Transabdominal Robotic-Assisted Partial Nephrectomy and CT-Guided Percutaneous Cryoablation for the Treatment of De Novo Kidney Tumors After Liver Transplantation

The management of de novo kidney tumors (DKTs) after liver transplantation (LT) is challenging due to previous transplant surgery and calcineurin inhibitors (CNI)-related nephrotoxicity. Minimally invasive renal-sparing strategies like robot-assisted partial nephrectomy (RPN) are favored, but a transperitoneal approach may be limited by the previous transplant surgery and the location of the DKT; in such cases, CT-guided cryoablation may be an alternative option. In this retrospective cohort study, we aimed to compare RPN and cryoablation for the treatment of DKT in LT recipients. The primary endpoints were the efficacy (R0 resection in RPN, absence of the tumor at first follow-up for cryoablation) and the safety of the procedures (postoperative morbidity and increase in creatine level). The periprocedural costs and the oncologic efficacy (recurrence and overall survival) were the secondary endpoints. Twelve LT recipients (91.7% males, mean age 65 years) underwent RPN (n = 6) or cryoablation (n = 6) for DKT; the median interval between LT and diagnosis of DKT was 142.5 vs. 117.5 months, respectively. Efficacy was obtained in all patients after RPN and cryoablation. Postoperative morbidity was 16.7% in each group, and the postoperative increase in creatinine values was similar. Hospital stay was shorter following cryoablation vs. RPN (3.1 vs. 6.7 days; p = 0.03). The mean procedural costs were higher for RPN. There was no mortality and none of the patients had signs of recurrence after a median follow-up of 40.5 months. Both RPN and CT-guided cryoablation were safe and effective for the treatment of selected patients with DKT after LT. When applicable, cryoablation may be cost-effective and provide faster recovery.

Cervical cancer burden and attributable risk factors across different age and regions from 1990 to 2021 and future burden prediction: results from the global burden of disease study 2021

Background

Cervical cancer (CC) is a global public health problem. We aimed to evaluate the global and regional CC burden between 1990 and 2021, identify the attributable risk factors, and project its burden up to 2035.

Methods

Data were extracted from the Global Burden of Disease Study 2021, and the CC incidence, mortality, age-standardized incidence rate (ASIR), age-standardized death rate (ASDR), age-standardized disability-adjusted life years (DALYs), and attributable risk factors from 1990 to 2021 were analyzed. The impacts of geographical variations, different age groups, and the socio-demographic index (SDI) on CC morbidity and mortality measurements were assessed. The attributable risk factors to CC death and DALY were evaluated, and the incidence, mortality, and DALYs to 2035 were projected.

Results

Globally, the number of CC cases has increased from 409,548.49 cases in 1990 to 667,426.40 cases in 2021. However, the ASIR decreased from 18.11 to 15.32 per 100,000, with the greatest ASIR decrease in high SDI regions (estimated annual percentage change: -1.41). Between 1990 and 2021, the global ASDR decreased from 9.68 to 6.62 per 100,000, and the rate of age-standardized DALYs decreased from 330.11 to 226.28 per 100,000. However, these improvements were not consistent across different SDI regions. The CC incidence was the highest in the 55-59 age group, globally. The risk factors, which included unsafe sex and smoke, significantly varied by region. The global ASIR exhibited a downward trend from 2021 to 2035.

Conclusion

From 1990 to 2021, although the overall trend in incidence, mortality, and DALYs of CC exhibited a global and regional downward trend, there were significant disparities among areas with different socioeconomic development. More efficient targeted prevention and management strategies, easy access to health care in less developed regions, and risk factor modifications should be promoted, in order to reduce the global burden of CC.

Effect of Low-Dose Ketamine Infusion in the Intensive Care Unit on Postoperative Opioid Consumption and Traumatic Memories After Hospital Discharge: A Randomized Controlled Trial

BACKGROUND

Low-dose ketamine may have an opioid-sparing effect in critically ill patients but may also predispose them to traumatic memories. We evaluated the effects of low-dose ketamine infusion in the intensive care unit (ICU) on fentanyl consumption and traumatic memories after hospital discharge.

METHODS

This randomized, double-blind, controlled trial was conducted at a university-based surgical ICU. 118 adult patients who were admitted to the ICU after noncardiac, nonneuro, nontrauma surgery between March 2019 and May 2021 were randomized to receive ketamine 1.5 µg/kg/min (n = 60) or placebo (n = 58). Fentanyl was given to achieve pain control (10-point numerical rating scale pain score [NRS] < 4) and sedation control (Richmond Agitation and Sedation Scale [RASS] level between -2 and 0). A secondary study was conducted by a telephone interview after ICU discharge using the Thai version of the posttraumatic stress disorder (PTSD) questionnaire to evaluate signs and symptoms of PTSD and traumatic memories to the time spent in the ICU.

RESULTS

24-hour fentanyl consumption was lower in patients who received ketamine compared with placebo (399 µg [95% confidence interval {CI}, 345-454] vs 468 µg [95% CI, 412-523], difference -68 µg; 95% CI, -67 to -69; P = .041); RASS and NRS scores did not differ between the 2 groups. Exploratory effect modification analysis suggested that the opioid-sparing effect of ketamine may be more relevant in patients with intraabdominal surgery (P-for-interaction = 0.012, difference, -177 µg; 95% CI, -204 to -149 µg; P = .001). No acute adverse effects of ketamine were observed. The secondary study included the information from 91 patients from the primary study. Long-term follow-up data was available for 45 patients (23 in the control group, 22 in the ketamine group), and the evaluations were taken 43 ± 8 months after ICU discharge. In this secondary study, ketamine use was associated with a higher incidence of frightening and delusional memories of critical illness and ICU treatment (65% vs 41%, P = .035).

CONCLUSIONS

Low-dose ketamine is associated with a small but statistically significant reduction (15%) of postoperative opioid consumption in the ICU. Our secondary study revealed that patients who received low-dose ketamine during fentanyl-based postoperative pain therapy in the ICU recalled more frightening and delusional memories after ICU discharge.

Differences in Treatment of Supracondylar Humerus Fractures Requiring Transfer Between Facilities

Purpose

The current study aims to elucidate the differences in the timing of the management of operative supracondylar humerus fractures (SCHF) based on whether or not the patient is transferred between facilities.

Methods

This was a prospective cohort study of patients with surgically treated SCHF conducted at a level I pediatric trauma center. The management of these fractures was compared based on their presenting facility (pediatric trauma center versus another facility). Primary outcomes were time to orthopaedic consult, time to surgery, need for open reduction, and operative times. Secondary outcomes include the need for repeat imaging, transfer time, transfer vehicle, and transfer distance.

Results

A total of 146 (78 female) patients with an average age of 5.70 (±2.12) years were included in the study. Time from initial presentation to orthopaedic consult (P ​< ​0.001) and time from initial presentation to surgery (P ​= ​0.006) was shorter for Children's hospital patients compared to outside facility patients. Repeat radiographs were more common when patients presented to outside facilities compared to children's hospital (P ​< ​0.001). Operative times were the same for both groups (31 ​min children's hospital, 32 ​min outside facility). Patients arriving from the outside facility via ambulance traveled further in comparison to those arriving via private vehicle (P ​= ​0.009) but had a shorter time to operation (P ​= ​0.002).

Conclusions

Efficient processes and collaboration between healthcare facilities to ensure timely and effective care for pediatric patients with SCHF are essential. Patients from outside facilities experienced longer times to orthopaedic consult and surgery while having similar baseline characteristics.

Key Concepts

(1)Patients arriving from outside facilities had an overall longer time to orthopaedic consult and definitive fixation.(2)There was no difference in the need for open reduction or the operative time based on the patient's presenting facility.(3)Transferred patients often underwent repeat imaging prior to consult.

Level of Evidence

II.

Long-Term Effects of Direct-Acting Antivirals on Hepatitis C: Trends in Liver Disease-Related Hospitalisations in Italy

This study aimed to evaluate the effectiveness of direct-acting antivirals (DAAs) on hepatitis C virus (HCV) hospitalisation trends in Italy, the country with not only the highest burden of HCV-related disease but also the highest number of patients treated for chronic HCV infection in Europe. Incident hospital discharge records in Italy from 2012 to 2019 that included a liver cirrhosis diagnosis without mention of alcohol, hepatocellular carcinoma (HCC), HCV and liver cirrhosis without mention of alcohol and/or HCC, cirrhosis with mention of alcohol, as defined by the International Classification of Diseases (ICD-9-CM) were reviewed. An interrupted time series analysis compared the incidence of cirrhosis and HCC before and after the introduction of DAAs (Year 2015). Overall, non-alcoholic cirrhosis significantly decreased after the introduction of DAAs (β3 = 0.03) and for those 40-59 years of age (β3 = 0.025). HCV with cirrhosis and/or HCC significantly reduced overall for those aged 40-59 and older than 60 (β 3 = 0.002 $$ {\beta}_3=0.002 $$ ). HCC-related hospitalisation rates significantly decreased in patients younger than 60 (β 3 = 0.03 $$ {\beta}_3=0.03 $$ ). Cirrhosis-related hospitalisations with mention of alcohol did not differ during the study period before and after the year 2015 (β 3 = 0.4 $$ {\beta}_3=0.4 $$ ). There was a significant reduction in HCV-related hospitalisations throughout Italy after introducing DAAs.

