P; 16.7% vs 0.0%) or hot-snare polypectomy (8.3% vs 0.0%) was more frequently performed in the microperforation group. Muscle fibers at the polypectomy site were more frequently visible in the microperforation group (58.3% vs 8.3%). By multivariate analysis, right colon location and visible muscle fibers were independent risk factors for microperforation. All patients with microperforation received intravenous antibiotics and were advised to fast. Patients responded well to these conservative treatments and were discharged after a median of 3 (2-6.75) days of hospital stay.

Conclusion

Our data suggest that conservative treatment is feasible and could be the primary management option for selected patients with microperforations postcolonoscopic polypectomy. Right-sided colonic polyps and visible muscle fibers predispose to microperforations.

Comparison between laparoscopic complete mesocolic excision and D2 radical operation in colon carcinoma resection: A propensity score matching analysis

BACKGROUND

Surgery remains the most effective treatment for colon cancer. However, there are still controversies regarding the tumor treatment effect, prognosis, and perioperative impact of complete mesocolic excision (CME) surgery in colon carcinoma resection.

OBJECTIVE

This study aims to compare laparoscopic complete mesocolic excision (LCME) and traditional open D2 radical surgery in colon carcinoma resection through a retrospective analysis using 1:1 propensity score matching (PSM).

METHODS

98 cases undergoing LCME or open D2 colon carcinoma resection at our hospital from January 2014 to November 2021 were retrospectively collected. After excluding cases and 1:1 matching using PSM based on baseline clinical data, 86 patients were assigned in research queue. 43 patients were in each group. Two groups were compared for general clinical baseline indicators. Surgical results and postoperative adverse events of patients were also compared. Disease-free survival (DFS) rate and overall survival (OS) rate was analyzed.

RESULTS

After 1:1 PSM matching, there was no statistically significant differences in baseline data between the LCME group and D2 group (P> 0.05). LCME was characterized by longer total duration of surgery (P< 0.001), less intraoperative bleeding volume (P< 0.001), more postoperative drainage fluid volume (P< 0.001), greater number of lymph nodes retrieved (P= 0.014). No statistically differences was observed regarding intraoperative blood transfusion, hospital stay, Clavien-Dindo complicating disease classification (all P> 0.05), 1 and 3-year DFS rate (P= 0.84) and OS rate (P⩾ 0.1).

CONCLUSION

LCME had a longer duration of surgery but less intraoperative bleeding volume and more postoperative drainage fluid volume and retrieved lymph nodes compared to D2 radical surgery. LCME surgery is comparable to D2 surgery in terms of postoperative prognosis, but LCME surgery shows a positive trend in the overall survival curve.

Pancreas Preservation: Hypothermic Oxygenated Perfusion to Improve Graft Reperfusion

BACKGROUND

The clinical standard for pancreas preservation for transplantation is static cold storage (SCS). Oxygenation during preservation has been shown to be advantageous in clinical studies. This study evaluates the efficiency of different oxygenation modalities during hypothermic pancreas preservation.

METHODS

Thirty-two porcine pancreases were procured in a controlled donation after circulatory death model and were divided to be preserved in 8 groups: (1) SCS, (2) hypothermic machine perfusion (HMP), (3) hypothermic oxygenated machine perfusion (HOPE) with 21% oxygen, (4) HOPE and 100%, (5) SCS and oxygen carrier, M101, (6) HMP and M101, (7) HOPE 21% and M101, and (8) HOPE 100% and M101. All the groups underwent 24 h of hypothermic preservation, followed by 2 h of normothermic reperfusion. Oxygen partial pressures were assessed using parenchymal probes. Perfusion parameters, perfusate samples, and tissue biopsies were analyzed.

RESULTS

This study showed that HMP was linked to higher tissue oxygen partial pressures, lower succinate levels, and better reperfusion parameters. Furthermore, the addition of M101 to either SCS or HMP was associated with lower succinate and creatinine phosphokinase accumulation, suggesting a protective effect against ischemia.

CONCLUSIONS

Our research has demonstrated the efficacy of machine perfusion in hypothermic conditions in providing oxygen to the pancreas during preservation and conditioning the pancreatic microvasculature for reperfusion during transplantation. Furthermore, the addition of M101 suggests a protective effect on the graft from ischemia.

Endoscopic management of colonic perforations

PURPOSE OF REVIEW

We will review the current management of colonic perforations, with particular emphasis on iatrogenic perforations caused by colonoscopy, the leading etiology. We will focus on recently developed endoscopic techniques and technologies that obviate morbid emergency surgery (the standard management approach in years past).

RECENT FINDINGS

Colonic perforations are rare but potentially fatal complications of both diagnostic and therapeutic colonoscopy resulting in death in approximately 5% of cases with the mortality increasing with delay in diagnosis and treatment. As novel endoscopic techniques and tools have flourished in recent years, our approach to management of these perforations has evolved. With the availability of newer tools such as over the scope clips, enhanced through the scope clips and novel endoscopic suturing devices, colonic perforations can be managed effectively in many or most patients without the morbidity of surgical interventions.

