Basiliximab Induction and Postoperative Steroid-free Immunosuppression With Tacrolimus in Pediatric Liver Transplantation: A Randomized Clinical Trial

BACKGROUND

Optimizing the immunosuppressive regimen is essential to improve the long-term outcomes of pediatric liver transplant recipients.

METHODS

We conducted a prospective, randomized, open-label study to compare the safety and efficacy of 2 treatment approaches during pediatric liver transplantation: tacrolimus monotherapy following basiliximab induction (the study group) and a dual regimen of tacrolimus plus steroids (the control group). A total of 150 patients were enrolled, with 75 patients allocated to each group.

RESULTS

In both groups, recipients achieved graft and recipient overall survival rates exceeding 93%, with no statistically significant differences between them. However, the study group exhibited a significantly lower incidence of acute cellular rejection (ACR), delayed occurrence of ACR, and an improved ACR-free survival rate at 2 y compared with the control group. Notably, the study group also showed a significant reduction in the incidence of de novo donor-specific antibodies at 3-mo and 2-y posttransplant. Furthermore, 6 mo after the transplant, the study group demonstrated significant improvements in weight-for-age Z score and height-for-age Z score. No notable differences were observed in postoperative complications or the incidence of liver fibrosis between the 2 groups.

CONCLUSIONS

Basiliximab induction combine with tacrolimus (TAC) monotherapy is a safe and effective immunosuppressive regimen to reduce the episodes of ACR without influencing the development of liver fibrosis and graft and recipient survival rate after pediatric liver transplantation.

Appendicitis tends to be complicated during the COVID-19 epidemic: A multicentre retrospective study

Background

In past studies, non-medical factors in the social-healthcare-patient triad associated with the prevalence of COVID-19 have led to delays in the presentation of patients with acute appendicitis and an increase in complications. However, as research progresses, there is increasing evidence of a clinical association between COVID-19 and the development of acute appendicitis.

Methods

The effect of COVID-19 prevalence and associated factors on acute appendicitis in the control (2016-2019) and exposed (2020-2023) groups was derived from a retrospective study of 3070 patients with acute appendicitis from 2016 to 2023.

Results

After the implementation of the restrictions, the rate of acute appendicitis visits in the exposed group compared to the control group dropped sharply in the initial period (P = 0.047) and recovered gradually with the relaxation of the restrictions. Similar changes occurred in the number of acute complicated appendicitis visits. In addition, after the lifting of restrictions and the COVID-19 outbreak, the proportion of acute complicated appendicitis in the exposed group increased significantly (P < 0.001) and an increase in the number of complicated appendicitis visits was observed (P < 0.001) compared with the control group. In addition, the age distribution of acute appendicitis during this period showed an ageing trend (P = 0.001).

Conclusion

COVID-19 infections may be more likely to progress to complicated appendicitis after an episode of appendicitis, even if they have been cured for the same period of time. In addition, the proportion of elderly patients with appendicitis increased after the COVID-19 epidemic.

IMPDH2 suppression impedes cell proliferation by instigating cell cycle arrest and stimulates apoptosis in pediatric hepatoblastoma

BACKGROUND

Hepatoblastoma (HB) is the most common pediatric liver tumor, presenting significant therapeutic challenges due to its high rates of recurrence and metastasis. While Inosine Monophosphate Dehydrogenase 2(IMPDH2) has been associated with cancer progression, its specific role and clinical implications in HB have not been fully elucidated.

METHODS

This study utilized Quantitative Real-Time Polymerase Chain Reaction (qRT-PCR) and Tissue Microarray (TMA) for validation. Following this, IMPDH2 was suppressed, and a series of in vitro assays were conducted. Flow cytometry was employed to assess apoptosis and cell cycle arrest. Additionally, the study explored the synergistic therapeutic effects of mycophenolate mofetil (MMF) and doxorubicin (DOX) on HB cell lines.

RESULTS

The study identified a marked overexpression of IMPDH2 in HB tissues, which was strongly correlated with reduced Overall Survival (OS) and Event-Free Survival (EFS). IMPDH2 upregulation was also found to be associated with key clinical-pathological features, including pre-chemotherapy alpha-fetoprotein (AFP) levels, presence of preoperative metastasis, and the pre-treatment extent of tumor (PRETEXT) staging system. Knockdown of IMPDH2 significantly inhibited HB cell proliferation and tumorigenicity, inducing cell cycle arrest at the G0/G1 phase. Notably, the combination of MMF, identified as a specific IMPDH2 inhibitor, with DOX, substantially enhanced the therapeutic response.

CONCLUSION

The overexpression of IMPDH2 was closely linked to adverse outcomes in HB patients and appeared to accelerate cell cycle progression. These findings suggest that IMPDH2 may serve as a valuable prognostic indicator and a potential therapeutic target for HB.

IMPACT

The present study unveiled a significant overexpression of inosine monophosphate dehydrogenase 2 (IMPDH2) in hepatoblastoma (HB) tissues, particularly in association with metastasis and recurrence of the disease. The pronounced upregulation of IMPDH2 was found to be intimately correlated with adverse outcomes in HB patients. This overexpression appears to accelerate the progression of the cell cycle, suggesting that IMPDH2 may serve as a promising candidate for both a prognostic marker and a therapeutic target in the context of HB.

Safety and antibody response of the BNT162b2 SARS-CoV-2 vaccine in children aged 5-11 years with underlying diseases: A prospective observational study

BACKGROUND

Data on the safety and antibody response of the BNT162b2 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccine in children aged 5-11 years with underlying diseases are limited. Thus, our study aimed to address this gap.

METHODS

This prospective observational study investigated the antibody titers for SARS-CoV-2 spike protein receptor-binding domain (S-IgG) and nucleocapsid protein (N-IgG) in patients aged 5-11 years with chronic underlying diseases following two doses of BNT162b2. Additionally, a questionnaire was used to assess adverse events (AEs) arising within 7 days after each dose. Data on severe AEs arising within 28 days after each dose were extracted from the patients' electronic medical records.

RESULTS

Among 122 patients, 24.6% (30/122) were immunocompromised. Furthermore, 79 patients experienced at least one AE following vaccination, but all recovered without sequelae, including one severe case after the first dose. The seropositivity rate after the second dose was 99.1% (116/117). Excluding 19 N-IgG-positive patients, the geometric mean antibody titer (GMT) was significantly higher in immunocompetent patients than in immunocompromised patients (1496 U/mL [95% confidence interval 1199-1862] vs. 472 U/mL [200-1119], p = 0.035). Additionally, the GMT of S-IgG was higher in N-IgG-positive patients than in N-IgG-negative patients (8203 [5847-11482] U/mL vs. 1127 [855-1486] U/mL, p < 0.001).

CONCLUSIONS

BNT162b2 is acceptably safe and immunogenic for children aged 5-11 years with underlying diseases. Although seroconversion was satisfactory in immunocompromised patients, the titers were lower than in immunocompetent patients.

