Hepaticojejunostomy and long-term interventional treatment for recurrent biliary stricture after proximal bile duct injury: A case report

BACKGROUND

Proximal bile duct injury (BDI), which often occurs after laparoscopic cholecystectomy (LC), can lead to complex biliary stricture and recurrent cholangitis. This case report presented a 39-year-old woman who experienced proximal BDI during LC in 2017, leading to multiple episodes of cholangitis and subsequent hepaticojejunostomy in 2018. Despite these interventions, persistent biliary complications necessitated repeated hospital admissions and antibiotic treatment. Imaging studies revealed persistent stricture at the site of hepaticojejunostomy, prompting a series of percutaneous procedures, including balloon dilatation and biliary drainage. In August 2024, she underwent biodegradable biliary stenting, which significantly improved her condition. Subsequently, she remained clinically stable for 5 months without further episodes of cholangitis and had improved liver function tests. This case highlighted the complexities of managing postinjury biliary stricture, underscored the potential of biodegradable stents as an effective treatment option, and emphasized the need for a multidisciplinary approach in managing such complications. Long-term follow-up is essential for monitoring treatment effectiveness and preventing recurrence.

CASE SUMMARY

A 39-year-old female had a routine LC in 2017. The patient sustained a proximal BDI during the surgery. In the months that followed, recurrent bouts of cholangitis occurred. A hepaticojejunostomy biliary reconstruction was performed in 2018. However, hepatic cholangitis persisted. In 2021 and 2022, MRCP scans revealed biliary stasis, duct dilation, and a stricture at the hepaticojejunostomy site. A subsequent percutaneous transhepatic cholangiography (PTC) confirmed these findings and led to drain placement. The treatment included internal and external biliary drain placements, repeated balloon dilations of the stricture, percutaneous transhepatic cholangioscopy to extract intrahepatic lithiasis, and insertion of a biodegradable biliary stent. Since the first PTC intervention, there have been no hospital admissions for cholangitis. Liver function tests showed improvement, and for five months following the biodegradable stenting, the condition remained stable. Long-term surveillance with regular imaging and blood work has been emphasized. The final diagnosis is recurrent biliary stricture secondary to proximal BDI. Treatment, including hepaticojejunostomy, repeated PTC with balloon dilation, and biodegradable biliary stenting, has led to complete drainage of the biliary system. Ongoing follow-up remains crucial for monitoring the patient's progress and maintaining their health.

CONCLUSION

This case demonstrated how strictures and recurrent cholangitis complicate the management of BDI after LC. A customized and multidisciplinary approach to control chronic biliary disease was proven effective, as shown by the patient’s good outcome. This was achieved by integrating balloon dilatation sessions, biliary drainage, stone clearing, and biodegradable stent placement. Long-term follow-up and continued monitoring remain essential to ensure patient stability and prevent further complications.

State of the Art of Bioengineering Approaches in Beta-Cell Replacement

Purpose of the Review

Despite recent advancements in technology for the treatment of type 1 diabetes (T1D), exogenous insulin delivery through automated devices remains the gold standard for treatment. This review will explore progress made in pancreatic islet bioengineering within the field of beta-cell replacement for T1D treatment.

Recent Findings

First, we will focus on the use of decellularized extracellular matrices (dECM) as a platform for pancreatic organoid development. These matrices preserve microarchitecture and essential biochemical signals for cell differentiation, offering a promising alternative to synthetic matrices. Second, advancements in 3D bioprinting for creating complex organ structures like pancreatic islets will be discussed. This technology allows for increased precision and customization of cellular models, crucial for replicating native pancreatic islet functionality. Finally, this review will explore the use of stem cell-derived organoids to generate insulin-producing islet-like cells. While these organoids face challenges such as functional immaturity and poor vascularization, they represent a significant advancement for disease modeling, drug screening, and autologous islet transplantation.

Summary

These innovative approaches promise to revolutionize T1D treatment by overcoming the limitations of traditional therapies based on human pancreatic islets.

New methods for improving pancreas preservation

PURPOSE OF REVIEW

Pancreas and islet transplantation face critical organ shortage challenges, with many potential grafts discarded due to concerns about consequences of ischemia-reperfusion injury, particularly from donation after circulatory death (DCD) donors. Static cold storage remains standard practice but has significant limitations. Novel preservation technologies may improve transplant outcomes, donor selection and even expand the donor pool.