SUMMARY

With expanding use of colonoscopy, inadvertent outcomes such as perforations are bound to increase as well. Early diagnosis permits minimally invasive, nonsurgical, endoscopic management in most cases if the expertise and tools are available. Centers with high colonoscopy volumes including therapeutic procedures would be well served to invest in the requisite technologies and expertise.

Comparison of Post-Radical Cystectomy Renal Function and Ileal Conduit-Related Complications Between Extracorporeal and Robot-Assisted Intracorporeal Urinary Diversion: A Single-Center Experience

INTRODUCTION

Limited evidence exists regarding differences in post-operative renal function and ileal conduit-related complications, including ureteroenteric anastomotic stricture (UAS) and parastomal hernia (PH), between radical cystectomy (RC) with extracorporeal urinary diversion (ECUD) and robot-assisted RC with intracorporeal UD (ICUD).

METHODS

We retrospectively collected the baseline and post-RC follow-up data from 179 patients receiving RC with ileal conduit UD (152 ECUD and 27 ICUD). The estimated glomerular filtration rate (eGFR, mL/min/1.73 m2) and occurrence of UAS and PH were post-operatively monitored. Chronic kidney disease (CKD) stages were determined based on eGFR level. UD-related complications were evaluated using the Clavien-Dindo system. Time-course changes in eGFR level and CKD-related survival rates were compared in both the original and propensity score-matched cohorts.

RESULTS

Although the original ECUD group had higher eGFR levels (median, 60.9 vs. 52.1), comparison of the adjusted cohorts revealed no significant difference at any time points, CKD upstaging-free survival, and CKD stage 3b-free survival. Out of 179 patients, three (1.7%), eight (4.5%), and 14 (7.8%) experienced grade I, II, and IIIa UAS, respectively. Thirteen (7.3%) developed PH during follow-up. No significant differences were observed in UAS rates (p = 0.38), PH rates (p = 0.69), CKD upstaging-free survival, and CKD stage 3b-free survival between two groups.

CONCLUSION

No significant difference was observed in post-operative renal function and UD-related complication rates among the different types of surgery in patients undergoing RC in our institute. Further research is needed to determine the optimal surgical approach for each patient to minimize risks of CKD upstaging, UAS, and PH.

Biliary complications of surgical procedures: what the radiologist needs to know

Post-surgical biliary complications increase morbidity, mortality, and healthcare utilization. Early detection and management of biliary complications is thus of great clinical importance. Even though the overall risk for biliary complications is low after laparoscopic cholecystectomy, post-cholecystectomy biliary complications are frequently encountered in clinical practice as laparoscopic cholecystectomy is the most common surgical procedure performed in the United States. Other surgical procedures fraught with biliary complications include liver transplantation, pancreaticoduodenectomy, hepatic resection, and gastric surgeries.The clinical presentation of biliary complications is variable; imaging, thus, plays a vital role in diagnosis and management. Biliary leak (BL) and stricture are the most common biliary complications. Although Ultrasound (US) and Computed Tomography (CT) can detect collections and free fluid due to a BL, imaging confirmation of a biliary origin requires the use of a Hepatobiliary Iminodiacetic Acid (HIDA) scan or Magnetic Resonance Cholangiopancreatography (MRCP) with hepatocyte-specific contrast agent. Biliary strictures can present months to years after the original injury; the attendant biliary dilation is well seen on cross-sectional modalities. MRCP plays a crucial role in excluding features suggestive of a malignant etiology and establishing the type and anatomical extent of the injury for therapeutic planning. Radiologists thus play a vital role in detecting and managing biliary complications. This article provides an overview of the applied anatomy, clinical presentation, imaging, and therapeutic considerations of biliary complications after surgical procedures.

Laparoscopic cholecystectomy with communicating accessory hepatic duct injury and management: A case report

BACKGROUND

Laparoscopic cholecystectomy is considered the gold standard for the treatment of patients with gallstones. However, bile duct injury is one of the most serious complications of this surgery, with an incidence rate of 0.3%-0.7%. Variations in anatomical structures are one of the main reasons for such injuries.

CASE SUMMARY

We report a 26-year-old male patient who presented with repeated upper abdominal pain for 1 year. Ultrasound examination and blood tests indicated gallstones accompanied by chronic cholecystitis. The patient underwent laparoscopic cholecystectomy. During the surgery, a communicating bile duct connecting the gallbladder neck and the right hepatic duct was discovered and injured. Meticulous dissection identified it as a communicating accessory hepatic duct, which was then definitively ligated. Postoperatively, the patient recovered well, magnetic resonance imaging and magnetic resonance cholangiopancreatography showed no intrahepatic or extrahepatic bile duct strictures. The pathology report showed chronic cholecystitis with gallstones.

CONCLUSION

Carefully manage communicating accessory bile ducts in cholecystectomy using cholangiography or meticulous separation, followed by ligation is effective.

Association between ZJU index and gallstones in US adult: a cross-sectional study of NHANES 2017-2020

BACKGROUND

Based on triglyceride, body mass index (BMI), alanine aminotransferase/ aspartate aminotransferase ratio, fasting blood glucose, the ZJU index is proven to be a novel and effective parameter for screening NAFLD in Chinese. This study aims to evaluate the correlation between ZJU values and the risk of developing gallstones.