Implementation of Green Surgery Approach in Healthcare System and its Effect on Carbon Footprint Reduction in Operating Theatres

Healthcare systems, particularly operating theatres (OTs), are among the leading causes of pollution due to energy-intensive procedures, anaesthetic gases, and single-use surgical instruments. This perspective review provides actionable, evidence-based recommendations that not only minimise the environmental impact but also offer quality patient care. A wide literature search of available studies on green surgery was conducted. Searches were conducted in databases, including PubMed, Science Direct, Scopus, ProQuest, and Web of Science, from January 2013 to the present. A review of global practices highlighted the effectiveness of green surgical initiatives. Some initiatives related to the health sector report reductions in carbon emissions by reusable surgical instrument implementation in hospitals of up to 97%, energy savings of up to 50% with modifications to heating, ventilation, and air-conditioning (HVAC) systems, and waste management programmes, including the recycling and reprocessing of single-use devices, reporting waste reductions from 40% to 66%. Key strategies include shifting to renewable energy sources by promoting reusable instruments, optimising HVAC systems, and promoting comprehensive staff training for sustainability. All these factors are important for decreasing the environmental burden without compromising operational efficiency. The integration of sustainable practices in Malaysian OTs can significantly reduce carbon emissions and waste generated by hospitals while maintaining patient safety. These measures support the national goals of achieving Sustainable Development Goals (SDGs) and advancing Universal Health Coverage (UHC). Aligning with global sustainability efforts, Malaysia's health care system can reduce its carbon footprint.

[Multimorbidity in liver surgery]

Multimorbidity is characterized by the presence of at least 3 chronic diseases with a prevalence of more than 50% of patients over 60 years old. The Charlson comorbidity index (CCI) enables a description of the severity of the multimorbidity and also provides a correlation with the postoperative outcome after liver resection. According to this, multimorbid patients are at increased risk of morbidity and mortality after liver resection, mostly due to postoperative liver failure. In particular, open major liver resection with biliary reconstruction and primary liver tumors linked to metabolic associated fatty liver disease (MAFLD) pose an increased risk for multimorbid patients. In contrast, minimally invasive resection leads to a clear reduction in postoperative morbidity and mortality. Preconditioning of the liver and the implementation of perioperative strategies according to the enhanced recovery after surgery (ERAS) concept can also lead to an improvement of the postoperative outcome.

A German's Perspective on the Way toward Ambulatory Laparoscopic Cholecystectomy: A Postoperative Questionnaire

Introduction

Ambulatory surgeries are on the rise in recent years and can offer benefits to patients as well as healthcare providers. Laparoscopic cholecystectomy is one of the procedures commonly done in an ambulatory setting, in some European countries. This study aims to gather patients' perceptions towards ambulatory cholecystectomy after undergoing laparoscopic cholecystectomy in an inpatient setting.

Methods

A total of 300 patients from two different hospitals in Germany received a postoperative questionnaire aimed at evaluating their willingness to undergo an ambulatory surgery. Surgeries were performed between January 1, 2017, and July 11, 2018. Operation setting (acute vs. elective), ASA classification, length of hospital stay, age, sex, living situation and location (city vs. rural), as well as status of employment were documented.

Results

Overall, 23% of patients reported considering ambulatory laparoscopic cholecystectomy (ALC), while 77% rejected an ALC. Objections included fear of complications (69%), anticipated pain (65%), concerns about their living situation/home care (21%), other reasons (8%), nausea and vomiting (3.4%). Baseline characteristics of the participants provided no statistical significance on willingness to undergo ALC: acute versus elective (p = 0.22), ASA classification (p = 0.77), age ≥65 years versus <65 years (p = 0.60), gender (p = 0.07), living situation (p = 0.49), location (p = 0.15).

Conclusion

There is a willingness for ALC, albeit still limited. Chosen criteria did not show a significant association for positive perception of ALC.

Criteria and prognostic models for patients with hepatocellular carcinoma undergoing liver transplantation

Hepatocellular carcinoma (HCC) is a leading cause of cancer-associated death globally. Liver transplantation (LT) has emerged as a key treatment for patients with HCC, and the Milan criteria have been adopted as the cornerstone of the selection policy. To allow more patients to benefit from LT, a number of expanded criteria have been proposed, many of which use radiologic morphological characteristics with larger and more tumors as surrogates to predict outcomes. Other groups developed indices incorporating biological variables and dynamic markers of response to locoregional treatment. These expanded selection criteria achieved satisfactory results with limited liver supplies. In addition, a number of prognostic models have been developed using clinicopathological characteristics, imaging radiomics features, genetic data, and advanced techniques such as artificial intelligence. These models could improve prognostic estimation, establish surveillance strategies, and bolster long-term outcomes in patients with HCC. In this study, we reviewed the latest findings and achievements regarding the selection criteria and post-transplant prognostic models for LT in patients with HCC.

Viability Assessment During Normothermic Machine Liver Perfusion: A Literature Review

BACKGROUND AND OBJECTIVE

The discrepancy between donor organ availability and demand leads to a significant waiting-list dropout rate and mortality. Although quantitative tools such as the Donor Risk Index (DRI) help assess organ suitability, many potentially viable organs are still discarded due to the lack of universally accepted markers to predict post-transplant outcomes. Normothermic machine perfusion (NMP) offers a platform to assess viability before transplantation. Thus, livers considered unsuitable for transplantation based on the DRI can be evaluated and potentially transplanted. During NMP, various viability criteria have been proposed. These criteria are neither homogeneous nor consensual. In this review, we aimed to describe the viability criteria during NMP and evaluate their ability to predict hepatic graft function following transplantation. We conducted a PubMed search using the terms 'liver transplantation', 'normothermic machine perfusion' and 'assessment', including only English publications up to February 2024. Viability assessment during NMP includes multiple hepatocellular and cholangiocellular criteria. Lactate clearance and bile production are commonly used indicators, but their ability to predict post-transplant outcomes varies significantly. The predictive value of cholangiocellular criteria such as bile pH, bicarbonate and glucose levels remains under investigation. Novel markers, such as microRNAs and proteomic profiles, offer the potential to enhance graft evaluation accuracy and provide insights into the molecular mechanisms underlying liver viability. Combining perfusion parameters with biomarkers may improve the prediction of long-term graft survival. Future research should focus on standardising viability assessment protocols and exploring real-time biomarker evaluations, which could enhance transplantation outcomes and expand the donor pool.

Immunosuppression protocols for emerging oncological indications in liver transplantation: A systematic review and pooled analysis

The evolving field of liver transplant (LT) oncology calls for tailored immunosuppression protocols to minimize the risk of tumor recurrence. We systematically reviewed the available evidence from inception to May 2023 regarding immunosuppression protocols used in patients undergoing LT for cholangiocarcinoma, neuroendocrine tumors (NET), hepatic-endothelial hemangioendothelioma, and colorectal liver metastases (CRLM) to identify common practices and to evaluate their association with oncological outcomes. Studies not involving humans, case reports, and short case series (ie, n < 10) were excluded. Among 3374 screened references, we included 117 studies involving 6797 patients distributed as follows: cholangiocarcinoma (58.1%), NETs (18.8%), hepatic-endothelial hemangioendothelioma (7.7%), CRLM (6.8%), mixed neoplasms (6.8%), or others (1.7%). Only 41% of the studies disclosed details of the immunosuppression protocol, and 20.8% of studies provided drug trough concentrations during follow-up. The immunosuppression protocols described were heterogeneous and broadly mirrored routine practices for nontumoral indications. The only exception was CRLM, where tacrolimus minimization-or even withdrawal-in combination with inhibitors of the mammalian target of rapamycin (mTORi) were consistently reported. None of the studies evaluated the relationship between the immunosuppression protocol and oncological outcomes. In conclusion, based on low-quality and indirect scientific evidence, patients with tumoral indications for LT should receive the lowest tacrolimus level tolerated under close surveillance. The combination with mTORi titrated to achieve the top therapeutic range of trough concentrations could allow complete tacrolimus withdrawal. This approach may be particularly useful in patients with cholangiocarcinoma and CRLM, in whom tumor recurrence is the main cause of death. We propose a tool for reporting immunosuppression protocols, which could be implemented in future transplant oncology studies.

Fairness and pitfalls of the Italian waiting list for elective liver transplantation: The ECALITA registry study

BACKGROUND

The challenge of transplant waiting-lists is to provide organs for all candidates while maintaining efficiency and equity.

AIMS

We investigated the probability of being transplanted or of waiting-list dropout in Italy.

METHODS

Data from 12,749 adult patients waitlisted for primary liver-transplantation from January 2012 to December 2022 were collected from the National Transplant-Registry.The cohort was divided into Eras:1 (2012-2014);2 (2015-2018);and 3 (2019-2022).