RECENT FINDINGS

Normothermic regional perfusion in DCD donors has increased pancreas utilization with promising one-year graft survival comparable to donation after brain-death (DBD) donors. Hypothermic machine perfusion maintains tissue integrity and shows promising preclinical results. Oxygenated hypothermic machine perfusion successfully restores tissue adenosine triphosphate (ATP) levels without notable tissue injury. Normothermic machine perfusion, despite challenges, offers potential for viability assessment and resuscitation.

SUMMARY

Advanced preservation technologies provide platforms for assessment, reconditioning, and therapeutic interventions for pancreas grafts. Clinical translation requires consensus on perfusion parameters and perfusate composition optimized for pancreatic preservation. Future developments should focus on implementing sensitive and specific assessment methods, including beta-cell specific biomarkers, to confidently select and utilize marginal pancreas grafts for transplantation.

Validation of the Back-table Graft Arterial Anastomosis Between the Splenic Artery and Superior Mesenteric Artery: Arterial Complications After a 21-year Single-center Experience of Pancreas Transplantation

OBJECTIVE

To determine the role of the arterial splenomesenteric anastomosis (ASMA) vascular reconstruction technique in terms of arterial vascular complications in pancreas transplantation (PT) recipients.

BACKGROUND

The ASMA technique was first described in 1992 by the Hospital Clínic Barcelona group. Regardless that the iliac Y-graft technique is the most frequently used worldwide, evidence of arterial complications and implications of using a different back-table reconstruction is conspicuously absent in the literature.

METHODS

Descriptive review of 407 PTs performed at a single center (1999-2019) by analyzing the type of arterial reconstruction technique, focusing on ASMA. The end points were the management of arterial complications and long-term patient and graft survival.

RESULTS

ASMA was performed in 376 cases (92.4%) and a Y-graft in 31 cases (7.6%). A total of 34 arterial complications (8.3%) were diagnosed. In the ASMA group (n=30, 7.9%), they comprised 15 acute thrombosis, 4 stenosis, 1 pseudoaneurysm, and 10 diverse chronic arterial complications, whereas in the Y-graft group (n=4, 12.9%), 3 acute thrombosis and 1 chronic artery-duodenal fistula occurred. Graft salvage was achieved in 16 patients (53.3%) from the ASMA group and in 2 (50%) from the Y-graft. After a median follow-up of 129.2 (IQR 25-75%, 77.2-182) months, the overall graft and patient survival for the whole cohort at 1, 5, and 10 years were 86.7%, 79.5%, and 70.5%, and 98.5%, 95.3%, and 92.5%, respectively.

CONCLUSIONS

The ASMA proves to be a safe and more easily reproducible technique and could therefore be considered a safe alternative vascular reconstruction procedure to the Y-graft in the PT population.

Pancreas rejection: quieting the storm to preserve graft function

PURPOSE OF REVIEW

Allograft rejection remains enigmatic and elusive following pancreas transplantation. In the absence of early technical pancreas graft failure, pancreas allograft rejection is the major cause of death-censored pancreas graft loss both short- and long-term. Despite this circumstance, there are variations in the diagnosis and treatment of pancreas rejection. In this article, we summarize recent literature, review common practices, and discuss various management algorithms.

RECENT FINDINGS

Although pancreas allograft biopsy is the gold standard for the diagnosis of rejection, not all transplant centers have the capability to perform pancreas allograft biopsy. Some centers depend on clinical or laboratory parameters exclusively or rely on dysfunction or biopsy of a simultaneous kidney allograft as a marker for pancreas allograft rejection. New biomarkers are evolving to assess the risk for rejection and may help to diagnose early rejection. In the future, the use of machine learning algorithms and artificial intelligence may play a role identifying patients at risk and detecting pancreas rejection without performing a pancreas allograft biopsy.

SUMMARY

Despite decades of experience in pancreas transplantation, the diagnosis and management of pancreas rejection remains challenging. Emerging biomarkers and machine learning algorithms are needed to mitigate immunological complications and guide immunosuppression in these patients.