METHODS

The data from the National Health and Nutrition Examination Survey (NHANES) database during the period from 2017 to 2020 were analyzed in this cross-sectional study. And 6155 participants were included to assess the correlation between the ZJU index and the formation of gallstones through multivariate logistic regression, receiver operating characteristic (ROC) curve, subgroup analysis, and restricted cubic spline regression (RCS) analyses.

RESULTS

In this population-based study, 6155 participants aged 18 years and older were included, among which, 671 had gallstones. Logistic regression and RCS regression analyses indicated a significant positive non-linearly correlation between the ZJU index and the prevalence of gallstones (OR = 1.044, 95% CI: 1.032, 1.056), with an inflection point of 40.6. Subgroup analysis further revealed a stronger correlation between the risk of developing gallstones and the ZJU index in females. ROC analysis indicated that the ZJU index (AUC = 0.653) can serve as a more robust predictor for developing gallstones compared to traditional indices, with a sensitivity of 55.9%, a specificity of 67.1% and a cutoff of 43.4.

CONCLUSION

This study provides evidence that elevated the ZJU index is correlated with an increased risk of developing gallstones.

Current Challenges in Pancreas and Islet Transplantation: A Scoping Review

Type 1 diabetes mellitus is an autoimmune condition characterized by the destruction of pancreatic β-cells, necessitating insulin therapy to prevent life-threatening complications such as diabetic ketoacidosis. Despite advancements in glucose monitoring and pharmacological treatments, managing this disease remains challenging, often leading to long-term complications and psychological burdens, including diabetes distress. Advanced treatment options, such as whole-pancreas transplantation and islet transplantation, aim to restore insulin production and improve glucose control in selected patients with diabetes. The risk of transplant rejection necessitates immunosuppressive therapy, which increases susceptibility to infections and other adverse effects. Additionally, surgical complications, including infection and bleeding, are significant concerns, particularly for whole-pancreas transplantation. Recently, stem cell-derived therapies for type 1 diabetes have emerged as a promising alternative, offering potential solutions to overcome the limitations of formerly established transplantation methods. The purpose of this scoping review was to: (1) summarize the current evidence on achieved insulin independence following various transplantation methods of insulin-producing cells in patients with type 1 diabetes; (2) compare insulin independence rates among whole-pancreas transplantation, islet cell transplantation, and stem cell transplantation; and (3) identify limitations, challenges and potential future directions associated with these techniques. We systematically searched three databases (PubMed, Scopus, and Web of Science) from inception to November 2024, focusing on English-language, peer-reviewed clinical studies. The search terms used were 'transplantation' AND 'type 1 diabetes' AND 'insulin independence'. Studies were included if they reported on achieved insulin independence, involved more than 10 patients with type 1 diabetes, and had a mean follow-up period of at least one year. Reviewers screened citations and extracted data on transplant type, study population size, follow-up duration, and insulin independence rates. We identified 1380 papers, and after removing duplicates, 705 papers remained for title and abstract screening. A total of 139 English-language papers were retrieved for full-text review, of which 48 studies were included in this review. The findings of this scoping review indicate a growing body of literature on transplantation therapy for type 1 diabetes. However, significant limitations and challenges, like insufficient rates of achieved insulin independence, risks related to immunosuppression, malignant diseases, and ethical issues remain with each of the established techniques, highlighting the need for innovative approaches such as stem cell-derived islet transplantation to promote β-cell regeneration and protection.

Impact of Resuscitated Cardiac Arrest in the Brain-dead Donors on the Outcome of Liver Transplantation: A Retrospective and Propensity Score Matching Analysis

Objective

To evaluate the impact of cardiac arrest time (CAT) in brain-dead donors on graft and recipient outcomes following liver transplantation.

Background

The outcome of livers from brain-dead donors with a history of cardiac arrest (CA) remains controversial, and the duration of the CAT has never been evaluated.

Methods

A retrospective review of data from the Scientific Registry of Transplant Recipients between 2003 and 2022 was conducted. Propensity score matching was performed to minimize confounding effects.

Results

A total of 115,202 recipients were included, 7364 (6.4%) and 107,838 (93.6%) of whom were of the CA and non-CA group, respectively. After 1:1 propensity score matching, each group consisted of 7157 cases. The CA group demonstrated shorter hospital stay (15.5 ± 20.0 days vs. 16.2 ± 21.3 days, P = 0.041), with comparable incidence of early graft failure (EGF, 5.8% vs. 6.2%, P = 0.161). The CA group demonstrated slightly higher graft survival rates (1 year, 90% vs. 88%; 5 years, 76% vs. 74%; and 10 years, 61% vs. 58%, P < 0.001). CAT positively correlated with EGF [odds ratio (OR) = 1.03, 95% confidence interval (CI) = 1.02-1.04, P < 0.001], with a sensitivity and specificity of 73% and 86% at a cutoff of 30 minutes. The CAT <30 minutes group demonstrated significantly lower incidence of EGF (5.0%), compared with 7.8% of the CAT >30 minutes group and 6.2% of the non-CA group (P < 0.001).

Conclusions

The use of brain-dead donors with a history of CA did not increase the risk of liver graft failure in our study. A downtime of <30 minutes may confer protective effects on transplanted grafts.