RESULTS

The one-year probability of undergoing transplant increased (67.6 % in Era 1vs73.8 % in Era 3,p < 0001) with a complementary 46 % decrease in waiting-list failures. Patients with hepatocellular-carcinoma were transplanted more often than cirrhotics[at model for end-stage liver-disease (MELD)-15:HR = 1.28,95 %CI:1.21-1.35;at MELD-25:HR = 1.04,95 %CI:0.92-1.19) and those with other indications (at MELD-15:HR = 1.27,95 %CI:1.11-1.46) across all eras. Candidates with Hepatitis-B-virus (HBV)related disease had a greater probability of transplant than those with Hepatitis-C virus-related (HR = 1.13,95 %CI:1.07-1.20), alcohol-related (HR = 1.13,95 %CI:1.05-1.21), and metabolic-related (HR = 1.18,95 %CI:1.09-1.28)disease. Waiting-list failures increased by 27 % every 5 MELD-points and by 14 % for every 5-year increase in recipient-age and decreased by 10 % with each 10-cm increase in stature. Blood-group O patients showed the highest probability of waiting-list failure (HR = 1.28,95 %CI:1.15-1.43).

CONCLUSIONS

Liver-transplantation waiting-list success-rates have significantly improved in Italy, with patients with hepatocellular-carcinoma and/or HBV-related diseases being favored. High MELD-score, old-age, short-stature, and blood-group O were significant risk-factors for waiting-list failure. Efforts to improve organ-allocation and prioritization-policies are underway.

European guidelines for the diagnosis and treatment of pancreatic exocrine insufficiency: UEG, EPC, EDS, ESPEN, ESPGHAN, ESDO, and ESPCG evidence-based recommendations

Pancreatic exocrine insufficiency (PEI) is defined as a reduction in pancreatic exocrine secretion below the level that allows the normal digestion of nutrients. Pancreatic disease and surgery are the main causes of PEI. However, other conditions and upper gastrointestinal surgery can also affect the digestive function of the pancreas. PEI can cause symptoms of nutritional malabsorption and deficiencies, which affect the quality of life and increase morbidity and mortality. These guidelines were developed following the United European Gastroenterology framework for the development of high-quality clinical guidelines. After a systematic literature review, the evidence was evaluated according to the Oxford Center for Evidence-Based Medicine and the Grading of Recommendations Assessment, Development, and Evaluation methodology, as appropriate. Statements and comments were developed by the working groups and voted on using the Delphi method. The diagnosis of PEI should be based on a global assessment of symptoms, nutritional status, and a pancreatic secretion test. Pancreatic enzyme replacement therapy (PERT), together with dietary advice and support, are the cornerstones of PEI therapy. PERT is indicated in patients with PEI that is secondary to pancreatic disease, pancreatic surgery, or other metabolic or gastroenterological conditions. Specific recommendations concerning the management of PEI under various clinical conditions are provided based on evidence and expert opinions. This evidence-based guideline summarizes the prevalence, clinical impact, and general diagnostic and therapeutic approaches for PEI, as well as the specifics of PEI in different clinical conditions. Finally, the unmet needs for future research are discussed.

Two-Dimensional Shear Wave Ultrasound Elastography for Monitoring Pediatric Liver Transplantation: A Review of Recent Advances

Pediatric liver transplantation (PLT) is a life-saving procedure for children with end-stage liver disease. However, post-transplant monitoring, particularly the diagnosis and prognosis of complications such as allograft fibrosis, remains challenging. Traditionally, liver biopsy has been the gold standard for assessing allograft fibrosis, despite its invasive nature and inherent procedural risks. Recently, shear wave ultrasound elastography (SWE) has seen increasing use as a noninvasive method to provide real-time, quantitative measurements of liver stiffness as a proxy for fibrosis. In this review, the latest developments in the use of SWE as a method to assess allograft fibrosis post-PLT are presented, including the current technical challenges associated with its clinical implementation.

Particular Chinese contributions to extracorporeal liver surgery

Extracorporeal liver surgery (ELS), also known as liver autotransplantation, is a hybrid (cross-fertilized) surgery incorporating the technical knowledge from extreme liver and transplant liver surgeries, and recently became more embraced and popularized among leading centers. ELS could be summarized into three major categories, namely, ex-situ liver resection and autotransplantation (ELRA), ante-situm liver resection and autotransplantation (ALRA) and auxiliary partial liver autotransplantation (APLA). The successful development of ELS during the past 37 years is definitely inseparable from continuous efforts done by Chinese surgeons and researchers. Especially, the precision liver surgery paradigm has allowed to transform ELS into a modularized, more simplified, and standardized surgery, to upgrade surgical skills, to improve peri-operative outcome and long-term survival, to increase the capability of surgeons to select more complex diseases and to expand the level of medical service to the population. This review highlights the Chinese contributions to the field of ELS, focusing thereby on features of different surgical types, technical innovations, disease selection and surgical indication, patient prognosis and future perspectives.

Challenges and opportunities in organ donation after circulatory death

In recent years, there has been resurgence in donation after circulatory death (DCD). Despite that, the number of organs transplanted from these donors remains low due to concerns about their function and a lack of an objective assessment at the time of donation. This overview examines the current DCD practices and the classification modifications to accommodate regional perspectives. Several risk factors underscore the reluctance to accept DCD organs, and we discuss the modern strategies to mitigate them. The advent of machine perfusion technology has revolutionized the field of DCD transplantation, leading to improved outcomes and better organ usage. With many strategies at our disposal, there is an urgent need for comparative trials to determine the optimal use of perfusion technologies for each donated organ type. Additional progress in defining therapeutic strategies to repair the damage sustained during the dying process should further improve DCD organ utilization and outcomes. However, there remains wide variability in access to DCD donation and transplantation, and organizational efforts should be doubled up with consensus on key ethical issues that still surround DCD donation in the era of machine perfusion.

Emergency department trends for inguinal hernia and gallbladder disease before and after COVID-19 scheduled surgery interruptions: lessons for hospital capacity management

OBJECTIVES

Postponing scheduled surgeries may alleviate emergency department (ED) crowding by increasing inpatient beds for ED patients but the impact of such measures are unclear. We determined if scheduled surgery cancellations for inguinal hernia and gallbladder disease during the coronavirus pandemic affected ED presentations, hospitalizations, and complications.

METHODS

This database review included Albertans ≥ 18 with ED presentations for inguinal hernia and gallbladder disease from March 1, 2018 to May 31, 2022. The primary outcome examined ED hospitalizations and complications in the pre- (March 1, 2018-March 18, 2020) and post-cancellation (May 4, 2020-May 31, 2022) periods utilizing interrupted time series analysis. The secondary outcome reported scheduled surgery trends.

RESULTS

78,315 (10.6% inguinal hernia n = 8268; 89.4% gallbladder disease n = 70,064; n = 17 both inguinal hernia and gallbladder disease) patients were included. The post-cancellation period experienced a decreased trend change for inguinal hernia patients who received hospital admission (- 146.0%; p < 0.001), urgent interventions (- 171.0%; p < 0.001), and hernia repairs (- 164.0%; p < 0.001). For gallbladder disease patients, the post-cancellation period demonstrated a decreased trend in hospital admission (- 106.0%; p = 0.038) and an increased trend in day surgery transfers (- 1285.0%; p = 0.015) and median ED length of stay (82.0%; p = 0.0042). During the cancellation period, inguinal hernia and gallbladder disease surgeries decreased by 66.7% and 55.6%, respectively.

CONCLUSIONS

Despite a two-month surgery cancellation period, inguinal hernia and gallbladder disease patients demonstrated minimal differences in outcomes. During periods of ED boarding and crowding, scheduled surgery cancellations may be considered with minimal risk of potential adverse patient effects.

Comparison of Bupivacaine Trocar Site Infiltration and Peritoneal Instillation for Postoperative Pain in Pediatric Laparoscopic Surgery

Background Laparoscopic surgery has become the treatment of choice for pediatric patients due to its numerous advantages over open surgery. However, postoperative pain remains a significant barrier to rapid recovery. The intraperitoneal use of local anesthetics for pain management is underutilized in the pediatric population. This study aimed to compare the effectiveness of bupivacaine administered at the trocar site versus in the peritoneal cavity for managing postoperative pain in pediatric laparoscopic surgery. Methodology This quasi-experimental study was conducted in the Department of Pediatric Surgery at the Combined Military Hospital, Lahore. A total of 80 patients who underwent laparoscopic surgery were divided into two groups of 40 each. The W Group received bupivacaine trocar site infiltration, while the P Group received intraperitoneal bupivacaine instillation at the end of surgery. Pain scores were recorded in both groups at one, two, four, six, and eight hours postoperatively. The need for rescue analgesia and the incidence of shoulder pain were also evaluated as secondary outcomes in both groups. Results The mean pain score was 19.15 ± 3.8 in the W group, compared to 17.30 ± 4.0 in the P group, with a calculated p-value of 0.03, indicating a significant difference between the two groups. Similarly, interval pain scores, the need for rescue analgesia, and the incidence of shoulder pain were significantly lower in the P group compared to the W group. Conclusion We concluded that intraperitoneal instillation of bupivacaine is more effective than trocar site infiltration with the same agent in reducing postoperative pain across various pediatric laparoscopic procedures. This approach should be adopted to maximize the benefits of minimally invasive surgery in the pediatric population.