Impacts of Radiation on Metabolism and Vascular Cell Senescence

Significance: This review investigates how radiation therapy (RT) increases the risk of delayed cardiovascular disease (CVD) in cancer survivors. Understanding the mechanisms underlying radiation-induced CVD is essential for developing targeted therapies to mitigate these effects and improve long-term outcomes for patients with cancer. Recent Advances: Recent studies have primarily focused on metabolic alterations induced by irradiation in various cancer cell types. However, there remains a significant knowledge gap regarding the role of chronic metabolic alterations in normal cells, particularly vascular cells, in the progression of CVD after RT. Critical Issues: This review centers on RT-induced metabolic alterations in vascular cells and their contribution to senescence accumulation and chronic inflammation across the vasculature post-RT. We discuss key metabolic pathways, including glycolysis, the tricarboxylic acid cycle, lipid metabolism, glutamine metabolism, and redox metabolism (nicotinamide adenine dinucleotide/Nicotinamide adenine dinucleotide (NADH) and nicotinamide adenine dinucleotide phosphate (NADP+)/NADPH). We further explore the roles of regulatory proteins such as p53, adenosine monophosphate-activated protein kinase, and mammalian target of rapamycin in driving these metabolic dysregulations. The review emphasizes the impact of immune-vascular crosstalk mediated by the senescence-associated secretory phenotype, which perpetuates metabolic dysfunction, enhances chronic inflammation, drives senescence accumulation, and causes vascular damage, ultimately contributing to cardiovascular pathogenesis. Future Directions: Future research should prioritize identifying therapeutic targets within these metabolic pathways or the immune-vascular interactions influenced by RT. Correcting metabolic dysfunction and reducing chronic inflammation through targeted therapies could significantly improve cardiovascular outcomes in cancer survivors. Antioxid. Redox Signal. 00, 000-000.

Hospital-Related Determinants of Refusal of Organ Donation in France: A Multilevel Study

In a worldwide context of organ shortage, refusal of organ donation remains the main reason for the non-procurement of organs from deceased donors. Many studies have characterized the clinical or psychological factors of refusal but not organizational and structural factors in healthcare centers. We used multilevel logistic regression models with hospitals as a random effect to analyze organ procurement among 6734 potential brain-dead donors recorded in the national register in France in 2018 and 2019. According to the opt-out law, 29% of the potential donors refused to donate. Among hospital-related factors, low probability of refusal was related to hospitals audited for the organ donation process by the national program (adjusted odds ratio [aOR] 0.74, 95% confidence interval [CI]: 0.58-0.94), hospitals with high inpatient satisfaction scores for care (aOR 0.95, 95% CI 0.92-0.99) and facilities with a high ratio of nurse donor coordinators to donors (aOR: 0.78; 95% CI: 0.64-0.95). Among clinical factors, the odds of refusal were associated with age younger than 65 years (18-49 years; aOR 1.58, 95% CI 1.37-1.83) and donors with blood group B (aOR 1.32, 95% CI: 1.10-1.59). Hospital-related factors are just as important as individual factors in the procurement of organs from potential brain-dead donors.

Management of Ascites: AJR Expert Panel Narrative Review

Ascites can develop in the setting of a variety of pathologies. The approach to treatment depends on accurate determination of the underlying cause, for which fluid analysis plays a central role. In particular, the serum-ascites-albumin gradient serves as a primary diagnostic test for differentiating among causes, with certain additional fluid tests performed based on clinical suspicion. Treatment options range from nonspecific fluid removal, including large-volume paracentesis and tunneled peritoneal catheters, to targeted therapies (e.g., diuretics, transjugular intrahepatic portosystemic shunt, and lymphangiography). Societal guidelines exist for the approach to cirrhotic ascites, but the management of other less common causes remains less well defined. The goal of this AJR Expert Panel Narrative Review is to provide guidance for the diagnosis and management of ascites, based on available evidence and the authors' clinical experience.