Factors Influencing the Achievement of the Critical View of Safety in Laparoscopic Cholecystectomy: A Prospective Observational Study in Yemen

Background The critical view of safety (CVS) is a critical technique to minimize the risk of bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC). This study evaluated the rate of CVS achievement and examined factors influencing its success. Methods This prospective study included 97 patients undergoing LC. Data on demographic characteristics, preoperative factors, surgical difficulty, and surgeon experience were collected. CVS achievement was assessed using Strasberg's criteria, and associated factors were analyzed. Results CVS was successfully achieved in 31 of 97 cases (32%), while it was not achieved in 66 cases (68%). Factors significantly associated with failure to achieve CVS included previous abdominal surgery (p = 0.024), prior endoscopic retrograde cholangiopancreatography (ERCP) (p = 0.024), acute cholecystitis (p = 0.024), and higher difficulty grades according to the modified Nassar scale (p < 0.001). Although there was no statistically significant difference in CVS achievement between specialists and residents (p = 0.223), specialists had a higher success rate (37.5%) compared to residents (28%). Achieving CVS was associated with shorter operative times (mean: 60 vs. 70 minutes, p < 0.001) and reduced use of postoperative drains (16.1% vs. 83.9%, p < 0.001). Importantly, no BDIs were observed. Conclusion Achieving CVS remains a challenge, particularly in complex cases and patients with prior abdominal interventions or acute inflammation. Enhanced surgical training, meticulous preoperative planning, and the use of adjunctive technologies may improve CVS success rates and contribute to safer outcomes in LC.

Intraoperative Anesthetic Strategies to Mitigate Early Allograft Dysfunction After Orthotopic Liver Transplantation: A Narrative Review

Orthotopic liver transplantation (OLT) is the most effective treatment for patients with end-stage liver disease (ESLD). Hepatic insufficiency within a week of OLT, termed early allograft dysfunction (EAD), occurs in 20% to 25% of deceased donor OLT recipients and is associated with morbidity and mortality. Primary nonfunction (PNF), the most severe form of EAD, leads to death or retransplantation within 7 days. The etiology of EAD is multifactorial, including donor, recipient, and surgery-related factors, and largely driven by ischemia-reperfusion injury (IRI). IRI is an immunologic phenomenon characterized by dysregulation of cellular oxygen homeostasis and innate immune defenses in the allograft after temporary cessation (ischemia) and later restoration (reperfusion) of oxygen-rich blood flow. The rising global demand for OLT may lead to the use of marginal allografts, which are more susceptible to IRI, and thus lead to an increased incidence of EAD. It is thus imperative the anesthesiologist is knowledgeable about EAD, namely its pathophysiology and intraoperative strategies to mitigate its impact. Intraoperative strategies can be classified by 3 phases, specifically donor allograft procurement, storage, and recipient reperfusion. During procurement, the anesthesiologist can use pharmacologic preconditioning with volatile anesthetics, consider preharvest hyperoxemia, and attenuate the use of norepinephrine as able. The anesthesiologist can advocate for normothermic regional perfusion (NRP) and machine perfusion during allograft storage at their institution. During recipient reperfusion, the anesthesiologist can optimize oxygen exposure, consider adjunct anesthetics with antioxidant-like properties, and administer supplemental magnesium. Unfortunately, there is either mixed, little, or no data to support the routine use of many free radical scavengers. Given the sparse, limited, or at times conflicting evidence supporting some of these strategies, there are ample opportunities for more research to find intraoperative anesthetic strategies to mitigate the impact of EAD and improve postoperative outcomes in OLT recipients.

Left-Sided Gallbladder: Tips and Tricks to Safe Cholecystectomy

Left-sided gallbladder (LSGB) is a rare anatomical variation where the gallbladder is to the left of the falciform ligament and ligamentum teres. Most commonly, it is discovered as an incidental finding at the time of operation (typically for cholecystectomy). We describe a case of left-sided gallbladder in a 71-year-old female. The patient presented with complaints of pain in the right upper quadrant and epigastric area, which had persisted for two months, accompanied by intermittent biliary colic over the previous five years. An ultrasound demonstrated a single 39 mm gallstone. She underwent an elective laparoscopic cholecystectomy, during which an incidental discovery of an LSGB occurred. Patients with LSGB have a relatively high risk of complications when proceeding with operative interventions, likely secondary to concurrent biliary and arterial anatomical variants. Images of the anatomy of LSGB and possible adaptations to the usual laparoscopic cholecystectomy techniques necessary to perform a safe operation are discussed, including division of the falciform ligament and altered port placements. LSGB is a rare anatomical variation that increases surgical risk at the time of cholecystectomy. Understanding this variation in anatomy is critical to undertaking safe operative interventions in these patients.

Endoscopic or combined management of post-surgical biliary leaks: a two-center recent experience

BACKGROUND AND AIMS

Post-surgical biliary leaks (PSBL) are one of the most prevalent and significant adverse events emerging after liver or biliary tract surgeries. Endoscopic retrograde cholangiopancreatography (ERCP) alone or combined with another approach (Rendez Vous) as treatment of PSBL obtains optimal outcomes due to the possibility of modifying the resistances in the biliary tree.