Is Survival Impacted by One or Several Successive Cancers After Liver Transplantation? A French National Study

BACKGROUND AND AIM

De novo cancers after liver transplantation (LT) are major causes of complications and mortality after LT. No report was found in the literature on several successive cancers (SSC). The aim of this study was to see if the survival of one or more cancers was different and to study the survival prognostic factors of patients with one cancer or SSC after LT.

METHODS

Using data from the French national database, 114 French patients who underwent LT between 1993 and 2012 were followed up until their death or until June 2016. The Cox model performed to analyze potential risk factors (cancer characteristics, immunosuppressive therapy (IT), smoking, and alcohol use).

RESULTS

After an average follow-up of 9.8 ± 5.1 years, 52 patients developed 1 cancer, 49 had 2 cancers, and 13 had 3 cancers. The reduction in survival time was significantly and independently associated with the metastatic stage (hazard ratio (HR) = 3.98, 95% confidence interval (95% CI) = [1.45-10.93], p < 0.001), ENT (otolaryngology), and respiratory cancer versus genitourinary (HR = 8.28, 95% CI = [3.12-22.02], p < 0.001), and SSC (HR = 2.54, 95% CI = [1.39-4.65], p = 0.014).

CONCLUSION

The patients with ENT, respiratory cancers have a shorter survival. The stage of cancer and SSC reduces median survival at 10 years. The earliness of the first cancer should be taken as a warning signal of risk of SSC and impaired survival.

P2Y14R activation facilitates liver regeneration via CREB/DNMT3b/Dact-2/β-Catenin signals in acute liver failure

Acute liver failure (ALF) is lack of broadly approved therapeutic strategy except liver transplantation. As a glycogen metabolic intermediate, UDP-glucose (UDP-G) has been considered to accelerate liver repairment. Nevertheless, the role of UDP-G and its receptor P2Y purinoceptor 14 (P2Y14R) in ALF remains unknown. The present study aims to investigate the role and underlying mechanisms of UDP-G/P2Y14R axis in ALF. In this study, hepatic P2Y14R is significantly increased in TAA-induced and partial hepatectomy-induced ALF, while knockout of whole-body P2Y14R aggravates liver failure, manifested by inhibiting β-Catenin-mediated liver regeneration. Consistently, P2Y14R deficiency exhibits impaired liver regeneration in mice suffer partial hepatectomy. Importantly, only hepatocellular specific deletion of P2Y14R (P2Y14R flox/flox Alb cre/+ ) mice shows a similar phenomenon, rather than stellate cell specific deletion of P2Y14R (P2Y14R flox/flox Lrat cre/+ ) mice. Mechanistically, P2Y14R induction regulates methylation of Dact-2 through CREB/DNMT3b signals in hepatocytes, subsequently inhibiting the expression of Dact-2 which is a stabilizer of β-Catenin degradation complex, leading to the activation of β-Catenin -mediated liver regeneration. Interestingly, the administration of exogenous UDP-G can accelerate liver regeneration and liver function recovery after partial hepatectomy in hepatocellular carcinoma mice. Together, the findings propose an unrecognized role of P2Y14R in ALF and provide an effective adjuvant strategy for treatment of ALF.

Significance of administering postoperative pancreatic enzyme replacement therapy for fat digestion and absorption functions in patients who underwent initial total pancreatectomy

OBJECTIVES

To evaluate the effects of postoperative pancreatic enzyme replacement therapy on fat digestion and absorption in patients following initial total pancreatectomy.

METHODS

Data were retrospectively collected from patients who underwent initial total pancreatectomy at our department between 2012 and 2020. Fat digestion, absorption functions, serum nutritional markers, HbA1c levels, and hepatic steatosis before and after the initial total pancreatectomy were evaluated. The rate of change in these parameters pre- and 1-year postoperatively were compared between patients with initial total pancreatectomy and pancreaticoduodenectomy. Patients underwent the 13C-labeled mixed triglyceride breath test to evaluate fat digestion and absorption functions. Hepatic steatosis was assessed using computed tomography.

RESULTS

Of 17 consecutive patients who underwent initial total pancreatectomy, 12 were men, and the median age was 70 years. All 17 patients received 1800 mg pancrelipase when food intake was resumed after surgery. The pre- and 1-year postoperative median % dose 13C cum 7 h (%), serum nutritional markers, HbA1c levels, and liver computed tomography findings did not differ significantly. Two patients had nonalcoholic fatty liver disease after surgery, without serious disease progression. In total, 48 patients who underwent pancreaticoduodenectomy were found eligible. The median change in % dose 13C cum 7 h (%), serum nutritional markers, HbA1c levels, and liver computed tomography findings pre and 1-year postoperatively showed no significant differences between the initial total pancreatectomy and pancreaticoduodenectomy groups.

CONCLUSIONS

High-dose pancreatic enzyme replacement therapy after initial total pancreatectomy might maintain fat digestion and absorption functions and nutritional status and prevent hepatic steatosis.

Acute appendicitis and its treatment: a historical overview

PURPOSE

Acute appendicitis (AA) is the leading cause of acute abdomen worldwide, with an incidence of 90-100 cases per 100,000 individuals annually and a lifetime risk of 7-12%. Despite its prevalence, historical accounts of AA are limited, particularly when compared to conditions like haemorrhoids, likely due to the appendix's internal location. This article traces the historical evolution of AA treatment from ancient times to the present, highlighting key contributions.

METHODS

A review of common research databases and relevant literature on AA was conducted.

RESULTS

Evidence from ancient Egypt suggests early recognition of the appendix, referring to it as the "worm of the bowel." However, detailed anatomical descriptions and treatment approaches for AA did not emerge until the Renaissance, particularly with contributions from Leonardo da Vinci and Berengario da Carpi. The article traces the progression of AA management, including the first autopsies and surgeries, the development of surgical techniques predating anaesthesia and antisepsis, and advancements achieved from the nineteenth to the twenty-first century. The shift from conservative to surgical approaches is discussed, alongside innovations such as laparoscopic appendicectomy, single-incision laparoscopic surgery (SILS), natural orifice transluminal endoscopic surgery (NOTES), and endoscopic retrograde appendicitis therapy (ERAT). The impact of the COVID-19 pandemic on AA treatment, including adaptations in medical practices, is also explored.

CONCLUSIONS

This review highlights the significant historical developments in AA treatment and its pivotal role in advancing abdominal surgery.

Reducing outpatient wait times through telemedicine: a systematic review and quantitative analysis

OBJECTIVES

Population ageing and the rise in chronic diseases place continual stress on healthcare systems. Scarce resources often impede equitable access to healthcare, particularly in rural areas, resulting in prolonged waiting times and heightened risks of morbidity and mortality. Telemedicine has emerged as a promising solution, offering remote and equitable care that could potentially bridge access gaps and enhance health outcomes. This systematic review aims to quantitatively examine the impact of telemedicine implementation on waiting times, defined as the time passed from the booking of a visit for an outpatient to the administration of the service.

DESIGN

A systematic review was conducted using studies on telemedicine interventions that specifically addressed waiting times. Bias assessment was performed with three tools: ROBINS-I ("Risk of Bias In Non-Randomized Studies of Interventions"), AXIS ("Appraisal tool for Cross-Sectional Studies") and RoB-2 ("Risk of Bias-2"). A weighted mean approach was used to synthesise results, with medians synthesised using a median approach.

DATA SOURCES

Articles in English were retrieved from the PubMed and Scopus databases.

ELIGIBILITY CRITERIA

Studies were excluded if they did not specifically address waiting times related to telemedicine interventions. Only studies that considered waiting times defined as the time passed from the booking of a visit for an outpatient to the administration of the service and any telemedicine intervention were included.

DATA EXTRACTION AND SYNTHESIS

A total of 53 records were included, encompassing 270 388 patients in both the experimental and control groups. The weighted mean reduction in waiting times was calculated, and bias was assessed. No record was evaluated to be at high risk of bias, with 69.8% of studies evaluated at low risk and 26.4% at moderate risk (3.8% were surveys). Results were synthesised using a weighted mean approach for studies reporting means, and a median approach for studies reporting medians.

RESULTS

Overall, a weighted mean reduction of 25.4 days in waiting times was observed. Focusing on clinical specialties (n=114 042), the weighted mean reduction amounted to 34.7 days, while in surgical patients (n=156 346), telemedicine was associated with a weighted mean of 17.3 days saved.

CONCLUSIONS

The implementation of telemedicine solutions may significantly improve waiting times, potentially leading to more efficient and equitable healthcare systems.

PROSPERO REGISTRATION NUMBER

CRD42023490822.