Comparative analysis of surgical versus medical treatment in non-localized primary hyperparathyroidism: renal and skeletal outcomes

Primary hyperparathyroidism (PHPT) presents diverse phenotypic variations. Few studies have investigated potential peculiarities of non-localized PHPT. This retrospective study aimed to compare renal and skeletal outcomes in patients with non-localized PHPT subjected to medical versus surgical treatment. Patients with non-localized PHPT from two European Tertiary Centers were divided into Group A (medical treatment, 42 patients) and Group B (Surgery, 45 patients). Biochemical markers, renal function, and bone mineral density (BMD) were assessed at baseline and 18-24 months post-treatment. At initial univariate analysis, Student's t test, Fisher's exact test, Wilcoxon test, and Friedman's non-parametric test were utilized. The two groups displayed significant differences in age and vitamin D levels. Group B exhibited notable post-operative reductions in serum calcium (p value < 0.00001, versus p < 0.001 for group A), PTH (p < 0.00001 versus 0.078 for group A), and calciuria (p < 0.05 versus 0.3657 for group A). Surgical intervention yielded significant improvements in BMD (group B: p < 0.0001; group A: p = 0.3359) at femoral and lumbar sites, with no post-treatment fractures in Group B, contrasting with Group A (4 new fractures). The GFR of group A showed a statistically non-significant change with a p value of 0.631. Conversely, for the group B, the GFR displayed a statistically significant change (p < 0.001.). Surgical intervention in non-localized PHPT showcased distinct advantages in normalizing calcemia and PTH levels and improving skeletal metabolism. Although few significant differences in renal function were observed post-surgery, the apparent advantage of group B should be interpreted taking into account the different average ages of the two cohorts.

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.

The United Kingdom's experience of controlled donation after circulatory death direct procurement of lungs with concomitant abdominal normothermic regional perfusion with an analysis of short-term outcomes

BACKGROUND

Abdominal Normothermic Regional Perfusion (A-NRP) improves outcomes for transplanted abdominal organs from Donation after Circulatory Death (DCD) donors. Concerns have been raised about the effect of A-NRP on lungs procured during multi-organ donation. We present the UK experience of performing direct procurement (DRP) of lungs from DCD donors with A-NRP.

METHODS

Retrospective analysis of all 487 UK DCD lung donors between 1 April 2011 and 31 December 2023. Organ transplantation rate and30-day, 90-day and 1-year survival rates were compared between DRP of DCD lungs, DRP of DCD lungs with A-NRP and DBD lungs. PGD rates were compared between DCD lungs with and without A-NRP.

RESULTS

Three hundred ninety-seven DCD donors resulted in a lung transplant (22 retrieved by DRP with A-NRP). There was no difference in lung transplantation rates between DRP and DRP with A-NRP. Of the 390 first adult-only lung transplants performed from DCD donors, there was no significant difference in 30-day, 90-day and 1-year survival between DRP of DCD lungs and DRP with A-NRP. There was a significant difference in survival between standard DCD donors and DBD donors at 30-days and 90-days, but not 1 year. There was no significant difference in grade 3 PGD rates at 72 hours post-implantation for DCD lungs with or without A-NRP.

CONCLUSION

In the UK experience, use of A-NRP is not detrimental to procurement of DCD lungs. We advocate the use of this technique until further studies can explore the safety and efficacy of thoraco-abdominal NRP for lungs in multi-organ retrieval.

Combination of radiomic and clinical characteristics to predict mortality in patients with colorectal perforation

PURPOSE

We aim to construct and verify a model combining radiomic and clinical data to predict early mortality in patients with colorectal perforation in a two-center study.

METHODS

Data from 147 patients at Xiaogan Central Hospital (2014-2024) and 52 patients at Southern Hospital of Southern Medical University (2021-2023) were collected for model training and validation. Univariate and multivariate analyses were performed to identify risk factors associated with mortality. Radiomic characteristics from CT scans were extracted via least absolute shrinkage and selection operator (LASSO) regression to construct an imaging score. A nomogram was developed by integrating the findings from the multivariate analysis. Predictive performance was evaluated via the area under the receiver operating characteristic curve (AUC), and clinical utility was assessed via decision curve analysis (DCA).

RESULTS

Univariate analysis highlighted age, ASA classification, shock index, rad-score, white blood cell (WBC) count, neutrophil (N) and lymphocyte (L) counts, sodium (Na+), creatinine (Cr), and procalcitonin (PCT) as significant prognostic indicators for mortality (p < 0.05). Multivariate analysis confirmed age, ASA classification, PCT, and rad-score as independent prognostic factors. The radiomic combined with clinical characteristics nomogram (RCCCN) includes four variables: the patient's age, ASA classification, PCT level, and rad-score. The RCCCN model demonstrated excellent predictive performance for mortality risk in the validation cohort (AUC: 0.92, 95% CI: 0.84-0.99) with good calibration.