A Comprehensive Review on Comparative Analysis of Operative Efficiency and Postoperative Recovery in Robotic Versus Laparoscopic Hepatectomy

Minimally invasive liver surgery, particularly hepatectomy, has evolved significantly with the advent of laparoscopic and robotic techniques. These approaches offer potential benefits over traditional open surgery, including reduced postoperative pain, shorter hospital stays, faster recovery, and improved cosmetic outcomes. This comprehensive review aims to compare the operative efficiency and postoperative recovery outcomes of robotic and laparoscopic hepatectomy. It seeks to provide an in-depth analysis of the advantages and limitations of each technique, assess their cost-effectiveness, and explore emerging trends and future directions in minimally invasive liver surgery. A comprehensive literature search was conducted to identify studies comparing robotic and laparoscopic hepatectomy. The review includes an analysis of operative time, intraoperative blood loss, conversion rates, postoperative pain, length of hospital stay, complication rates, oncological outcomes, and overall cost. Additionally, advancements in technology and future research directions were explored to provide a comprehensive overview of the current landscape and future potential of these surgical techniques. Both robotic and laparoscopic hepatectomy have demonstrated comparable outcomes in terms of oncological safety and effectiveness. However, robotic hepatectomy offers advantages in terms of precision and dexterity, particularly in complex cases, due to its advanced visualization and instrumentation. Laparoscopic hepatectomy, while associated with shorter operative times and lower costs, is limited by technical challenges, especially in major liver resections. The review also highlights the increasing adoption of robotic systems, despite their higher costs and the need for specialized training. Robotic and laparoscopic hepatectomy are both viable options for minimally invasive liver surgery, each with distinct advantages and limitations. The choice between the two should be based on patient-specific factors, the complexity of the procedure, and the surgeon's expertise. Ongoing advancements in technology, including the integration of artificial intelligence and augmented reality, are expected to further refine these techniques, enhancing their efficacy and accessibility. Future research should focus on large-scale, multicenter trials to provide more definitive comparisons and guide clinical decision-making.

Artificial intelligence and liver transplantation: looking inside the Pandora’s box

Artificial intelligence (AI) is the discipline of computer science dedicated to processing a large amount of throughput data and is based on algorithms that can rationalize increasingly complex tasks and ultimately reproduce human intelligence. It has been speculated for clinical uses in liver transplantation (LT) for several years, but its application remains incipient worldwide. Therefore, the recent advancements of digital and robotic tools in daily medical practice make the modern environment propitious to its proper implementation. Nevertheless, it is noteworthy that this technology has significant limitations: (i) its unconditional dependence on a pre-established reliable and extensive database; (ii) the potential impact on independent medical decision-making; and (iii) a major economic and environmental burden. So, despite its seducing and flawless simplicity features, AI emerges as a new “Pandora’s box” that should be carefully understood and used under the light of ethical principles to improve clinical outcomes, promote medical and para-medical working conditions, and increase patient safety and access to medical care. The present work aims to review literature data supporting AI implementation on this basis.

Regulatory B Cells Expressing Granzyme B from Tolerant Renal Transplant Patients: Highly Differentiated B Cells with a Unique Pathway with a Specific Regulatory Profile and Strong Interactions with Immune System Cells

The aim of our study was to determine whether granzyme B-expressing regulatory B cells (GZMB+ B cells) are enriched in the blood of transplant patients with renal graft tolerance. To achieve this goal, we analysed two single-cell RNA sequencing (scRNAseq) datasets: (1) peripheral blood mononuclear cells (PBMCs), including GZMB+ B cells from renal transplant patients, i.e., patients with stable graft function on conventional immunosuppressive treatment (STA, n = 3), drug-free tolerant patients (TOL, n = 3), and patients with antibody-mediated rejection (ABMR, n = 3), and (2) ex-vivo-induced GZMB+ B cells from these groups. In the patient PBMCs, we first showed that natural GZMB+ B cells were enriched in genes specific to Natural Killer (NK) cells (such as NKG7 and KLRD1) and regulatory B cells (such as GZMB, IL10, and CCL4). We performed a pseudotemporal trajectory analysis of natural GZMB+ B cells and showed that they were highly differentiated B cells with a trajectory that is very different from that of conventional memory B cells and linked to the transcription factor KLF13. By specifically analysing GZMB+ natural B cells in TOLs, we found that these cells had a very specific transcriptomic profile associated with a reduction in the expression of HLA molecules, apoptosis, and the inflammatory response (in general) in the blood and that this signature was conserved after ex vivo induction, with the induction of genes associated with migration processes, such as CCR7, CCL3, or CCL4. An analysis of receptor/ligand interactions between these GZMB+/- natural B cells and all of the immune cells present in PBMCs also demonstrated that GZMB+ B cells were the B cells that carried the most ligands and had the most interactions with other immune cells, particularly in tolerant patients. Finally, we showed that these GZMB+ B cells were able to infiltrate the graft under inflammatory conditions, thus suggesting that they can act in locations where immune events occur.

Colon signet-ring cell carcinoma with chylous ascites caused by immunosuppressants following liver transplantation: A case report

BACKGROUND

Chylous ascites is caused by disruption of the lymphatic system, which is characterized by the accumulation of a turbid fluid containing high levels of triglycerides within the abdominal cavity. The two most common causes are cirrhosis and tuberculosis, and colon signer ring cell carcinoma (SRCC) due to the use of immunosuppressants is extremely rare in cirrhotic patients after liver transplantation, making it prone to misdiagnosis and missed diagnosis.

CASE SUMMARY

A 52-year-old man who underwent liver transplantation and was administered with immunosuppressants for 8 months was admitted with a 3-month history of progressive abdominal distention. Initially, based on lymphoscintigraphy and lymphangiography, lymphatic obstruction was considered, and cystellar chyli decompression with band lysis and external membrane stripping of the lymphatic duct was performed. However, his abdominal distention was persistent without resolution. Abdominal paracentesis revealed allogenic cells in the ascites, and immunohistochemistry analysis revealed adenocarcinoma cells with phenotypic features suggestive of a gastrointestinal origin. Gastrointestinal endoscopy was performed, and biopsy showed atypical signet ring cells in the ileocecal valve. The patient eventually died after a three-month follow-up due to progression of the tumor.

CONCLUSION

Colon SRCC, caused by immunosuppressants, is an unusual but un-neglected cause of chylous ascites.

Development of a diagnostic model for biliary atresia based on MMP7 and serological tests using machine learning

OBJECTIVE

To develop a machine learning diagnostic model based on MMP7 and other serological testing indicators for early and efficient diagnosis of biliary atresia (BA).

METHODS

A retrospective analysis was conducted on patient information from those hospitalized for pathological jaundice at Beijing Children's Hospital between January 1, 2019, and December 31, 2023. Patients with serum MMP7, liver stiffness measurements, and other routine serological tests were included in the study. Six machine learning models were constructed, including logistic regression (LR), random forest (RF), decision tree (DET), support vector machine classifier (SVC), neural network (MLP), and extreme gradient boosting (XGBoost), to diagnose BA. The area under the receiver operating characteristic curve was used to evaluate the diagnostic efficacy of the various models.