METHODS

A retrospective double-center study was conducted in two tertiary centers. Consecutive patients who underwent at least one attempt of PSBL correction by ERCP or Rendez Vous procedure between January 2018 and August 2023 were included. The primary outcome was overall endoscopic clinical success. In contrast, the secondary outcomes were hospital stay exceeding five days and endoscopic clinical success with the first endoscopic procedure at the tertiary center. Both univariate and multivariate analyses were used to assess outcomes.

RESULTS

65 patients were included. Patients with one or multiple) leaks had more possibility to achieve the endoscopic clinical success compared to those affected by the association of leaks and stricture (96% vs 67%, p value 0.005). Leaks occurring in the main biliary duct had less probability (67%) to achieve the overall endoscopic clinical success compared to those in the end-to-end anastomosis (90%), in the resection plane or biliary stump (96%) or first or secondary order biliary branches (100%, p value 0.038). A leak-bridging stent positioning had more probability of achieving the endoscopic clinical success than a not leak-bridging stent (91% vs 53%, p value 0.005).

CONCLUSIONS

ERCP and Rendez Vous procedures are safe and effective for treating PSBL, regardless of the type of preceding surgery, even if technical or clinical success was not achieved on the first attempt. A stent should be placed, if feasible, leak-bridging to enhance treatment efficacy.

The Use of Long-Term Monthly Basiliximab Infusions as Rescue Maintenance Immunosuppression in Pancreas Transplant Recipients

This single-center retrospective study was designed to evaluate the use of basiliximab as an alternative rescue maintenance immunosuppression in situations where standard maintenance immunosuppression is not tolerated after a pancreas transplant. All pancreas transplants performed between January 11, 2006, and January 6, 2022, were reviewed. All recipients received rabbit antithymocyte globulin (rATG) induction with tacrolimus + sirolimus maintenance for simultaneous pancreas and kidney (SPK) and additional low-dose mycophenolic acid for pancreas transplant alone (PTA). Basiliximab 40mg IV q 4 weeks was either added to or in replacement of adjunct immunosuppression in cases of medication intolerance. All recipients who received ≥3 months of basiliximab with ≥1 year follow-up were included. 29/557 (5.2%) recipients (5 SPK and 24 PTA) were identified. Median time to switch was 13 months. When compared 1:2 to matched controls on standard immunosuppression, there was no difference in pancreas rejection, allograft loss, or mortality. Eleven recipients had 13 episodes of pancreas rejection at a median of 28 months post conversion. Eight pancreas allografts failed at a median of 28 months post conversion, and there were five deaths-all occurring in PTA, 4/5 occurring ≥1 year after discontinuation of basiliximab. Renal allograft rejection occurred in one SPK and there was one renal allograft loss. Five PTA developed renal failure. Ten remain on basiliximab (2/5 SPK, 8/24 PTA) at a median of 44 months with good pancreas and kidney function; 4 pts > 4 years. Basiliximab can be considered an alternative rescue maintenance strategy in pancreas transplant recipients who failed other conventional agents.

Preoperative Waiting Time Affects the Length of Stay of Patients Treated via Laparoscopic Cholecystectomy in an Acute Care Surgical Setting

Background/Objectives: Acute cholecystitis (AC) presents a significant burden in emergency surgical settings. Early laparoscopic cholecystectomy (ELC) is the standard of care for AC, yet its implementation varies. This study aims to assess the impact of preoperative waiting time (WT) on postoperative length of stay (LOS) in patients undergoing urgent cholecystectomy. Methods: From June 2021 to September 2022, data on patients undergoing urgent cholecystectomy for AC or pancreatitis were collected from two university hospitals. Patients were categorized into early (ELC) or delayed (DLC) cholecystectomy groups based on WT. The primary outcome was the assessment of the variables influencing LOS via univariate and multivariate analyses. Results: This study included 170 patients, predominantly female, with a median age of 64.50 years. ELC was performed in 58.2% of cases, with a median WT of 0 days, while DLC was performed in 41.8%, with a median WT of 3 days. Postoperative complications occurred in 21.8% of cases, with LOS being significantly shorter in the ELC group (median 5 days vs. 9 days; p = 0.001). Multivariate analysis confirmed that WT (OR 8.08 (1.65-77.18; p = 0.033)) was the most important predictor of LOS. Conclusions: ELC is associated with a shorter LOS and with DLC, aligning with the WSES recommendations. Earlier surgery reduces the risk of complications and overall hospital costs. An extended WT contributes to a prolonged LOS, underscoring the importance of timely access to operating theaters for acute biliary pathologies.

Exploring colorectal cancer patients' diagnostic pathways and general practitioners' assessment of the diagnostic processes: a Danish survey study

INTRODUCTION

Colorectal cancer (CRC) is among the most common cancers and the prognosis of CRC is highly dependent on stage at diagnosis. Although many cases are diagnosed swiftly, there is still room for improvement.

AIM

We aimed to explore CRC diagnostic pathways, encompassing (1) place of initial contact; (2) associations with symptom presentations, sex, and age with events in the diagnostic process and initial referrals and (3) the general practitioner's (GP's) evaluation of the diagnostic processes.