CONCLUSION

A nomogram combining radiomic features and clinical characteristics effectively predicts mortality in patients with colorectal perforation, providing a valuable tool for clinical decision-making and patient management.

Exploring the topography of the splenic artery: a comprehensive analysis

INTRODUCTION

Comprehensive knowledge of the complete anatomy of the splenic artery (SA) is of utmost importance in various abdominal surgical procedures. The present study aims to present a novel arterial map of the SA, showcasing its origin and course in the abdominal cavity. We hope that our results can be of great value to physicians performing the aforementioned procedures.

METHODS

The research involved the analysis of records from 75 consecutive patients who underwent abdomen and pelvis computed tomography angiography. Morphometric characteristics of the SA and/or its associated anatomical area were evaluated across 42 categories.

RESULTS

The SA was identified to originate from the celiac trunk in 73 cases (98.6%) and in one case from the aorta (1.4%). The most common branching pattern was the left gastric artery, followed by the common trunk of SA and the common hepatic artery occurring in 51 cases (69.9%). The median SA length (in a straight line) was determined to be 74.18 mm (LQ = 64.50; HQ = 87.22). Moreover, the median length of SA (over the surface) was 149.28 mm (LQ = 119.28, HQ = 177.50).

CONCLUSION

The present study demonstrated the high complexity of the arterial blood supply of the spleen. The SA exhibited a significant degree of variability regarding its course, branching pattern, and spatial relationship to the pancreas. By creating a novel arterial heat map, we provided a detailed visualization of the SA's course. These findings aim to improve the pre- and intraoperative identification of the SA, potentially reducing costs and the risk of complications associated with iatrogenic vessel injury during various surgical and endovascular procedures.

Estimating the Morbidity of Robot-Assisted Radical Cystectomy Using the Comprehensive Complication Index: Data from the Asian Robot-Assisted Radical Cystectomy Consortium

Background/Objectives: The Clavien-Dindo classification (CDC) grades the most severe post-operative complication and may not comprehensively reflect cumulative surgical morbidity. Our objective was to investigate the potential incremental role of the comprehensive complication index (CCI) over the CDC in defining the quality of robot-assisted radical cystectomy (RARC). Methods: Data were extracted from the Asian RARC Consortium database. Complications were classified using the CCI (CCI = 0, CCI < 75th and ≥75th percentile) and CDC. Adverse peri-operative outcomes such as length of stay >14 days (LOS > 14 days), estimated blood loss >350 mL (EBL > 350 mL), time to solid food intake >4 days (TFI > 4 days) and 30-day readmission rates were analyzed. The area under the curve (AUC) of the receiver operating characteristic (ROC) curves for CCI and CDC were compared for the various adverse outcomes. Results: The peri-operative complication rate was 44.4%, comprising 11.6% with severe complications (CDC ≥ III). The mean CCI was 10.2 (±13.5) while median CCI was 0 (IQR 0-21). There were 7.6% of patients with >one perioperative complication. On adjusted analysis, CCI ≥ 75th percentile was significantly associated with greater LOS (>14 days) (OR 2.21, 95% CI 1.47-3.31, p < 0.001) compared to when CCI = 0. There were no significant differences in the AUC between CDC and CCI in predicting LOS > 14 days, TFI > 4 days, 30-day readmission or EBL > 350 mL. Conclusions: In our multi-institutional cohort, the CCI did not provide additional discrimination over CDC, and this is likely related to the limited number of complications that occurred per individual in the Asian RARC cohort. Hence, the perceived advantages of CCI over CDC are contextual.

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.

Incidence and risk factors of biliary leaks after partial hepatectomy within an enhanced recovery perioperative pathway: a single-center retrospective cohort study

PURPOSE

Biliary leak is a specific and frequent complication after hepatectomy. This study aimed to assess the incidence and risk factors of biliary leak after hepatectomy.