RESULTS

A total of 98 patients were included in the study, comprising 64 BA patients and 34 patients with other cholestatic liver diseases. Among the six machine learning models, the XGBoost algorithm model and RF algorithm model achieved the best predictive performance, with an AUROC of nearly 100% in both the training and validation sets. In the training set, these two algorithm models achieved an accuracy, precision, recall, F1 score, and AUROC of 1. Through model interpretation analysis, serum MMP7 levels, serum GGT levels, and acholic stools were identified as the most important indicators for diagnosing BA. The nomogram constructed based on the XGBoost algorithm model also demonstrated convenient and efficient diagnostic efficacy.

CONCLUSION

Machine learning models, especially the XGBoost algorithm and RF algorithm models, constructed based on preoperative serum MMP7 and serological tests can diagnose BA more efficiently and accurately. The most important influencing factors for diagnosis are serum MMP7, serum GGT, and acholic stools.

Anterior quadratus lumborum block provided superior pain control and reduced opioid consumption in kidney transplantation: A randomized controlled trial

BACKGROUND

The research aimed to assess the effectiveness of inside-out anterior quadratus lumborum (QL3) block and local wound infiltration in managing postoperative pain and total morphine dosage following kidney transplantation.

METHODS

In this prospective, randomized, double-blind study; 46 end-stage renal disease patients undergoing kidney transplantation were randomly allocated into 2 groups: a QL group (n = 23) receiving 20 mL of 0.25% bupivacaine using the ultrasound-assisted inside-out technique before wound closure, while the local wound infiltration (LA) group (n = 23) receiving the same dose around the surgical wound and drain at the time of skin closure. The primary outcome measure was the numerical pain rating scale, with secondary outcomes including amount of morphine consumption at various postoperative time points (2nd, 4th, 6th, 12th, 18th and 24th hours).

RESULTS

Patients in the QL group had significantly lower numerical rating scale scores at the 2nd and 4th hours, both at rest and during movement (P < .05). Although pain scores at rest and during movement at later time points were lower in the QL group compared to the LA group, these differences were not statistically significant. Cumulative morphine consumption at postoperative 4th, 6th, 12th, 18th and 24th hours was significantly lower in the QL group (P < .05). No patients experienced complications from the QL3 block.

CONCLUSION

Ultrasound-assisted inside-out QL3 block significantly reduced postoperative pain levels at the 2nd and 4th hours, both at rest and during movement, and led to a reduction in cumulative morphine consumption from the 4th hour postoperatively, and persisting throughout the 24-hour period.

Estimation of lifetime costs for patients receiving a transplant: the case of liver transplantation related to hepatitis B in Italy

Introduction

In Italy, post-liver transplant (LT) hepatitis B virus (HBV) reinfection prophylaxis is frequently based on a combined regimen of anti-HBV immunoglobulin (HBIG) and oral antivirals. However, little information is available at the national level on the cost of LT and the contribution of HBV prophylaxis. This study aimed to quantify the direct healthcare cost for adult patients undergoing LT for HBV-related disease over a lifetime horizon and from the perspective of a National Healthcare Service.

Methods

A pharmaco-economic model was implemented with a 4-tiered approach consisting of 1) preliminary literature research to define the research question; 2) pragmatic literature review to retrieve existing information and inform the model; 3) micro-simulated patient cycles; and 4) validation from a panel of national experts.

Results

The average lifetime healthcare cost of LT for HBV-related disease was €395,986. The greatest cost drivers were post-transplant end-stage renal failure (31.9% of the total), immunosuppression (20.6%), and acute transplant phase (15.8%). HBV reinfection prophylaxis with HBIG and antivirals accounted for 12.4% and 6.4% of the total cost, respectively; however, lifetime HBIG prophylaxis was only associated with a 6.6% increase (~€422 k). Various sensitivity analyses have shown that discount rates have the greatest impact on total costs.

Conclusion

This analysis showed that the burden of LT due to HBV is not only clinical but also economic.

Randomized Controlled Trial of Enhanced Recovery After Surgery Protocols in Live Kidney Donors: ERASKT Study

Background

Enhanced recovery after surgery (ERAS) pathways represent a comprehensive approach to optimizing perioperative management and reducing hospital stay and cost. In living donor kidney transplantation, key impediments to postoperative discharge include pain, and opioid associated complications such as nausea, vomiting, and the return of gastrointestinal function.

Methods

In this randomized controlled trial, living kidney transplantation donors were assigned to either the ERAS or control group. The ERAS group patients received 15 preoperative, 17 intraoperative, 19 postoperative element intervention. The control group received standard care. The ERAS group received a multimodal opioid sparing pain management including an intraoperative transverse abdominis plane block. Our primary outcome measure was postoperative opioid consumption. The secondary outcome measures were postoperative pain scores, first oral intake, and hospital length of stay.

Results

There were no significant differences in demographics between the 2 groups. The ERAS group had a statistically significant reduction in total postoperative opioid consumption calculated in intravenous morphine equivalents (24.2 ± 20.2 versus 71 ± 39.5 mg, P < 0.01). Postoperative pain scores were significantly lower (P < 0.001) from 1 h postoperatively to 48 h. Surgical time was 45 min shorter (P = 0.037). Intraoperative PlasmaLyte administration was lower (PlasmaLyte: 1444 ± 907 versus 2168 ± 1347 mL, P = 0.049). Time to tolerating regular diet was shorter by 2 h (P < 0.008), and length of hospital stay was decreased by 10.1 h.

Conclusions

The ERAS group experienced superior postoperative analgesia and a shorter length of hospital stay compared with controls.

Liver Graft Machine Perfusion: From History Perspective to Modern Approaches in Transplant Surgery

The shortage of donor organs remains an unresolved issue in livertransplantation worldwide. Consequently, strategies for expanding the donor pool are currently being developed. Donors meeting extended criteria undergo thorough evaluation, as livers obtained from marginal donors yield poorer outcomes in recipients, including exacerbated reperfusion injury, acute kidney injury, early graft dysfunction, and primary nonfunctioning graft. However, the implementation of machine perfusion has shown excellent potential in preserving donor livers and improving their characteristics to achieve better outcomes for recipients. In this review, we analyzed the global experience of using machine perfusion in livertransplantation through the history ofthe development ofthis method to the latest trends and possibilities for increasing the number of liver transplants.

Low-dose Interleukin-2 Therapy: Fine-tuning Treg in Solid Organ Transplantation?

Regulatory T cells (Treg), a subset of CD4 + T cells, are potent regulators of immune reactions, which have been shown to be a promising therapeutic alternative to toxic immunosuppressive drugs. Data support the utility of Treg in managing immunopathologies, including solid organ transplant rejection, graft-versus-host disease, and autoimmune disorders. Notably, reports suggest that interleukin-2 (IL-2) is critical to survival of Treg, which constitutively express high levels of CD25, that is, the IL-2 receptor α-chain, and are exquisitely sensitive to IL-2, even at very low concentrations in contrast to effector T cells, which only upregulate IL-2 receptor α-chain on activation. This has led to the notion of using low doses of exogenous IL-2 therapeutically to modulate the immune system, specifically Treg numbers and function. Here, we summarize developments of clinical experience with low-dose IL-2 (LD-IL-2) as a therapeutic agent. So far, no clinical data are available to support the therapeutic use of LD-IL-2 therapy in the solid organ transplant setting. For the latter, fine-tuning by biotechnological approaches may be needed because of the narrow therapeutic window and off-target effects of LD-IL-2 therapy and so to realize the therapeutic potential of this molecule.