METHODS

All GPs in North-, Central-, and Southern Denmark were invited to fill in questionnaires for their listed patients diagnosed with cancer during the past two years.

RESULTS

Among 1,032 recorded CRC patients, 65% had their initial contact in general practice, 5% within the out-of hours service, 10% in the hospital, and 20% were diagnosed based on screening. A total of 27% of CRC patients over 40 who initially presented in general practice were treated or referred on suspicion of another disease first, and 9% were reported to have had hesitated in seeking medical attention. Some 37% presented solely non-specific symptoms, increasing the odds of the GP advising watchful waiting (OR 2.48; 95% CI 1.06-5.81), treating or referring on the suspicion of another illness first (OR 2.57; 95% CI 1.76-3.75), wait due to normal findings (OR 2.11; 95% CI 1.16-3.85), or referring to diagnostic imaging (OR 3.07; 95% CI 1.63-5.79). The GPs assessed nearly one fifth of the diagnostic processes as poor.

CONCLUSION

Most CRC patients are diagnosed with initial presentation in general practice. Having non-specific symptoms is common and challenges timely diagnosis.

A qualitative study exploring barriers and facilitators in deceased organ donation process among transplant coordinators in India

Although India's organ donation rate is less than 1 per million population, significant disparities exist between the regions and centres within the country, leading to varying consent rates among different organ donation centres. Therefore, this study aimed to understand the experience of transplant coordinators and their barriers and facilitators in the deceased organ donation process across various organ donation centres in India. A phenomenological study using interviews was conducted among fourteen transplant coordinators purposefully recruited from public and private organ donation centres in India, with experience between six years and more than a decade. Audio recordings were transcribed and analysed using framework analysis. Five themes were identified namely: (1) supportive management policies, (2) infrastructure for the deceased organ donation process, (3) delays in the processing time, (4) active involvement in the identification process, and (5) explaining the concept of brain death. The study identifies that implementation priorities include strengthening teamwork, streamlining processes, optimising infrastructure for sensitive discussions, efficient donor identification, and empathetic handling of donor families' grief stages. Collaborating with law enforcement, applying successful medico-legal strategies, improving family communication, and clarifying brain death concepts ethically and legally can boost consent rates, fostering informed decisions and possibly achieving self-sufficiency in deceased organ donation.

Retroperitoneal pancreas transplantation with a Roux-en-Y duodenojejunostomy for exocrine drainage

BACKGROUND

Pancreatic transplantation is the only definitive surgical treatment for diabetes mellitus. Currently, most transplant centers use enteric exocrine drainage of pancreatic secretions; however, experts disagree on which part of the gastrointestinal tract is preferable for enteric anastomosis. We analyzed the outcomes of retroperitoneal pancreatic transplantation with enteric drainage of pancreatic secretions.

MATERIALS AND METHODS

We evaluated the outcomes of 60 simultaneous retroperitoneal pancreas-kidney transplantations. Based on the type of enteric anastomosis, the patients were divided into two groups: the study group consisted of 10 patients who underwent enteric drainage via Roux-en-Y duodenojejunostomy, and the control group included 50 patients who underwent exocrine drainage via duodenoduodenal anastomosis. No statistically significant differences were observed between the groups in terms of the main parameters.

RESULTS

The rate of surgical complications did not differ significantly between the groups (p > 0.05). Clavien IVb complications occurred only in the control group (n = 4.8%). The in-hospital pancreatic graft survival rate in both groups was 80%, whereas the recipient survival rates were 90% and 84%, in the study and control groups, respectively (p < 0.05).

CONCLUSION

Retroperitoneal pancreatic transplantation with exocrine drainage via a Roux-en-Y duodenojejunostomy is an effective alternative technique that reduces the rate of severe surgical complications.

An exploration of radiological signs in post-intervention liver complications

The advent and progression of radiological techniques in the past few decades have revolutionized the diagnostic and therapeutic landscape for liver diseases. These minimally invasive interventions, ranging from biopsies to complex therapeutic procedures like transjugular intrahepatic portosystemic shunt placement and transarterial embolization, offer substantial benefits for the treatment of patients with liver diseases. They provide accurate tissue diagnosis, allow real-time visualization, and render targeted treatment for hepatic lesions with enhanced precision. Despite their advantages, these procedures are not without risks, with the potential for complications that can significantly impact patient outcomes. It is imperative for radiologists to recognize the signs of these complications promptly to mitigate further health deterioration. Ultrasound, CT, and MRI are widely utilized examinations for monitoring the complications. This article presents an overarching review of the most commonly encountered hepatobiliary complications post-radiological interventions, emphasizing their imaging characteristics to improve patient post-procedure management.