Unveiling the digital future: perspectives of Hungarian physicians under 35 years old on eHealth solutions

Background

The COVID-19 pandemic has catalysed the emergence of digital solutions in all areas of medicine. Our prior study on the digital health related experiences and opinions of Hungarian physicians highlights the crucial role of age in shaping attitudes towards digital health solutions among medical doctors. Our aim was to examine how under 35-year-old Hungarian physicians relate to digital technologies, the advantages and disadvantages they perceive, and how they would like to incorporate these technologies into their everyday medical practice.

Methods

As part of the "E-physicians and E-patients in Hungary" study, we conducted an online representative survey among medical practitioners in Hungary between July 2021 and May 2022 (n = 1,774). The main target group of our research were physicians under 35 years of age: n = 399 (25.3%). Besides descriptive statistical analyses, cluster analysis and binary logistic regression were applied to analyse the digital health related attitudes of the young age group.

Results

Our cluster analysis confirmed that younger doctors perceived more advantages (on average 7.07 items vs. 8.52 items) and disadvantages (on average 4.06 vs. 4.42) of digital health solutions. They also demonstrated greater familiarity with (8.27 vs. 9.79) and use of (1.94 vs. 2.66) a broader spectrum of technologies. Proficiency and active utilization of diverse technologies correlates with a more comprehensive understanding of both pros and cons, as well as a more realistic self-assessment of areas of further improvement. Doctors under 35 years express a notable demand for significantly increased incentives, both in terms of knowledge transfer/training and infrastructure incentives. Multivariate analyses revealed that young doctors, compared to their older counterparts, perceived enhanced patient adherence as one of the greatest benefits of digital health solutions. Additionally, young doctors expect that digital health solutions could reduce burnout.

Conclusion

Our results underscore the inevitable transformation of the 21st-century physician role: the success of digital health solutions hinges on active patient involvement and management, which requires proper patient education and professional support in navigating the digital space. Digital health solutions can be a bridge between different generations of doctors, where young people can help their older colleagues navigate the digital world.

Exploring auxiliary liver transplantation in the era of transplant oncology-A proposal for a new liver splitting program (ALERT-50)

Total hepatectomy and liver transplantation have emerged as a game-changing strategy in the treatment of several liver-confined primary or metastatic tumors, opening a new era of transplant oncology. However, the expansion of indications is going to worsen the chronic scarcity of organs, and new strategies are needed to enlarge the donor pool. A possible source of organs could be developing split liver transplantation programs. We propose to refer donors aged 18-50 years unsuitable for pediatric patients and donors aged 50-60 years for split evaluation. This will generate new small left lateral grafts that can be used for resection and partial liver segment II-III transplantation with delayed total hepatectomy procedures, based on a national waiting list specifically for non-HCC oncologic patients. Centralized imaging review will streamline the donor-recipient matching process and address organizational challenges. Additionally, adopting an ex situ splitting technique during hypothermic oxygenated machine perfusion could further enhance logistical efficiency and improve graft viability. The proposed protocol (ALERT 50) will therefore promote the development of oncologic indications without affecting the standard waiting list and without competing with urgent or pediatric patients.

Causal analysis of dietary preferences and the risk of endometriosis using large-scale population data

Dietary factors have recently been recognized as potentially influential in the pathogenesis of endometriosis (EM), yet studies on the causal relationship between dietary preferences and EM are limited. The present study aimed to explore the causal relationships between 187 dietary preferences and EM using Mendelian randomization (MR) methods. This study utilised genome-wide association study data from over 500,000 European participants for dietary preferences and 64,658 EM patients from Finland. Dietary preferences with potential causal relationships to EM were identified using two-sample MR methods. P-values from the inverse variance weighted (IVW) analysis were corrected using the false discovery rate (FDR) method to ensure accuracy. Additionally, heterogeneity analysis, pleiotropy assessment, leave-one-out analysis, and reverse MR analysis were conducted to further validate and solidify the findings of the study. After FDR correction, IVW analysis revealed that asparagus preference was significantly protective against EM, including in American Society for Reproductive Medicine (ASRM) stages 1-2 and 3-4. Conversely, preferences for different types of coffee and orange juice were associated with an increased likelihood of EM across these stages. Subgroup analysis indicated that asparagus preference had a protective effect against deep EM, ovarian EM, pelvic peritoneal EM, and rectovaginal septum and vaginal EM. In contrast, coffee preference increased the risk of pelvic peritoneal EM, fallopian tube EM, and unspecified EM, whereas orange juice preference increased the risk of deep EM, rectovaginal septum and vaginal EM, pelvic peritoneal EM, and unspecified EM. Reverse MR analysis did not identify causal relationships between EM and the specific dietary preferences that were analysed in this study. These findings suggest that asparagus preference significantly reduces the risk of developing EM, whereas preferences for orange juice and different types of coffee may increase the risk, offering new insights into EM management through dietary modifications.

Unlocking the Potential of RNA Sequencing in COVID-19: Toward Accurate Diagnosis and Personalized Medicine

COVID-19 has caused widespread morbidity and mortality, with its effects extending to multiple organ systems. Despite known risk factors for severe disease, including advanced age and underlying comorbidities, patient outcomes can vary significantly. This variability complicates efforts to predict disease progression and tailor treatment strategies. While diagnostic and therapeutic approaches are still under debate, RNA sequencing (RNAseq) has emerged as a promising tool to provide deeper insights into the pathophysiology of COVID-19 and guide personalized treatment. A comprehensive literature review was conducted using PubMed, Scopus, Web of Science, and Google Scholar. We employed Medical Subject Headings (MeSH) terms and relevant keywords to identify studies that explored the role of RNAseq in COVID-19 diagnostics, prognostics, and therapeutics. RNAseq has proven instrumental in identifying molecular biomarkers associated with disease severity in patients with COVID-19. It allows for the differentiation between asymptomatic and symptomatic individuals and sheds light on the immune response mechanisms that contribute to disease progression. In critically ill patients, RNAseq has been crucial for identifying key genes that may predict patient outcomes, guiding therapeutic decisions, and assessing the long-term effects of the virus. Additionally, RNAseq has helped in understanding the persistence of viral RNA after recovery, offering new insights into the management of post-acute sequelae, including long COVID. RNA sequencing significantly improves COVID-19 management, particularly for critically ill patients, by enhancing diagnostic accuracy, personalizing treatment, and predicting therapeutic responses. It refines patient stratification, improving outcomes, and holds promise for targeted interventions in both acute and long COVID.

Updates in Biliary Atresia: Aetiology, Diagnosis and Surgery

Biliary atresia (BA) is an obliterative disease of the bile ducts affecting between 1 in 10,000-20,000 infants with a predominance in Asian countries. It is clinically heterogeneous with a number of distinct variants (e.g., isolated, Biliary Atresia Splenic Malformation syndrome, Cat-eye syndrome, cystic BA, and CMV-associated BA). Facts about its aetiology are hard to encounter but might include genetic, developmental, exposure to an environmental toxin, or perinatal virus infection. However, the cholestatic injury triggers an intrahepatic fibrotic process beginning at birth and culminating in cirrhosis some months later. Affected infants present with a triad of conjugated jaundice, pale stools, and dark urine and may have hepatosplenomegaly upon examination, with later ascites coincident with the onset of progressive liver disease. Rapid, efficient, and expeditious diagnosis is essential with the initial treatment being surgical, typically with an attempt to restore the bile flow (Kasai portoenterostomy (KPE)) or primary liver transplantation (<5%) if considered futile. Failure to restore bile drainage or the onset of complications such as recurrent cholangitis, treatment-resistant varices, ascites, hepatopulmonary syndrome, and occasionally malignant change are usually managed by secondary liver transplantation. This issue summarises recent advances in the disease and points a way to future improvements in its treatment.

Evaluation of neutralizing antibody titers against SARS-CoV-2 JN.1 omicron subvariant during pregnancy - A case series study

Background

SARS-CoV-2 infection during pregnancy poses health risks to both mother and fetus. This study investigates neutralizing antibodies (NAbs) against the SARS-CoV-2 JN.1 Omicron subvariant in pregnant women, focusing on responses to natural infection, vaccination, and passive immunity.

Methods

A single-center, prospective study collected blood samples from 19 pregnant women at various pregnancy stages and postpartum. NAb titers were analyzed using a pseudovirus neutralization assay, with statistical analyses (p-value <0.05) conducted using unpaired t-test with Welch's correction.

Results

Among participants, 63.2 % had at least one positive NAb titer, with only one vaccinated case. No significant difference in NAb titers was found between symptomatic and asymptomatic women. NAbs were detected in cord blood, especially when infection or vaccination occurred close to delivery, indicating passive immunity transfer to the newborn.

Conclusion

NAb titers change dynamically during pregnancy, increasing then decreasing. Most pregnant women were asymptomatic and NAbs were effectively transferred to the fetus when infection or vaccination occurred near delivery. These findings highlight the importance of vaccination timing, suggesting late second or third trimester vaccination may provide better protection, emphasizing the need for adherence to vaccination guidelines to optimize maternal and neonatal immunity.