Sequential immunotherapy: towards cures for autoimmunity

Despite major progress in the treatment of autoimmune diseases in the past two decades, most therapies do not cure disease and can be associated with increased risk of infection through broad suppression of the immune system. However, advances in understanding the causes of autoimmune disease and clinical data from novel therapeutic modalities such as chimeric antigen receptor T cell therapies provide evidence that it may be possible to re-establish immune homeostasis and, potentially, prolong remission or even cure autoimmune diseases. Here, we propose a 'sequential immunotherapy' framework for immune system modulation to help achieve this ambitious goal. This framework encompasses three steps: controlling inflammation; resetting the immune system through elimination of pathogenic immune memory cells; and promoting and maintaining immune homeostasis via immune regulatory agents and tissue repair. We discuss existing drugs and those in development for each of the three steps. We also highlight the importance of causal human biology in identifying and prioritizing novel immunotherapeutic strategies as well as informing their application in specific patient subsets, enabling precision medicine approaches that have the potential to transform clinical care.

Recombinant human IL-37 attenuates acute cardiac allograft rejection in mice

BACKGROUND

Allograft rejection remains a major obstacle to long-term graft survival. Although previous studies have demonstrated that IL-37 exhibited significant immunomodulatory effects in various diseases, research on its role in solid organ transplantation has not been fully elucidated. In this study, the therapeutic effect of recombinant human IL-37 (rhIL-37) was evaluated in a mouse cardiac allotransplantation model.

METHODS

The C57BL/6 recipients mouse receiving BALB/c donor hearts were treated with rhIL-37. Graft pathological and immunohistology changes, immune cell populations, and cytokine profiles were analyzed on postoperative day (POD) 7. The proliferative capacities of Th1, Th17, and Treg subpopulations were assessed in vitro. Furthermore, the role of the p-mTOR pathway in rhIL-37-induced CD4+ cell inhibition was also elucidated.

RESULTS

Compared to untreated groups, treatment of rhIL-37 achieved long-term cardiac allograft survival and effectively alleviated allograft rejection indicated by markedly reduced infiltration of CD4+ and CD11c+ cells and ameliorated graft pathological changes. rhIL-37 displayed significantly less splenic populations of Th1 and Th17 cells, as well as matured dendritic cells. The percentages of Tregs in splenocytes were significantly increased in the therapy group. Furthermore, rhIL-37 markedly decreased the levels of TNF-α and IFN-γ, but increased the level of IL-10 in the recipients. In addition, rhIL-37 inhibited the expression of p-mTOR in CD4+ cells of splenocytes. In vitro, similar to the in vivo experiments, rhIL-37 caused a decrease in the proportion of Th1 and Th17, as well as an increase in the proportion of Treg and a reduction in p-mTOR expression in CD4+ cells.

CONCLUSIONS

We demonstrated that rhIL-37 effectively suppress acute rejection and induce long-term allograft acceptance. The results highlight that IL-37 could be novel and promising candidate for prevention of allograft rejection.

Graft reduction in adult liver transplantation: indications, techniques, and outcomes

PURPOSE

Graft reduction can be a patient's graft-saving option to avoid large-for-size (LFS) syndrome. This study aimed to summarize the literature on graft reduction in adult liver transplantation and to demonstrate the technique of H67 graft hepatectomy.

METHODS

The technique, shown in a didactical video, entails an ex situ posterior sectionectomy under hypothermic perfusion. The right hepatic vein is identified, and the transection line follows the right hepatic fissure. The Glissonean pedicles are ligated during parenchymal transection.

RESULTS

A narrative review of the literature yielded 7 studies. A total of 15 liver grafts were reduced in adult liver transplantations. Most of the reductions were ex situ (11/15 [73.3%]). Graft reduction entailed an H67 sectionectomy in 10 cases and an H23 sectionectomy in 1 case. In situ reduction included 1 right hepatectomy (H5678), 2 H67 sectionectomies, and 1 H23 left lateral sectionectomy. The duration of the ex situ reduction averaged 56 minutes (median: 40.5 minutes; IQR, 33.0-130.0), and the graft weight-to-recipient weight ratio decreased from 3.57% ± 0.40% to 2.70% ± 0.50% after graft reduction. The average cold ischemia time was 390 minutes (IQR, 230-570). There was no liver retransplantation.

CONCLUSION

Graft reduction in adult liver transplantation may be necessary to avoid LFS syndrome. Ex-situ H67 posterior sectionectomy represents the easiest graft reduction hepatectomy and is able to minimize the occurrence of graft compression while leaving enough functional liver parenchyma.

Pediatric hepatocellular carcinoma in a 14-year-old boy: A rare case report

ABSTRACT

Hepatocellular carcinoma (HCC) is much rarer in children and adolescents in comparison to adults with an incidence of 0.7/1,000,000 per year. Hepatitis B virus, a known carcinogen increases the chances of HCC at a young age. Very few case reports of HCC developing in HBV-positive male children have been published.We present a case of a 14-year-old Hepatitis B-positive boy who presented with abdominal distension and jaundice. Contrast enhanced computerized tomography (CECT) whole abdomen suggested a diagnosis of multinodular HCC with no evidence of metastasis on FDG PET-CECT. Histopathology with immunohistochemistry confirmed the diagnosis of moderately differentiated HCC.Clinical presentation of HCC in children is similar to adults. Viral hepatitis, metabolic disorders, and male gender increase the risk of HCC. In our case, boy never had any prior history of jaundice, abdominal pain/distension, or any other illness suggestive of liver dysfunction. When the boy was found to be HBV positive, his mother was also screened and turned out to be Hepatitis B virus positive. Histopathology along with a panel of immunohistochemical markers clinched the final diagnosis.

The Perceived Impact of COVID-19 on Graduate Medical Education and Recommendations for Bridging the Educational Gap

INTRODUCTION

COVID-19 generated a system-wide shock causing an unbalanced equilibrium between producing adequately trained physicians and meeting extraordinary operational needs. Previous studies report the experience of surgical residents during COVID-19 at a regional level. This study measures the learning losses related with the redeployment of highly specialized medical professionals to the care of COVID-19 patients, while we systematically investigate proposed remedial strategies.

METHODS

We administered an online cross-sectional survey in 67 countries capturing training inputs (i.e., surgeries and seminars residents participated in) before and during the pandemic and retrieved residents' expected learning outputs, career prospects and recommended remedial measures for learning losses. We compared responses of residents working in (treatment group) and out (control group) of hospitals with COVID-19 patients.

RESULTS

The analysis included 432 plastic surgery residents who were in training during the pandemic. Most of the learning losses were found in COVID-19 hospitals with 37% and 16% loss of surgeries and seminars, respectively, per week. Moreover, 74%, 44%, and 55% of residents expected their surgical skill, scientific knowledge, and overall competence, respectively, to be lower than those of residents who graduated before COVID. Residents in COVID-19 hospitals reported participating in significantly (P < 0.001) fewer surgeries and having significantly (P < 0.001) lower surgical skill relative to those not in COVID-19 hospitals.