Factors Influencing Bile Duct Injuries: A Dreaded Complication of Laparoscopic Cholecystectomy

Bile duct injuries (BDIs) are dreaded complications of one of the most common general surgical procedures. The injury impacts the quality of life and may have several long-term complications. In some cases, it can also lead to mortality. This paper aims to review works that have already been published about bile duct injuries and elaborate on the factors leading to it. This includes elaborating on both surgical and non-surgical factors. It also plans to highlight practices and methods to avoid BDIs. Medical research databases were searched using cholecystectomy and bile duct injuries as keywords. Papers including pre-operative or intraoperative factors, that may cause bile duct injuries, were further shortlisted for this study. Understanding and knowledge of anatomy plays a key role in bile duct injuries and is essential before performing the surgery. Factors related to the patients, surgeons, and logistics also play a major role in causing bile duct injuries. Bile duct injuries can be reduced using certain strategies like the B SAFE strategy, R4U line, bail-out methods, imaging techniques along with referrals to Hepatobiliary specialist centers to avoid bile duct injuries.

Effectiveness of Prehabilitation Modalities on Postoperative Outcomes Following Colorectal Cancer Surgery: A Systematic Review of Randomised Controlled Trials

BACKGROUND

Postoperative morbidity in patients undergoing curative colorectal cancer surgery is high. Prehabilitation has been suggested to reduce postoperative morbidity, however its effectiveness is still lacking.

OBJECTIVE

The aim of this study was to investigate the effectiveness of prehabilitation in reducing postoperative morbidity and length of hospital stay in patients undergoing colorectal cancer surgery.

METHODS

A comprehensive electronic search was conducted in the CINAHL, Cochrane Library, Medline, PsychINFO, AMED, and Embase databases from inception to April 2023. Randomised controlled trials testing the effectiveness of prehabilitation, including exercise, nutrition, and/or psychological interventions, compared with usual care in patients undergoing colorectal cancer surgery were included. Two independent review authors extracted relevant information and assessed the risk of bias. Random-effect meta-analyses were used to pool outcomes, and the quality of evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines.

RESULTS

A total of 23 trials were identified (N = 2475 patients), including multimodal (3 trials), exercise (3 trials), nutrition (16 trials), and psychological (1 trial) prehabilitation. There was moderate-quality evidence that preoperative nutrition significantly reduced postoperative infectious complications (relative risk 0.65, 95% confidence interval [CI] 0.45-0.94) and low-quality evidence on reducing the length of hospital stay (mean difference 0.87, 95% CI 0.17-1.58) compared with control. A single trial demonstrated an effect of multimodal prehabilitation on postoperative complication.

CONCLUSION

Nutrition prehabilitation was effective in reducing infectious complications and length of hospital stay. Whether other multimodal, exercise, and psychological prehabilitation modalities improve postoperative outcomes after colorectal cancer surgery is uncertain as the current quality of evidence is low.

PROTOCOL REGISTRATION

Open Science Framework ( https://doi.org/10.17605/OSF.IO/VW72N ).

Outcomes of Gallbladder Drainage Techniques in Acute Cholecystitis: Percutaneous Versus Endoscopic Methods

Acute cholecystitis, often caused by gallstones obstructing the cystic duct, is a potentially life-threatening condition that requires timely intervention. High-risk patients, particularly those with significant comorbidities, may not be suitable candidates for laparoscopic cholecystectomy, necessitating alternative drainage techniques such as percutaneous cholecystostomy (PC) and endoscopic gallbladder drainage (EGD). This systematic review aims to compare the efficacy, safety, and outcomes of PC and EGD in managing acute cholecystitis in high-risk surgical patients. A comprehensive literature search was conducted across multiple databases, including PubMed, Medline, Embase, Cochrane Library, and Scopus, from inception to October 2024. Studies were included if they assessed the outcomes of PC versus EGD in high-risk patients with acute cholecystitis. Data extraction focused on primary outcomes such as complication rates, reintervention needs, symptom resolution, hospital stay duration, and mortality. A qualitative synthesis was conducted due to heterogeneity in the study designs. Four randomized controlled trials and cohort studies were included, encompassing a total of 238 high-risk patients. Laparoscopic cholecystectomy showed significantly better outcomes compared to percutaneous drainage in reducing major complications, reintervention rates, and recurrent biliary disease. Endoscopic drainage techniques, including naso-gallbladder drainage and gallbladder stenting, demonstrated similar clinical success rates with fewer complications than percutaneous methods, particularly in patients with concurrent biliary conditions. The findings suggest that while percutaneous drainage provides rapid symptom relief, it is associated with higher reintervention rates. Endoscopic techniques offer fewer complications and are particularly beneficial for patients with suspected choledocholithiasis. However, the choice of drainage method should be based on individual patient profiles, taking into account overall health status and comorbidities. Both percutaneous and endoscopic drainage methods are effective in managing acute cholecystitis in high-risk patients, with distinct advantages depending on patient-specific factors. Further research is needed to explore long-term outcomes and hybrid approaches that may optimize care for these patients.

Endoscopic management of postcholecystectomy complications at a Nigerian tertiary health facility

BACKGROUND

Cholecystectomy and common bile duct exploration for biliary stone disease are common hepatobiliary surgeries performed by general surgeons in Nigeria. These procedures can be complicated by injury to the biliary tree or retained stones, requiring repeat surgical intervention. This study presents the experience of using endoscopic retrograde cholangiopancreatography (ERCP) in the management of hepatobiliary surgery complications at the academic referral center of Obafemi Awolowo University Teaching Hospital (OAUTHC) Ile-Ife, Nigeria.