METHODS

A retrospective cohort study was performed. All consecutive patients who underwent hepatectomy between January 2013 and June 2022 were included. Abdominal drainage was performed in case of biliary anastomosis or major hepatectomy. Biliary leak was defined and classified according to the International Study Group for Liver Surgery definition with grades A, B, C based on the required management. Logistic binary regression was used to find risk factors.

RESULTS

Data were collected from 565 patients who underwent hepatectomy during the study period. Biliary leaks occurred in 10% (55/565) of patients. The rates of biliary leak grades A, B, and C were 18% (10/55), 37% (20/55), and 45% (25/55), respectively. A high nutrition risk screening (OR 2.1, 95% CI 1.3-3.4), preoperative biliary drainage (OR 4.6, 95% CI 1.5-13.5), and intraoperative biliary anastomosis (OR 3.4, 95% CI 1.3-8.9) were found as independent risk factors for biliary leak on multivariable analysis. In terms of morbidity, biliary leak patients had more infectious complications (46% vs. 8%, p < 0.001) and a longer median hospital stay (26 vs. 7 days, p < 0.001). Regarding treatment, 41 (75%) patients with biliary leak underwent drainage either endoscopically or percutaneously.

CONCLUSION

Preoperative biliary drainage, high nutrition risk screening, and intraoperative biliary anastomosis were independent predictive factors for postoperative biliary leaks. Most frequent treatments of biliary leaks after hepatectomy were antibiotics and drainage.

Knowledge, attitudes, and practices of organ, tissue, and cell donation in Nicaragua

Organ donation and transplantation are essential for improving the quality of life of people with organ failure due to chronic diseases (e.g., chronic kidney disease) or irreparable organ damage from accidents. In Nicaragua, chronic kidney disease of unknown etiology (CKDu) has emerged as a significant public health challenge, disproportionally affecting young agricultural workers and leading to premature deaths. Despite enactment of Law 847 in 2013, which regulates organ donations and transplantation, Nicaragua faces critical challenges, including lack of awareness, inadequate infrastructure, and limited public dissemination on the value of organ donation leading to an increasing number of patients on waiting lists. To address these gaps, we conducted an online cross-sectional survey to assess the knowledge, attitudes, and practices (KAP) regarding organ donation and transplantation in Nicaragua, a lower-middle-income country. We conducted an online cross-sectional survey among 4,407 Nicaraguan residents aged 18 and above from all 15 departments and two regions between November 2022 and February 2023. Most participants were women (60.3%), people aged 18-35 years (79.9%), and residents in urban areas (62.8%). The findings revealed that only 28.6% had good knowledge regarding organ and tissue donation and transplantation, 91.9% expressed positive attitudes toward organ and tissue donation, being willing to donate regardless of religious believes (88.5%) or personal health conditions (90.0%). About 72.6% engaged in donation-related behaviors. Men, those with higher education, and unemployed participants showed greater adherence to these practices. In summary, while Nicaraguans show positive attitudes towards organ and tissue donation and transplantation, significant knowledge and supply-demand gaps persist. Targeted educational campaigns and infrastructure development are urgently needed to address these gaps, enhance public awareness, and promote organ donation, particularly in the context of CKDu´s burden on public health.

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.

Systematic review on the use of artificial intelligence to identify anatomical structures during laparoscopic cholecystectomy: a tool towards the future

PURPOSE

Bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is a dreaded complication. Artificial intelligence (AI) has recently been introduced in surgery. This systematic review aims to investigate whether AI can guide surgeons in identifying anatomical structures to facilitate safer dissection during LC.

METHODS

Following PROSPERO registration CRD-42023478754, a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic search of MEDLINE (via PubMed), EMBASE, and Web of Science databases was conducted.

RESULTS

Out of 2304 articles identified, twenty-five were included in the analysis. The mean average precision for biliary structures detection reported in the included studies reaches 98%. The mean intersection over union ranges from 0.5 to 0.7, and the mean Dice/F1 spatial correlation index was greater than 0.7/1. AI system provided a change in the annotations in 27% of the cases, and 70% of these shifts were considered safer changes. The contribution to preventing BDI was reported at 3.65/4.

CONCLUSIONS

Although studies on the use of AI during LC are few and very heterogeneous, AI has the potential to identify anatomical structures, thereby guiding surgeons towards safer LC procedures.

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.