CONCLUSIONS

The perceived lower competence and the fall-off in surgical skill and scientific knowledge among future surgeons suggest that health-care systems globally may have limited capacity to perform specialized and costly procedures in the future.

Transplantation in the Pandemic Era: Perspectives on the Utilization of COVID-19 Positive Organs

BACKGROUND

At early stages of the pandemic, most organ procurements organizations considered COVID-19 infected donors to be ineligible for organ donation. The aim of this survey is to describe the current practices of the utilization of COVID-19 positive organs donors among American Society of Transplant Surgeons (ASTS) members.

METHODS

An anonymous 40-question redcap survey was emailed to ASTS members from June to August 2022.

RESULTS

One hundred forty-nine surveys from 10 countries were included for analysis. The majority of the responders were men (66.7%) from North America (95%) and identified as transplant surgeons (68.5%). Most work at academic institutions (76.5%). Almost all responders (94%) were willing to accept an organ from a donor with a history of COVID-19 who tested negative at the time of donation, however, there was no consensus on the length of time after the disease was resolved. Approximately 70% indicated they accept organs from asymptomatic donors with active disease. Only 32 responders indicated they would accept an organ from an individual with a history of "severe" COVID-19 infection and less than one third of the responders would accept an organ from a donor who died from COVID-19 infection. Interestingly, 80% indicated they have protocols at their institution to guide the acceptance of such organs.

DISCUSSION

Despite new evidence that the transmission of COVID-19 in non-lung organs is extremely rare, the results of this survey suggest significant heterogeneity in practice and perceptions of the use of COVID-19 positive organs across international centers. We suggest that the implementation of a standardized protocol is of paramount importance to continue safe transplant activity.

Cold ischemia time in liver transplantation: An overview

The standard approach to organ preservation in liver transplantation is by static cold storage and the time between the cross-clamping of a graft in a donor and its reperfusion in the recipient is defined as cold ischemia time (CIT). This simple definition reveals a multifactorial time frame that depends on donor hepatectomy time, transit time, and recipient surgery time, and is one of the most important donor-related risk factors which may influence the graft and recipient's survival. Recently, the growing demand for the use of marginal liver grafts has prompted scientific exploration to analyze ischemia time factors and develop different organ preservation strategies. This review details the CIT definition and analyzes its different factors. It also explores the most recent strategies developed to implement each timestamp of CIT and to protect the graft from ischemic injury.

Advancements in Predictive Tools for Primary Graft Dysfunction in Liver Transplantation: A Comprehensive Review

Orthotopic liver transplantation stands as the sole curative solution for end-stage liver disease. Nevertheless, the discrepancy between the demand and supply of grafts in transplant medicine greatly limits the success of this treatment. The increasing global shortage of organs necessitates the utilization of extended criteria donors (ECD) for liver transplantation, thereby increasing the risk of primary graft dysfunction (PGD). Primary graft dysfunction (PGD) encompasses early allograft dysfunction (EAD) and the more severe primary nonfunction (PNF), both of which stem from ischemia-reperfusion injury (IRI) and mitochondrial damage. Currently, the only effective treatment for PNF is secondary transplantation within the initial post-transplant week, and the occurrence of EAD suggests an elevated, albeit still uncertain, likelihood of retransplantation urgency. Nonetheless, the ongoing exploration of novel IRI mitigation strategies offers hope for future improvements in PGD outcomes. Establishing an intuitive and reliable tool to predict upcoming graft dysfunction is vital for early identification of high-risk patients and for making informed retransplantation decisions. Accurate diagnostics for PNF and EAD constitute essential initial steps in implementing future mitigation strategies. Recently, novel methods for PNF prediction have been developed, and several models for EAD assessments have been introduced. Here, we provide an overview of the currently scrutinized predictive tools for PNF and EAD evaluation strategies, accompanied by recommendations for future studies.

The Role of Interferon Regulatory Factors in Liver Diseases

The interferon regulatory factors (IRFs) family comprises 11 members that are involved in various biological processes such as antiviral defense, cell proliferation regulation, differentiation, and apoptosis. Recent studies have highlighted the roles of IRF1-9 in a range of liver diseases, including hepatic ischemia-reperfusion injury (IRI), alcohol-induced liver injury, Con A-induced liver injury, nonalcoholic fatty liver disease (NAFLD), cirrhosis, and hepatocellular carcinoma (HCC). IRF1 is involved in the progression of hepatic IRI through signaling pathways such as PIAS1/NFATc1/HDAC1/IRF1/p38 MAPK and IRF1/JNK. The regulation of downstream IL-12, IL-15, p21, p38, HMGB1, JNK, Beclin1, β-catenin, caspase 3, caspase 8, IFN-γ, IFN-β and other genes are involved in the progression of hepatic IRI, and in the development of HCC through the regulation of PD-L1, IL-6, IL-8, CXCL1, CXCL10, and CXCR3. In addition, IRF3-PPP2R1B and IRF4-FSTL1-DIP2A/CD14 pathways are involved in the development of NAFLD. Other members of the IRF family also play moderately important functions in different liver diseases. Therefore, given the significance of IRFs in liver diseases and the lack of a comprehensive compilation of their molecular mechanisms in different liver diseases, this review is dedicated to exploring the molecular mechanisms of IRFs in various liver diseases.

Human Amniotic Epithelial Cell Transplantation is Safe and Well Tolerated in Patients with Compensated Cirrhosis: A First-in-Human Trial

Placenta-derived human amniotic epithelial cells (hAEC) exhibit anti-inflammatory and anti-fibrotic effects in cirrhosis models. We conducted a first-in-human phase I clinical trial to assess the safety and tolerability of hAEC in adults with compensated cirrhosis. We examined increasing and repeated doses of hAEC in 9 patients in 3 cohorts. Cohort 1 patients received 0.5 × 106/kg hAEC in one IV infusion. Cohort 2 patients received 1 × 106/kg hAEC in one IV infusion. The patients in cohort 3 received 1 × 106/kg hAEC on days 0 and 28. Here, we report follow-up to post-infusion day 56 (D56), during which no serious adverse events occurred. Six patients experienced no study-related adverse events, while 3 patients reported mild (grade 1) headaches that were possibly infusion-related. A transient decrease in serum platelet count occurred in all patients, which returned to baseline screening values by day 5. FIB-4 values to assess fibrosis were significantly lower at D56. Although not statistically significant, serum AST levels and liver stiffness measurements at D56 were lower than those at baseline. The hepatic venous pressure gradient, a measure of portal hypertension, declined in 4 patients, did not change in 3 patients, and increased in 2 patients. In conclusion, intravenous infusion of allogeneic hAEC in patients with compensated cirrhosis at the doses used in this study was safe and well tolerated, with no difference observed between 1 and 2 doses. Decreased hepatic inflammation, liver stiffness, and portal hypertension support larger studies aimed at identifying patients who may benefit from this therapy. Clinical Trial registration: The trial was prospectively entered on the Australian Clinical Trials Registry (ANZCTR12616000437460).