Understanding the work-related challenges of organ and tissue donation coordinators during the COVID-19 pandemic: a mixed-method study

OBJECTIVES

This study aimed to explore the perceptions of donation coordinators in Canada and understand how the COVID-19 pandemic impacted their work activities.

DESIGN

A sequential mixed-method design incorporating a cross-sectional survey investigating demographic data, substance use and abuse and perceived stress related to the pandemic and semistructured qualitative interviews to further investigate those.

SETTING

Organ donation organisations across Canada.

PARTICIPANTS

Canadian organ and tissue donation coordinators working within deceased donation programmes. Participants were recruited using a purposive sampling technique for the survey and qualitative interviews. Recruitment and data collection took place between January 2022 and March 2023.

ANALYSIS

The data were analysed using descriptive statistics for the quantitative findings and content analysis for the qualitative data.

RESULTS

Of the 175 available coordinators, 120 participated in the survey, and 39 participated in the qualitative interviews. The great majority were female (n=98; 81.7%), registered nurses (n=117; 97.5%) and on average 42 years old (SD=9.64). The survey result for perceived stress showed that, on average, coordinators did not experience high stress levels during the pandemic. We also identified an increase in the consumption of substances to manage workplace stress near the pandemic's beginning. The qualitative interviews yielded two main themes (Personal Life Changes and Workplace Adjustments) in which coordinators reported their views on challenges with uncertainties, effects on their personal lives, redeployment, stressors and among others.

CONCLUSION

Our study's results provide a comprehensive understanding of the perceptions and experiences of coordinators in Canada during the COVID-19 pandemic. Using a combination of methods, we identified various ways coordinators were affected by the pandemic in their personal and professional lives. These findings highlight the need to support the development of adaptive strategies and promote resilience during crises.

Evaluating quality of life improvements in endometriosis patients following laparoscopic surgery using EHP-30 scale

This study aims to evaluate whether laparoscopic surgery enhances health-related quality of life (HRQoL) in endometriosis patients, utilizing the Endometriosis Health Profile-30 (EHP-30) questionnaire. The study also explores the correlations between disease severity, preoperative scores, and the subsequent changes following surgical intervention. This is a prospective observational study. Seventy women undergoing laparoscopic surgery for endometriosis at Fujian Maternity and Child Health Hospital were prospectively recruited. Each participant was assessed using the EHP-30 questionnaire both 4 weeks prior to and 3 months post-surgery to obtain preoperative and postoperative subscale scores. The Wilcoxon signed-rank test was applied to determine the statistical significance of changes in these scores. Spearman's rank correlation coefficient was employed to explore the relationships between preoperative EHP-30 scores, serum CA125 levels, and intraoperative revised American Society for Reproductive Medicine (rASRM) scores. Statistically significant correlations were further examined using multivariate linear regression analysis to adjust for potential confounders. Laparoscopic surgery resulted in a significant reduction in EHP-30 subscale scores (P ≤ 0.002), indicating a marked improvement in HRQoL among endometriosis patients. Spearman correlation analysis revealed positive correlations between preoperative serum CA125 levels (P = 0.005) and intraoperative rASRM scores with preoperative pain (P = 0.035) and sexual intercourse scores (P = 0.046). Additionally, multivariate linear regression analyses demonstrated that changes in pain scores (ΔPain), control and powerlessness (ΔControl and Powerlessness), and work life (ΔWork Life) were significantly interrelated (P < 0.01). Emotional well-being (ΔEmotional Well-being), control and powerlessness (ΔControl and Powerlessness), and work life (ΔWork Life) also exhibited significant mutual influences (P < 0.01). Furthermore, changes in social support (ΔSocial Support), self-image (ΔSelf-image), and treatment perception (ΔTreatment) were positively correlated (P < 0.01), as were changes in sexual intercourse (ΔSexual Intercourse) and concern about infertility (ΔConcern on Infertility) (P < 0.01). Laparoscopic surgery for endometriosis significantly improves HRQoL by alleviating pain and positively influencing daily functioning and emotional well-being. These findings highlight the critical role of laparoscopic surgery as an effective intervention for enhancing the quality of life in endometriosis patients.

Myosin Light Chain 9 Mediates Graft Fibrosis After Pediatric Liver Transplantation Through TLR4/MYD88/NF-κB Signaling

BACKGROUND & AIMS

The incidence of graft fibrosis is elevated after pediatric liver transplantation (pLT) and is influenced by cold ischemic time (CIT). Myosin light chain 9 (MYL9), a member of the myosin family, could act on hepatic stellate cells (HSCs) and induce a transition to active phase. We hypothesized that cold ischemic injury could stimulate MYL9 expression and lead to graft fibrosis.

METHODS

We tested the hypothesis by analyzing multi-omics data from human protocol liver biopsy samples 2 years after LT, performing rat LT with different CIT and conducting in vitro studies in HSC cell lines with MYL9 knockdown and overexpression.

RESULTS

Clinically, CIT is an independent risk factor for graft fibrosis after pLT. Omics analysis identified MYL9 as a prominent contributor in graft fibrosis. MYL9 is strongly correlated with liver fibrosis grade and the progression of fibrosis. The study of rat LT model demonstrated MYL9 expression increases with the prolongation of CIT, and its role is specific to transplant setting. Mechanistically, in vitro experiments with HSCs exposed to hypoxia/reoxygenation revealed a substantial decrease in HSCs activation after MYL9 knockdown. Conversely, overexpression of MYL9 significantly enhanced the activation of HSCs. Subsequent transcriptome sequencing of HSCs with MYL9 knockdown unveiled that MYL9 primarily functions through the TLR4/MYD88/NF-κB signaling pathway. Liver graft fibrosis was ameliorated when toll like receptor 4 signaling was inhibited in rats.

CONCLUSIONS

Our findings demonstrate that prolonged CIT up-regulates the expression of MYL9 in liver graft after LT. MYL9 activates HSCs and promotes fibrosis through a TLR4/MYD88/NF-κB signaling dependent manner.

Only IF/TA in the Histological Evaluation of Post-Reperfusion Baseline Biopsies Correlates With Kidney Transplant Outcome

Here, we retrospectively evaluated the informational yield of 338 post-reperfusion kidney transplant biopsies (including 95 living donations) assessed according to BANFF for the histological characteristics interstitial fibrosis and tubular atrophy (IF/TA), glomerulosclerosis, arteriosclerosis, and acute tubular injury (ATI). Associations with delayed graft function (DGF) and death-censored graft survival were explored through Cox-regression analyses. The maximum follow-up time was 11.4 years, with DGF observed in 108 (32%) cases. After deceased donation there was no association between DGF and histologic parameters. Univariable Cox-regression unveiled an association of IF/TA and glomerulosclerosis with long-term death-censored graft survival (HR per 10% increase: IF/TA 1.63; 95% CI 1.17-2.28; p = 0.003; glomerulosclerosis 1.19; 95% CI 1.01-1.39; p = 0.031). In multivariable Cox regression analyses, adjusted for recognized clinical risk variables like expanded criteria donor-status, donor age, history of diabetes, and HLA-mismatches, only IF/TA maintained association over the total observation period in deceased donations and in the total cohort. Arteriosclerosis and ATI were not associated with clinical outcome after deceased donation. Especially ATI did not affect delayed graft function if only deceased donations were considered. Our data underlines the role of organ quality for transplant outcome prior to acute lesions such as ATI during the transplantation process.

Evaluation of acute postoperative pain management after living donor nephrectomy during the transition from open access to laparoscopic and minimally invasive robotic surgical approach

Background

Living donor nephrectomies (LDN) at our institution transitioned from open access to laparoscopic and, more recently, to a minimally invasive robotic surgical approach between 2019 and 2022. Concurrently, postoperative analgesia transitioned from regional anesthesia to intravenous patient-controlled analgesia (PCA) and eventually to simple analgesics with additional rescue analgesic agents, as needed, in accordance with individual physicians' preferences. This retrospective study was designed to evaluate the impact of these changes on surgical practice on the analgesic requirements and effectiveness of postoperative pain management.

Methods

Electronic records of all LDN cases operated between January 2019 and March 2022 were accessed, and a comparative analysis of patient demographics, surgical approach, duration of surgery, postoperative pain scores, and the analgesics administered within the first 48 h was performed.

Results

LDN (n = 527) was performed via laparoscopic (n = 432, 82%), robotic (n = 87, 17%), and open (n = 8, 2%) approaches. All patients were administered regular paracetamol 1 g 6 hourly. IV PCA was used in 85% of cases, predominantly in the laparoscopic (99%) and open (75%) groups (LG and OG, respectively); in contrast, the robotic group (RG) was mostly treated without PCA (81.7%). A variety of analgesic techniques were employed for the remaining patients, including epidural (25% of OG) and rectus sheath/transversus abdominis plane (TAP) block (2% of LG). Additional rescue analgesics were administered to 98% of the patients; 92% of LG needed 1-3 analgesic agents, whereas all of the OG and 37% of RG needed 1-2 rescue analgesics. No correlation was found between patient demographics and surgery duration on pain scores or analgesic requirements.