Exploring the Role of Artificial Intelligence (AI)-Driven Training in Laparoscopic Suturing: A Systematic Review of Skills Mastery, Retention, and Clinical Performance in Surgical Education

Background: Artificial Intelligence (AI)-driven training systems are becoming increasingly important in surgical education, particularly in the context of laparoscopic suturing. This systematic review aims to assess the impact of AI on skill acquisition, long-term retention, and clinical performance, with a specific focus on the types of machine learning (ML) techniques applied to laparoscopic suturing training and their associated advantages and limitations. Methods: A comprehensive search was conducted across multiple databases, including PubMed, IEEE Xplore, Cochrane Library, and ScienceDirect, for studies published between 2005 and 2024. Following the PRISMA guidelines, 1200 articles were initially screened, and 33 studies met the inclusion criteria. This review specifically focuses on ML techniques such as deep learning, motion capture, and video segmentation and their application in laparoscopic suturing training. The quality of the included studies was assessed, considering factors such as sample size, follow-up duration, and potential biases. Results: AI-based training systems have shown notable improvements in the laparoscopic suturing process, offering clear advantages over traditional methods. These systems enhance precision, efficiency, and long-term retention of key suturing skills. The use of personalized feedback and real-time performance tracking allows learners to gain proficiency more rapidly and ensures that skills are retained over time. These technologies are particularly beneficial for novice surgeons and provide valuable support in resource-limited settings, where access to expert instructors and advanced equipment may be scarce. Key machine learning techniques, including deep learning, motion capture, and video segmentation, have significantly improved specific suturing tasks, such as needle manipulation, insertion techniques, knot tying, and grip control, all of which are critical to mastering laparoscopic suturing. Conclusions: AI-driven training tools are reshaping laparoscopic suturing education by improving skill acquisition, providing real-time feedback, and enhancing long-term retention. Deep learning, motion capture, and video segmentation techniques have proven most effective in refining suturing tasks such as needle manipulation and knot tying. While AI offers significant advantages, limitations in accuracy, scalability, and integration remain. Further research, particularly large-scale, high-quality studies, is necessary to refine these tools and ensure their effective implementation in real-world clinical settings.

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.

Deep learning implementation for extrahepatic bile duct detection during indocyanine green fluorescence-guided laparoscopic cholecystectomy: pilot study

BACKGROUND

A real-time deep learning system was developed to identify the extrahepatic bile ducts during indocyanine green fluorescence-guided laparoscopic cholecystectomy.

METHODS

Two expert surgeons annotated surgical videos from 113 patients and six class structures. YOLOv7, a real-time object detection model that enhances speed and accuracy in identifying and localizing objects within images, was trained for structures identification. To evaluate the model's performance, single-frame and short video clip validations were used. The primary outcomes were average precision and mean average precision in single-frame validation. Secondary outcomes were accuracy and other metrics in short video clip validations. An intraoperative prototype was developed for the verification experiments.

RESULTS

A total of 3993 images were extracted to train the YOLOv7 model. In single-frame validation, all classes' mean average precision was 0.846, and average precision for the common bile duct and cystic duct was 0.864 and 0.698 respectively. The model was trained to detect six different classes of objects and exhibited the best overall performance, with an accuracy of 94.39% for the common bile duct and 84.97% for the cystic duct in video clip validation.

CONCLUSION

This model could potentially assist surgeons in identifying the critical landmarks during laparoscopic cholecystectomy, thereby minimizing the risk of bile duct injuries.

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.

Nutritional Prehabilitation: Trends in Supplementation Based on Sustainable Dairy Protein Sources

PURPOSE OF REVIEW

Prehabilitation is an emerging clinical practice that aims to improve the surgical recovery and quality of life of patients undergoing intensive treatments. This review intends to describe the state of the art in prehabilitation, highlighting the role of nutritional strategies and the current trends in supplements.

RECENT FINDINGS

Up-to-date studies have shown the importance of optimizing the nutritional status of patients to cope with the physical and metabolic demands of surgery and intensive treatments. In the context of nutritional prehabilitation, oral nutritional supplementation has emerged as a preferred strategy. The effectiveness of prehabilitation has been demonstrated in various clinical contexts. However, the lack of standardized protocols makes it hard to compare the outcomes. Despite the variability in this type of nutritional intervention found in reports, it has been shown that the most common oral nutritional supplements (ONS) contain dairy proteins. The use of whey proteins represents a promising approach from both a nutritional and a sustainability perspective.