Heideveld-Chevalking A, Kristensen K, Huibertina Davida van Tuyl L, Põlluste K, Weynants C, Garel P, Sousa P, Talving P, Marx D, Žaludek A, Romero E, Rodríguez A, Orrego C, for the SAFEST consortium. Improving quality and patient safety in surgical care through standardisation and harmonisation of perioperative care (SAFEST project): A research protocol for a mixed methods study

INTRODUCTION

Adverse events in health care affect 8% to 12% of patients admitted to hospitals in the European Union (EU), with surgical adverse events being the most common types reported.

AIM

SAFEST project aims to enhance perioperative care quality and patient safety by establishing and implementing widely supported evidence-based perioperative patient safety practices to reduce surgical adverse events.

METHODS

We will conduct a mixed-methods hybrid type III implementation study supporting the development and adoption of evidence-based practices through a Quality Improvement Learning Collaborative (QILC) in co-creation with stakeholders. The project will be conducted in 10 hospitals and related healthcare facilities of 5 European countries. We will assess the level of adherence to the standardised practices, as well as surgical complications incidence, patient-reported outcomes, contextual factors influencing the implementation of the patient safety practices, and sustainability. The project will consist of six components: 1) Development of patient safety standardised practices in perioperative care; 2) Guided self-evaluation of the standardised practices; 3) Identification of priorities and actions plans; 4) Implementation of a QILC strategy; 5) Evaluation of the strategy effectiveness; 6) Patient empowerment for patient safety. Sustainability of the project will be ensured by systematic assessment of sustainability factors and business plans. Towards the end of the project, a call for participation will be launched to allow other hospitals to conduct the self-evaluation of the standardized practices.

DISCUSSION

The SAFEST project will promote patient safety standardized practices in the continuum of care for adult patients undergoing surgery. This project will result in a broad implementation of evidence-based practices for perioperative care, spanning from the care provided before hospital admission to post-operative recovery at home or outpatient facilities. Different implementation challenges will be faced in the application of the evidence-based practices, which will be mitigated by developing context-specific implementation strategies. Results will be disseminated in peer-reviewed publications and will be available in an online platform.

HOPE Mitigates Ischemia-Reperfusion Injury in Ex-Situ Split Grafts: A Comparative Study With Living Donation in Pediatric Liver Transplantation

Optimizing graft preservation is key for ex-situ split grafts in pediatric liver transplantation (PSLT). Hypothermic Oxygenated Perfusion (HOPE) improves ischemia-reperfusion injury (IRI) and post-operative outcomes in adult LT. This study compares the use of HOPE in ex-situ partial grafts to static cold storage ex-situ partial grafts (SCS-Split) and to the gold standard living donor liver transplantation (LDLT). All consecutive HOPE-Split, SCS-Split and LDLT performed between 2018-2023 for pediatric recipients were included. Post-reperfusion syndrome (PRS, drop ≥30% in systolic arterial pressure) and reperfusion biopsies served as early indicators of IRI. We included 47 pediatric recipients (15 HOPE-Split, 17 SCS-Split, and 15 LDLT). In comparison to SCS-Split, HOPE-Split had a significantly shorter cold ischemia time (CIT) (470min vs. 538 min; p =0.02), lower PRS rates (13.3% vs. 47.1%; p = 0.04) and a lower IRI score (3 vs. 4; p = 0.03). The overall IRI score (3 vs. 3; p = 0.28) and PRS (13.3% vs. 13.3%; p = 1) after HOPE-Split were comparable to LDLT, despite a longer CIT (470 min vs. 117 min; p < 0.001). Surgical complications, one-year graft, and recipient survival did not differ among the groups. In conclusion, HOPE-Split mitigates early IRI in pediatric recipients in comparison to SCS-Split, approaching the gold standard of LDLT.

Utilization of Hepatitis B viremic donors (NAT+) leads to improved kidney transplant access for older adult recipients with little to no wait time

BACKGROUND

Though the use of Hepatitis B viremic (HBV) donor kidneys may be a safe alternative to improve access to transplantation, there has not been wide acceptance of this practice. In this study, we determined the safety and effectiveness of HBV NAT (+) donor kidneys in a protocolized manner in an older adult population.

METHODS

Over a 3-year period, 16 decreased donor kidney transplants were performed with HBV NAT+ kidneys. Recipients of HBV NAT+ kidneys were treated with entecavir started pre-operatively and continued for 52 weeks.

RESULTS

HBV NAT+ kidneys were preferentially used in older (68 ± 5 vs. 64 ± 9 years; p = .01) recipients with less dialysis time (93.8% < 5 years vs. 67% <5 years; p = .03). In this cohort, 3/16 had detectable HBV PCR 1-week post-transplant, but all were negative at 9- and 12-months. Calculated estimated glomerular filtration rate (eGFR) was slightly decreased 12-months post-transplant. Post-transplant outcomes in an age-matched cohort showed no difference in rates of delayed graft function, readmission within 30 days, and graft loss or death within 6 months of transplant (p > .05).

CONCLUSION

Transplants with HBV NAT+ donor kidneys in a pre-emptive treatment protocol allow for increased safe access to transplantation in older adult recipients with little or no dialysis time.

Normothermic Liver Machine Perfusion and Successful Transplantation of Split Liver Grafts: From Proof of Concept to Clinical Implementation

BACKGROUND

Normothermic liver machine perfusion (NLMP) is advancing the field of liver transplantation (LT). Beyond improved preservation and organ assessment, NLMP helps to increase organ utilization. We herein address the feasibility and merit of NLMP in split liver transplantation (SLT) to postpone the transplantation of the second split graft to the following day.

METHODS

We analyzed the perfusion characteristics and outcomes of all consecutive adult recipients who underwent SLT following NLMP from February 1, 2018, to June 30, 2023. The primary endpoint was 90-d graft and patient survival. Secondary endpoints were posttransplant complications and 90-d morbidity.

RESULTS

Three right and 3 extended right SLT following NLMP have been performed. NLMP was uneventful in all cases. Perfusion characteristics differed according to graft volume. Mean perfusion time was 17:00 h (±05:13) and bile production ranged between 8 and 21 mL/h. All split grafts fulfilled predefined center viability criteria during NLMP and were transplanted on the following day. The 90-d graft and patient survival rate was 100%. Three patients (50%) required an early relaparotomy, and 2 patients (33.3%) developed biliary complications. The 90-d morbidity as recorded by the comprehensive complication index was 62.7 (±24.7).

CONCLUSIONS

NLMP of split liver grafts is technically feasible and safe. Through prolongation of preservation time, NLMP allows to safely postpone transplantation of the second split liver graft to the next day.

Normothermic machine perfusion for liver transplantation: current state and future directions

PURPOSE OF REVIEW

The number of patients on the liver transplant waitlist continues to grow and far exceeds the number of livers available for transplantation. Normothermic machine perfusion (NMP) allows for ex-vivo perfusion under physiologic conditions with the potential to significantly increase organ yield and expand the donor pool.