Conclusions

Robotic surgery was associated with the lowest postoperative pain scores and analgesic demand; laparoscopic resection was the most painful of all.

Positive Clinical, Neuropsychological, and Metabolic Impact of Liver Transplantation in Patients With Argininosuccinate Lyase Deficiency

Liver transplantation (LTx) is increasingly used in Urea Cycle Defects (UCDs) to prevent recurrent hyperammonemia and related neurological irreversible injury. Among UCDs, argininosuccinate lyase deficiency (ASLD) has a more complex phenotype than other UCDs, with long-term neurocognitive deficits. Therefore, the role of LTx in ASLD is still debated. The impact of LTx on nine patients with early-onset ASLD was assessed through pre- and post-LTx clinical, neuropsychological, MRI and biochemical evaluations. After LTx, no episodes of metabolic decompensations were reported. Neuropsychological evaluations documented significant improvement in cognitive/developmental functioning especially in patients transplanted in early childhood. Improvements were also highlighted in daily living skills and emotional-behavioral problems, with a reduction in attention disturbances and somatic complaints. Movement disorders resolved after LTx in patient transplanted in early childhood. Any patients developed epilepsy with stability of EEG alterations after LTx. A positive effect of LTx on other disease-related outcomes such as growth, diet, medications, hospitalizations, and long-term ASLD-related complications was highlighted. The primary biomarker argininosuccinic acid dramatically reduced in plasma after transplantation with a decreasing trend in CSF at long-term follow-up. Moreover, health-related quality of life improved after LTx, especially when assessed through MetabQoL, a tool designed for intoxication diseases such as ASLD. In conclusion, our study showed a global beneficial impact of LTx in early-onset ASLD patients to avoid episodes of hyperammonemia, and improve neurocognitive outcome, adaptive and behavioral deficits when performed in early childhood with a dramatic benefit in terms of quality of life.

Mucormycosis and COVID-19: Unraveling the Interplay of Fungal Infection in a Global Health Crisis: An Overview

The healthcare system has been greatly affected by the COVID-19 pandemic, resulting in an increase in secondary and co-infections among patients. Factors like pulmonary damage and weakened immune systems make patients more susceptible to fungal infections. Mucormycosis, an opportunistic fungal infection, prospers in environments with limited oxygen, and elevated glucose levels due to conditions such as diabetes and steroid use, as well as in acidic environments from metabolic acidosis and diabetic ketoacidosis, where it demonstrates heightened germination ability. Recognizing these complications is critical to minimize harm to patients. The insights gained from this review can improve our understanding of how fungal infections develop in connection to COVID-19, leading to better predictive algorithms, tailored care plans, enhanced antifungal treatments, quicker diagnostics, and improved management strategies.

Bibliometric and LDA analysis of acute rejection in liver transplantation: Emerging trends, immunotherapy challenges, and the role of artificial intelligence

With the rising demand for liver transplantation (LT), research on acute rejection (AR) has become increasingly diverse, yet no consensus has been reached. This study presents a bibliometric and latent Dirichlet allocation (LDA) topic modeling analysis of AR research in LT, encompassing 1399 articles. The United States, Zhejiang University, and the University of California, San Francisco emerged as leading contributors, while Levitsky J and Uemoto SJ were key researchers. The most influential journals included the American Journal of Transplantation, Journal of Hepatology, and Transplantation. The analysis reveals a transition from traditional histological assessments to molecular diagnostics, genetic and epigenetic profiling, and noninvasive biomarkers such as donor-derived cell-free DNA (dd-cfDNA) and microRNAs. Advances in immune checkpoint inhibitors (ICIs), cell-based therapies (Tregs, mesenchymal stem cells (MSCs)), AI-guided immunosuppression, and nanoparticle-mediated drug delivery systems reflect a growing emphasis on precision medicine. In addition, recent exploration of microbiome-based therapies and regenerative medicine, including MSCs and their extracellular vesicles, offers promising new avenues for reducing long-term immunosuppressive drug dependency and enhancing graft survival. These developments not only improve early AR detection and personalized treatment but also reduce toxicity, foster immune tolerance, and expand the scope of individualized therapeutic options. Global collaboration, supported by cutting-edge research and AI-driven decision-making, remains essential for refining AR strategies, improving graft survival, and achieving better long-term patient outcomes.

Liver Transplantation in Well-Selected Class III Obese Recipients Yields Good Outcomes

INTRODUCTION

Previous guidelines considered body mass index (BMI) over 40 kg/m2 a relative contra-indication to liver transplantation (LT). The aims were to examine the selection process and study outcomes of patients with Class I-III obesity.

METHODS

Retrospective analysis of outcomes of obese patients assessed for LT at our center between 2010 and 2023, divided into three groups: Class I (BMI30-34.9 kg/m2), Class II (BMI35-39.9 kg/m2), and Class III (BMI>40 kg/m2). Survival of non-obese adult patients was used for comparison.

RESULTS

Three hundred fifteen patients with BMI ≥30 kg/m2 were assessed for LT. Seventeen (5.4%) were not wait-listed due to comorbidities. One hundred sixty-eight patients were transplanted: 100 Class I, 43 Class II, and 25 Class III. There were no differences in postoperative complications (Clavien-Dindo Grade 3 or more; 41%, 42%, 48% for Class I-III obesity respectively) or patient and graft survival (5-y rates 84.4% and 82.7%, respectively, for the whole cohort) according to the different classes of obesity. Furthermore, patient and graft survival was not different between non-obese and obese patients (p = 0.932).

CONCLUSION

With a rigorous selection process, short-term outcomes after LT for patients with Class III obesity were comparable to patients with Class I-II obesity. Long-term survival was identical for obese and non-obese patients.

Impact of Preoperative Osteosarcopenia and Postoperative Administration of Pancrelipase on the Prognosis of Borderline Resectable and Unresectable Locally Advanced Pancreatic Cancer

BACKGROUND

This study aimed to identify postoperative recurrence and prognostic factors, including osteosarcopenia for borderline resectable (BR) and unresectable locally advanced (UR-LA) pancreatic cancer and to examine the impact of postoperative pancreatic enzyme replacement therapy (PERT).

METHODS

We retrospectively examined 32 resected patients with BR and UR-LA pancreatic cancer. We investigated independent factors in the disease-free survival and overall survival. The relation of osteosarcopenia with the clinicopathological factors was investigated. Additionally, the association of the administration of a standard dose of pancrelipase, the amount of lipase required for patients with pancreatic exocrine insufficiency, for ≥6 months postoperatively with improvement of sarcopenia, osteopenia, and osteosarcopenia and completion rate of adjuvant chemotherapy was investigated.

RESULTS

Multivariate analyses identified osteosarcopenia (P = 0.049) and lymph node metastasis (P = 0.01) as independent recurrence predictors, and osteosarcopenia (P = 0.002), maximum tumor diameter ≥40 mm (P = 0.006), and no adjuvant therapy (P = 0.01) as independent prognostic predictors. In the osteosarcopenia group, serum CA19-9 levels were higher (P = 0.03). The administration of a standard dose of pancrelipase for ≥6 months postoperatively was none in the osteosarcopenia group (0% vs 42.9%, P = 0.01), while significantly improved postoperative sarcopenia (33% vs 0%, P = 0.004), increased number of cycles of adjuvant chemotherapy (n = 6 vs n = 3, P = 0.03), and the completion rate of adjuvant chemotherapy in excluding cases interrupted because of recurrence (86% vs 25%, P = 0.007).

CONCLUSIONS

Osteosarcopenia was an independent recurrent and prognostic factor in patients after pancreatectomy for locally advanced pancreatic cancer. Appropriate postoperative PERT may contribute to a better prognosis by improving sarcopenia and increasing the completion rate of adjuvant chemotherapy.

Protection of liver sinusoidal endothelial cells using different preservation solutions

Donor liver preservation methods and solutions have evolved over the last years. Liver sinusoidal endothelial cell (LSEC) barrier function and integrity during preservation are crucial for outcomes of liver transplantation. Therefore, the present study aimed to determine optimal preservation of LSEC barrier function and integrity using different preservation solutions. Human umbilical vein endothelial cells (HUVECs) and LSECs were incubated in either University of Wisconsin machine perfusion solution (UW-MPS), histidine-tryptophan-ketoglutarate, or endothelial cell growth medium 2 (EGM2) (as a gold standard for cell culturing). Endothelial integrity was assessed by measurement of cellular morphology and expression of membrane proteins: PECAM-1, ICAM-1 and Fc-gamma receptor CD32b (FcΥRCD32b). Endothelial barrier function was measured by electric cell-substrate impedance sensing. Cellular response to inflammatory stimuli with tumor necrosis factor-alpha (TNF-α) was tested by studying trans-endothelial migration (TEM) under flow conditions. Differences in these parameters were analyzed between the different preservation solutions. PECAM-1 expression was high for all preservation solutions in HUVECs and LSECs. ICAM-1 expression was increased in both LSECs and HUVECs in all preservation solutions plus TNF-α. UW reduced PECAM-1 expression, whereas EGM2 medium promoted barrier function in LSECs and HUVECs, and monolayer recovery after wounding was best achieved in cells incubated in EGM2. LSECs and HUVECs incubated with EGM2 plus TNF-α both supported neutrophil adhesion and TEM, but much less to none when incubated in UW plus TNF-α. Overall, EGM2 showed the best results in preserving endothelial barrier function for both HUVECs and LSECs.