METHODS

All patients with postcholecystectomy complications referred to the endoscopy unit at OAUTHC from March 2018 to April 2023 were enrolled. Preoperative imaging included a combination of abdominal ultrasound, CT, MRI, magnetic resonance cholangiopancreatography (MRCP), and T-tube cholangiogram. All ERCP procedures were performed under general anesthesia.

RESULTS

Seventy-two ERCP procedures were performed on 45 patients referred for postcholecystectomy complications. The most common mode of presentation was ascending cholangitis [16 (35.6%)], followed by persistent biliary fistula [12 (26.7%)]. The overall median duration of symptoms after cholecystectomy was 20 weeks, with a range of 1-162 weeks. The most common postcholecystectomy complication observed was retained stone [16 (35.6%)]. Other postcholecystectomy complications included bile leakage, bile stricture, bile leakage with stricture, and persistent bile leakage from the T-tube in 12 (26.7%), 11 (24.4%), 4 (8.9%), and 2 (4.4%) patients, respectively. Ampullary cannulation during ERCP was successful in all patients (45, 100%). Patients with complete biliary stricture (10/12) required hepaticojejunostomy.

CONCLUSION

Endoscopic management of postcholecystectomy complications was found to be safe and reduce the number of needless surgeries to which such patients are exposed. We recommended prompt referral of such patients for ERCP.

Subclinical Pancreas Rejection on Protocol Biopsy Within the First Year of Simultaneous Pancreas Kidney Transplant

This single-center retrospective study investigated subclinical rejection prevalence and significance in simultaneous pancreas and kidney transplant (SPKT) recipients. We analyzed 352 SPKT recipients from July 2003 to April 2022. Our protocol included pancreas allograft surveillance biopsies at 1, 4, and 12months post-transplant. After excluding 153 patients unable to undergo pancreas biopsy, our study cohort comprised 199 recipients. Among the 199 patients with protocol pancreas biopsies, 107 had multiple protocol pancreas biopsies in the first year, totaling 323. Subclinical rejection was identified in 132 episodes (41%). Of these, 72% were Grade 1, 20% were indeterminate, and 8% were Banff Grade 2 or higher. All episodes of subclinical rejection were treated. Rates of pancreas graft loss (10% vs. 7%) and clinical rejection (21% vs. 20%) at 3 years were similar between those with and without subclinical rejection. Subclinical rejection Banff Grade 2 or more was associated with poor pancreas graft survival HR of 5.5 (95% CI: 1.24-24.37, p = 0.025). Of 236 simultaneous protocol kidney and pancreas biopsies, 102 (43%) showed pancreas subclinical rejection, while only 17% had concurrent kidney subclinical rejection. Our findings suggest limited predictive value of pancreatic enzymes and euglycemia in detecting pancreas rejection. Furthermore, poor concordance existed between pancreas and kidney subclinical rejection.

Indocyanine green in laparoscopic cholecystectomy: utility and correlation with a preoperative risk score

BACKGROUND

This study aims to compare the visualization of the cystic duct-common bile duct junction with indocyanine green (ICG) among 3 groups of patients divided according to the difficulty of elective laparoscopic cholecystectomy.

METHODS

Conducted at a single center, this non-randomized, prospective, observational study encompassed 168 patients who underwent elective laparoscopic cholecystectomy and were assessed with a preoperative risk score to predict difficult cholecystectomies, including clinical factors and radiological findings. Three groups were identified: low, moderate, and high risk. A dose of 0.25 mg of IV ICG was administered during anesthesia induction and the different objectives were evaluated.

RESULTS

The visualization of the cystic duct-common bile duct junction was achieved in 28 (100%), 113 (91.1%), and 10 (63%) patients in the low, moderate, and high-risk groups, respectively. The high-risk group had longer total operative time, higher conversion, more complications and longer hospital stay. In the surgeon's subjective assessment, ICG was considered useful in 36% of the low-risk group, 58% in the moderate-risk group, and 69% in the high-risk group. Additionally, there were no cases where ICG modified the surgeon's surgical approach in the low-risk group, compared to 11% in the moderate-risk group and 25% in the high-risk group (p < 0.01).

CONCLUSIONS

The results of this study confirm that in the case of difficult cholecystectomies, the visualization of the cystic duct-common bile duct junction is achieved in 63% of cases and prompts a modification of the surgical procedure in one out of four patients.

Thermosensitive Hydrogels as Targeted and Controlled Drug Delivery Systems: Potential Applications in Transplantation

Drug delivery in transplantation plays a vital role in promoting graft survival, preventing rejection, managing complications, and contributing to positive patient outcomes. Targeted and controlled drug delivery can minimize systemic effects. Thermosensitive hydrogels, due to their unique sol-gel transition properties triggered by thermo-stimuli, have attracted significant research interest as a potential drug delivery system in transplantation. This review describes the current status, characteristics, and recent applications of thermosensitive hydrogels for drug delivery. Studies aimed at improving allotransplantation outcomes using thermosensitive hydrogels are then elaborated on. Finally, the challenges and opportunities associated with their use are discussed. Understanding the progress of research will serve as a guide for future improvements in their application as a means of targeted and controlled drug delivery in translational therapeutic applications for transplantation.