RECENT FINDINGS

Several studies have found increased utilization of donation after cardiac death and extended criteria brain-dead donor livers with implementation of NMP, largely due to the ability to perform viability testing during machine perfusion. Recently, proposed viability criteria include lactate clearance, maintenance of perfusate pH more than 7.2, ALT less than 6000 u/l, evidence of glucose metabolism and bile production. Optimization of liver grafts during NMP is an active area of research and includes interventions for defatting steatotic livers, preventing ischemic cholangiopathy and rejection, and minimizing ischemia reperfusion injury.

SUMMARY

NMP has resulted in increased organ utilization from marginal donors with acceptable outcomes. The added flexibility of prolonged organ storage times has the potential to improve time constraints and transplant logistics. Further research to determine ideal viability criteria and investigate ways to optimize marginal and otherwise nontransplantable liver grafts during NMP is warranted.

"Water or not water: That is the question." Analysis of costs and consumption of the operating theaters in a greener perspective

OBJECTIVE

To compare the amounts of water and plastic used in surgical hand washing with medicated soaps and with alcohol-based products and to compare costs and consumption in a year, based on scheduled surgical activity.

METHOD

This retrospective study was carried out at Udine's Gynecology Operating Block from October to November 2022. We estimated the average amount of water with a graduated cylinder and the total cost of water usage based on euros/m3 indicated by the supplier; for each antiseptic agent we collected the data relevant to wash time, amount of water and product used per scrub, number of handscrubs made with every 500 mL bottle and cost of a single bottle. We put data into two hypothetical contexts, namely WHO guidelines and manufacturers' recommendations. Data were subjected to statistical analysis.

RESULTS

The daily amount of water using povidone-iodine, chlorhexidine-gluconate and alcohol-based antiseptic agents was 187.6, 140.7 and 0 L/day (P value = 0.001), respectively; A total of 69 000 L/year of water would be saved if alcohol-based products were routinely used. A single unit of an alcohol-based product allows three times as many handscrubs as any other product (P value = 0.001) with consequent reduction in plastic packaging.

CONCLUSION

Despite the cost saving being negligible, choosing alcohol-based handrub over medicated soap handrub - on equal antiseptic efficacy grounds - could lead to a significant saving of water and plastic, thus making our operating theaters more environmentally friendly.

Universal antifungal prophylaxis effectively prevents fungal bloodstream infection in pediatric liver transplant recipients: a retrospective real-world study

OBJECTIVES

Fungal bloodstream infection (fBSI) following pediatric liver transplantation presents a significant challenge; however, there remains a paucity of guidance regarding antifungal prophylaxis in this population. This study aimed to evaluate the effectiveness of universal antifungal prophylaxis and propose a desirable strategy.

METHODS

We enrolled 604 pediatric patients who underwent liver transplantation between 2020 and 2023, including 242 patients with empirical prophylaxis and 362 patients with universal prophylaxis. Univariate and multivariate logistic regression analyses were performed to identify independent factors for fBSI.

RESULTS

Eight (2.2%) pediatric recipients in the universal prophylaxis group and 13 (5.4%) in the empirical group developed fBSI (P = 0.038). Universal prophylaxis was a protective factor (P = 0.044), while high-volume intraoperative plasma transfusion and deceased donor liver transplantation were independent risk factors for fBSI (P = 0.035 and 0.008, respectively). Universal antifungal strategy showed an increased overall survival trend after liver transplantation although without significant statistical difference (P = 0.217). Patients with fBSI had poorer survival than those without fBSI (P <0.001).

CONCLUSIONS

Universal prophylaxis strategy for fBSI in pediatrics after liver transplantation is desirable as it could markedly decrease the occurrence of fBSI. Pediatric patients with deceased donors and high-volume intraoperative transfusion should be paid more attention to preventing fBSI.

Banff 2022 Liver Group Meeting report: Monitoring long-term allograft health

The Banff Working Group on Liver Allograft Pathology met in September 2022. Participants included hepatologists, surgeons, pathologists, immunologists, and histocompatibility specialists. Presentations and discussions focused on the evaluation of long-term allograft health, including noninvasive and tissue monitoring, immunosuppression optimization, and long-term structural changes. Potential revision of the rejection classification scheme to better accommodate and communicate late T cell-mediated rejection patterns and related structural changes, such as nodular regenerative hyperplasia, were discussed. Improved stratification of long-term maintenance immunosuppression to match the heterogeneity of patient settings will be central to improving long-term patient survival. Such personalized therapeutics are in turn contingent on a better understanding and monitoring of allograft status within a rational decision-making approach, likely to be facilitated in implementation with emerging decision-support tools. Proposed revisions to rejection classification emerging from the meeting include the incorporation of interface hepatitis and fibrosis staging. These will be opened to online testing, modified accordingly, and subject to consensus discussion leading up to the next Banff conference.

Is perioperative COVID-19 really associated with worse surgical outcomes among vaccinated patients?

INTRODUCTION

During the surge of the SARS-CoV-2 pandemic, studies revealed high complication and morbidity rates following surgical procedures in COVID-19 positive patients. Anesthetic and surgical societies swiftly developed strategies to mitigate these risks, including a recommended postponement of elective surgeries for a minimum of 7 weeks post-COVID infection. Nowadays, with a predominantly vaccinated population, it has become crucial to discern the influencing factors on post-COVID morbidity and mortality and a reevaluation of the existing recommendations pertaining to elective surgery.

METHODS

A single-center case-control study was conducted, including patients who underwent surgery between November 2021 and March 2022 and met the inclusion criteria. Eighty COVID-19 positive patients were matched 1:1 with 80 controls, each undergoing an identical intervention within a 2-week time frame. The primary outcome was 30-day postoperative mortality and secondary outcome postoperative complications (respiratory and thromboembolic).

RESULTS

At the time of surgery, 88.8% of patients in the case group and 92.5% in the control group had received at least one vaccine dose. Mortality and morbidity did not show a significant difference when comparing the case and control groups (7.5% vs 6.2%, p = 0.755; 11.3% vs 8.9%, p = 0.541 respectively). In the COVID-positive group, mortality was significantly associated with age over 70 years, ASA score over III, RCRI over 1, emergency procedures, and absence of thromboembolic prophylaxis.

CONCLUSIONS

In contrast to previously reported findings, we did not observe an increased morbi-mortality in patients with perioperative COVID-19 infection. It may not be necessary to delay elective interventions, except in cases with a high-risk.

Risk of Early Postoperative Cardiovascular and Cerebrovascular Complication in Patients with Preoperative COVID-19 Undergoing Cancer Surgery

BACKGROUND

As the COVID-19 pandemic shifts to an endemic phase, an increasing proportion of patients with cancer and a preoperative history of COVID-19 will require surgery. This study aimed to assess the influence of preoperative COVID-19 on postoperative risk for major adverse cardiovascular and cerebrovascular events (MACEs) among those undergoing surgical cancer resection. Secondary objectives included determining optimal time-to-surgery guidelines based on COVID-19 severity and discerning the influence of vaccination status on MACE risk.