Matching the opposites: liver transplantation from a situs viscerum inversus totalis donor

Situs viscerum inversus totalis (SIT) is a rare congenital anomaly. Deceased donors with this condition are often declined because of the technical issues in both the organ's procurement and its transplant. Only eight cases of deceased donor organs with SIT were reported to be used for liver transplantation (LT). We herein present a case of LT using a graft from an SIT donor: a modified retroversus piggyback technique was used. A 15 year-old female was referred to our institution as a potential donor. An SIT condition was discovered during standard donor evaluation together with the presence of a complex triple arterial pedicle. Procurement operative time was 125 min, from skin incision to cross-clamp. Liver extraction occurred 32 min after cold flush. The recipient was a 56 year-old male affected by recurrent hepatocellular carcinoma (HCC) on hepatitis C related liver cirrhosis. Position and orientation trials of the graft were made and it was decided to implant it with the retroversus technique. Direct duct-to-duct biliary reconstruction was achieved. The postoperative course was uneventful. To our knowledge, this is the first implant with retroversus technique combined to direct biliary reconstruction and the first repetition of that technique. Cases like this highlight how technical complexity can be overcome leading to successful management of difficult scenarios in a safe manner.

Growing challenge of multimorbidity in patients undergoing surgery

As populations age, the incidence of multimorbidity rises, posing significant challenges for surgical and perioperative healthcare systems. Emerging evidence suggests multimorbidity can lead to worse patient outcomes. Healthcare providers must consider multimorbidity as a critical factor when planning surgical interventions with patients. The potential for surgical pathways in addressing multimorbidity needs further exploration.

Letter on: "Platelet-Rich Plasma for Treatment of Hair Loss Improves Patient-Reported Quality of Life"

Authors comment on the paper "Platelet-Rich Plasma for Treatment of Hair Loss Improves Patient-Reported Quality of Life" written by Abigail Meyers et al in Aesthetic Plastic Surgery. Although the authors present interesting results on the quality of life of patients after platelet-rich plasma, we express some considerations about the proposed composition of PRP and hoping in larger sample study.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Animal models for transplant immunology: bridging bench to bedside

The progress of transplantation has been propelled forward by animal experiments. Animal models have not only provided opportunities to understand complex immune mechanisms in transplantation but also served as a platform to assess therapeutic interventions. While small animals have been instrumental in uncovering new therapeutic concepts related to immunosuppression and immune tolerance, the progression to human trials has largely been driven by studies in large animals. Recent research has begun to explore the potential of porcine organs to address the shortage of available organs. The consistent progress in transplant immunology research can be attributed to a thorough understanding of animal models. This review provides a comprehensive overview of the available animal models, detailing their modifications, strengths, and weaknesses, as well as their historical applications, to aid researchers in selecting the most suitable model for their specific research needs.

Advancing immunosuppression in liver transplantation: the role of regulatory T cells in immune modulation and graft tolerance

Prolonged immunosuppressive therapy in liver transplantation (LT) is associated with significant adverse effects, such as nephrotoxicity, metabolic complications, and heightened risk of infection or malignancy. Regulatory T cells (Tregs) represent a promising target for inducing immune tolerance in LT, with the potential to reduce or eliminate the need for life-long immunosuppression. This review summarizes current knowledge on the roles of Tregs in LT, highlighting their mechanisms and the impact of various immunosuppressive agents on Treg stability and function. The liver's distinct immunological microenvironment, characterized by tolerogenic antigen-presenting cells and high levels of interleukin (IL)-10 and transforming growth factor-β, positions this organ as an ideal setting for Treg-mediated tolerance. We discuss Treg dynamics in LT, their association with rejection risk, and their utility as biomarkers of transplant outcomes. Emerging strategies, including the use of low-dose calcineurin inhibitors with mammalian target of rapamycin inhibitors, adoptive Treg therapy, and low-dose IL-2, aim to enhance Treg function while providing sufficient immunosuppression. Thus, the future of LT involves precision medicine approaches that integrate Treg monitoring with tailored immunosuppressive protocols to optimize long-term outcomes for LT recipients.

Network meta-analysis of pharmacological treatment for antibody-mediated rejection after organ transplantation

Objective

This study aims to assess the efficacy of pharmacological interventions in mitigating graft injury in transplant patients with antibody-mediated rejection (AMR) through a network meta-analysis (NMA).

Methods

A search was conducted on databases such as Cochrane Library, PubMed, EmBase, and Web of Science for randomized controlled trials (RCTs) on pharmacological interventions for alleviating graft injury following AMR. The search was performed for publications up to April 12, 2024. Two reviewers conducted independent reviews of the literature, extracted data, and assessed the risk of bias (ROB) in the included studies using the ROB assessment tool recommended by the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0. A Bayesian NMA was conducted using R 4.4.0, RStudio software, and the GeMTC package to assess the outcomes in estimated glomerular filtration rate (eGFR), mean fluorescence intensity (MFI), g-score, and infection under pharmacological treatments.

Results

A total of 8 RCTs involving 215 patients and 6 different pharmacological treatments were included in this NMA. The results indicated that the increase in eGFR by eculizumab (SUCRA score: 81) appeared to be more promising. The decrease in MFI by bortezomib (SUCRA score: 72.3), rituximab (SUCRA score: 68.2), and clazakizumab (SUCRA score: 67.1) demonstrated better efficacy. The decrease in g-score by eculizumab (SUCRA score: 74.3), clazakizumab (SUCRA score: 72.2), and C1INH (SUCRA score: 63.6) appeared to have more likelihood. For infection reduction, clazakizumab (SUCRA score: 83.5) and bortezomib (SUCRA score: 66.8) might be better choices.

Conclusion

The results of this study indicate that eculizumab has the potential to enhance eGFR and reduce g-score. Bortezomib demonstrates superior efficacy in reducing MFI. Clazakizumab appears to be more effective in reducing infections.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024546483.

Assessment of Current Practices for Perioperative Antibiotic Prophylaxis in Kidney Transplantation in China: Results from a Nationwide Survey

Background

Current guidelines support routine perioperative antibiotic prophylaxis (PAP) to minimize surgical site infection in kidney transplantation (KT), though data regarding the current practices of PAP is lacking in China.

Objective

To survey the routine PAP strategies in KT, and analyze main clinical considerations associated with adjusted antibiotic dosing regimens in different Chinese hospitals.

Methods

A nationwide survey was conducted on behalf of the National Alliance of Transplant Pharmacists. An online questionnaire was created via Wen Juan Xing (http://www.wjx.cn) and sent to all pharmacists in the Alliance.

Results

Twenty-three pharmacists from different teaching hospitals with Grade IIIA participated in the survey, with a response rate of 46.0%. There were wide differences in routine dosing regimens and clinical considerations. Six strategies were involved in living-donor KT and monotherapy was most often used (80.9%), while combination therapy was most common (69.6%) among the ten strategies in deceased-donor KT. Of fifteen antibiotics submitted in the survey, eight agents were prescribed with different doses and/or frequencies among different hospitals. Only 37.5% and 23.1% of the hospitals would stop PAP within 72 hours in living-donor KT and deceased-donor KT, respectively. Among 28 preset factors, four factors were considered significantly important to decide PAP regimens, and eight factors were considered significantly unimportant (P<0.05).

Conclusion

There was wide variability in routine dosing regimens and clinical considerations in PAP decisions in KT. Further investigations are warranted to obtain high-quality evidence and to make PAP in KT more rational.

Cell therapy for end-stage liver disease: Current state and clinical challenge

ABSTRACT

Liver disease involves a complex interplay of pathological processes, including inflammation, hepatocyte necrosis, and fibrosis. End-stage liver disease (ESLD), such as liver failure and decompensated cirrhosis, has a high mortality rate, and liver transplantation is the only effective treatment. However, to overcome problems such as the shortage of donor livers and complications related to immunosuppression, there is an urgent need for new treatment strategies that need to be developed for patients with ESLD. For instance, hepatocytes derived from donor livers or stem cells can be engrafted and multiplied in the liver, substituting the host hepatocytes and rebuilding the liver parenchyma. Stem cell therapy, especially mesenchymal stem cell therapy, has been widely proved to restore liver function and alleviate liver injury in patients with severe liver disease, which has contributed to the clinical application of cell therapy. In this review, we discussed the types of cells used to treat ESLD and their therapeutic mechanisms. We also summarized the progress of clinical trials around the world and provided a perspective on cell therapy.