Complex abdomen: a scoping review

PURPOSE

This scoping review aimed to systematically map the existing evidence on the surgical management of complex abdominal wall hernias (CA), focusing on patient-specific factors, hernia characteristics, contamination and operative strategies to their management, in order to identify research gaps and areas for clinical improvement.

METHODS

A comprehensive literature search was conducted in PubMed and Scopus, covering publications from January 2015 to June 2024. A total of 6,445 articles were identified, of which 357 met inclusion criteria (303 primary studies and 54 systematic reviews). Studies were classified into three categories: patient-related factors (P), hernia-specific features (H), and contamination (W).

RESULTS

Patient-related factors, particularly obesity and associated comorbidities, were consistently related to higher rates of morbidity and hernia recurrence despite prehabilitation and bariatric surgery were evaluated, results were inconclusive. Hernia-specific features, including large defect size and loss of domain, were associated with increased complication rates. Midline restoration and its achievement with component separation or preoperative botulinum toxin injections, were extensively studied, showing potential benefits. In contaminated settings, synthetic meshes outperformed biologic alternatives, demonstrating lower recurrence and morbidity rates in recent trials. Research in biosynthetic mesh is still needed.

CONCLUSION

Surgical management of CA remains a highly demanding clinical scenario with significant variability in outcomes influenced by patient factors and hernia characteristics. Techniques such as component separation and the use of synthetic meshes hold promise, but further high-quality, randomized trials are required to establish standardized protocols and optimize clinical outcomes in this challenging patient population.

The Role of Parathyroid Hormone Level as a Predictor of Hypocalcemia After Total Thyroidectomy for Thyroid Cancer: A Cross-Sectional Study

This study aimed to investigate the utility of measuring parathyroid hormone (PTH) levels as a predictor of hypocalcemia in a population of patients undergoing total thyroidectomy for thyroid cancer between 2016 and 2019. We conducted an observational, analytical, descriptive, cross-sectional investigation, assessing PTH levels as a predictor of hypocalcemia following thyroidectomy. Among patients with hypoparathyroidism, 25.5% experienced hypocalcemia, while 74.5% had normal serum calcium levels. The likelihood of hypocalcemia was five times higher in patients with hypoparathyroidism (OR: 5.43; 95% CI: 1.89-15.6), a statistically significant finding (p < 0.05). Additionally, PTH values at 24 hours post-surgery averaged 28.9 pg/mL (SD: 30.8 pg/mL), ranging from 0.01 to 235 pg/mL. Serum calcium levels averaged 8.31 mg/dL (SD: 0.74), with values ranging from 6.5 to 10.6 mg/dL. The study demonstrates a statistically significant association between PTH levels and post-surgical serum calcium levels, albeit with moderate predictive power. These findings support the utility of PTH measurement in predicting hypocalcemia following thyroidectomy, underscoring its potential clinical relevance in patient management.

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.

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.

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.

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.

Primary ventral and incisional hernias: comprehensive review

BACKGROUND

Primary ventral and incisional hernias are frequent conditions that impact the quality of life of patients. Surgical techniques for ventral hernia repair are constantly evolving and abdominal wall surgery has turned into a highly specialized field.

METHODS

This is a narrative review of the most recent and relevant literature on the treatment of primary ventral and incisional hernias performed by eight experts in ventral hernia surgery from across the world and includes review of classification systems, preoperative measures, descriptions of surgical techniques, and postoperative complications.

RESULTS

Repairs of primary ventral and incisional hernias range from simple open procedures in healthy patients with small defects to complex procedures when patients are co-morbid and have large defects. Optimizing patient-related risk factors before surgery is important to decrease complication rates. Surgical repair techniques from open repairs to minimally invasive procedures are described in detail in the review. Minimally invasive techniques are technically more demanding and take longer, but decrease the risk of surgical-site infections and shorten the duration of hospital stay.

CONCLUSION

Treatment of ventral hernias aims to improve the quality of life of patients. The risks and benefits of procedures should be weighed against patients' complaints and co-morbidities. Optimizing patient-related risk factors before surgery is important.

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.