STUDY DESIGN

National COVID Cohort Collaborative Data Enclave, a large multi-institutional dataset, was used to identify patients that underwent surgical cancer resection between January 2020 and February 2023. Multivariate regression analysis adjusting for demographics, comorbidities, and risk of surgery was performed to evaluate risk for 30-day postoperative MACE.

RESULTS

Of 204,371 included patients, 21,313 (10.4%) patients had a history of preoperative COVID-19. History of COVID-19 was associated with an increased risk for postoperative composite MACE as well as 30-day mortality. Among patients with mild disease who did not require hospitalization, MACE risk was elevated for up to 4 weeks after infection. Postoperative MACE risk remained elevated more than 8 weeks after infection in those with moderate disease. Vaccination did not reduce risk for postoperative MACE.

CONCLUSIONS

Together, these data highlight that assessment of the severity of preoperative COVID-19 infection should be a routine component of both preoperative patient screening as well as surgical risk stratification. In addition, strategies beyond vaccination that increase patients' cardiovascular fitness and prevent COVID-19 infection are needed.

Full-left/Full-right Liver Splitting With Middle Hepatic Vein and Caval Partition During Dual Hypothermic Oxygenated Machine Perfusion

BACKGROUND

Split liver transplantation is a valuable means of mitigating organ scarcity but requires significant surgical and logistical effort. Ex vivo splitting is associated with prolonged cold ischemia, with potentially negative effects on organ viability. Machine perfusion can mitigate the effects of ischemia-reperfusion injury by restoring cellular energy and improving outcomes.

METHODS

We describe a novel technique of full-left/full-right liver splitting, with splitting and reconstruction of the vena cava and middle hepatic vein, with dual arterial and portal hypothermic oxygenated machine perfusion. The accompanying video depicts the main surgical passages, notably the splitting of the vena cava and middle hepatic vein, the parenchymal transection, and the venous reconstruction.

RESULTS

The left graft was allocated to a pediatric patient having methylmalonic aciduria, whereas the right graft was allocated to an adult patient affected by hepatocellular carcinoma and cirrhosis.

CONCLUSIONS

This technique allows ex situ splitting, counterbalancing prolonged ischemia with the positive effects of hypothermic oxygenated machine perfusion on graft viability. The venous outflow is preserved, safeguarding both grafts from venous congestion; all reconstructions can be performed ex situ, minimizing warm ischemia. Moreover, there is no need for highly skilled surgeons to reach the donor hospital, thereby simplifying logistical aspects.

Recurrent rejections after liver transplantation for hepatocellular carcinoma with stem cell features in an adult patient

Patients with hepatoblastoma featuring carcinoma characteristics have better outcomes after liver transplantation, than after chemotherapy and resection. Possibly this should be extrapolated to aggressive subtypes of hepatocellular carcinomas in non-cirrhotic livers, where early liver transplantation might also be indicated. However, the risks associated with liver transplantation and immunosuppressive treatment after liver transplantation are once again demonstrated by this case of a 32-year-old women with a negative personal and familial history of liver diseases. She underwent transplantation (DBD) for a hepatocellular carcinoma with stem cell features (HCC-HS; an aggressive 'hepatoblast subtype' of hepatocellular carcinoma) after chemotherapeutical downstaging techniques failed to sufficiently downstage the tumor. Despite being on conventional immunosuppressive regimens (tacrolimus and mycophenolate mofetil with initial corticosteroids tapered), this patient still developed two severe rejection episodes, one of which necessitated retransplantation (DCD). Both episodes were preceded by alterations in tacrolimus trough levels, either intentionally, when tacrolimus was reduced within a nephroprotective regimen, or unintentionally, when rifampicin, a CYP3A4 inducer, significantly lowered the trough levels. Together, these episodes stress the importance of therapeutic drug monitoring of tacrolimus. Furthermore, the patient experienced an everolimus-linked drug-induced thrombotic microangiopathy, underwent multiple ERCPs for an anastomotic stricture and only one and a half year after the first liver transplantation she already suffers from long-term immunosuppressive-related side effects such as impaired glucose tolerance, hypertension and a potential cardiomyopathy. At present, she is still alive and experienced no recurrence of her primary tumor. Her case underscores the significant challenges in post-liver transplantation care.

Normothermic Machine Perfusion Reduces Transfusion Requirements Even After Static Cold Storage: A 1 y Retrospective Single-center Analysis

Background

Normothermic machine perfusion (NMP) of liver grafts has been shown to reduce intraoperative catecholamine consumption and the need for allogenic blood products after reperfusion compared with organs undergoing classical static cold storage (SCS). This study aimed to investigate the effects of an NMP phase after SCS (NMP after SCS) of liver grafts in terms of postreperfusion hemodynamics and transfusion requirements.

Methods

Eighteen recipients of NMP after SCS grafts were matched according to recipient age, donor age, and model for end-stage liver disease score in a 1:2 ratio with recipients of an SCS graft. Postreperfusion hemodynamics and the need for catecholamines, blood products, and clotting factors were compared.

Results

After reperfusion of the organ, patients in the NMP after SCS group showed significantly reduced transfusion requirements for packed red blood cells and platelet concentrates compared with patients of the SCS group (P < 0.001 and P = 0.018, respectively). In addition, patients in the NMP after SCS group received less fibrinogen concentrate (NMP after SCS group 0 [0-1.5] g versus SCS group 2 [0-4] g; P = 0.0163). No differences in postreperfusion hemodynamics could be detected between groups.

Conclusions

This retrospective analysis shows that NMP reduces postreperfusion requirements of red blood cells, platelet concentrates, and fibrinogen concentrate even if installed after a phase of organ SCS, because it may be practiced on most centers where NMP is available.

Evaluation of surgical strategies and long-term outcomes in pediatric hepatocellular carcinoma

PURPOSE

Hepatocellular carcinoma (HCC), the second most common pediatric malignant liver tumor after hepatoblastoma, represents 1% of all pediatric tumors.

METHODS

A retrospective study was conducted on children with HCC treated at our center from March 2002 to October 2022, excluding those with inadequate follow-up or records. Demographic data, initial complaints, alpha-fetoprotein (AFP) values, underlying disease, size and histopathological features of the masses, chemotherapy, and long-term outcomes were analyzed.

RESULTS

Fifteen patients (8 boys, 7 girls) with a mean age of 11.4 ± 4.1 years (0.8-16.4 years) were analyzed. The majority presented with abdominal pain, with a median AFP of 3.9 ng/mL. Hepatitis B cirrhosis in one patient (6.6%) and metabolic disease (tyrosinemia type 1) in two patients (13.3%) were the underlying diseases. Histopathological diagnoses were fibrolamellar HCC (n:8; 53.3%), HCC (n:6; 40%). Four of the 15 patients underwent liver transplantation, and 9 underwent surgical resection. Due to late diagnosis, two patients were considered inoperable (13.3%). The survival rate for the four patients who underwent liver transplantation was found to be 75%.

CONCLUSION

Surgical treatment of various variants of HCC can be safely performed in experienced centers with a multidisciplinary approach, and outcomes are better than in adults.

Safety of Tonsillectomy and/or Adenoidectomy in Pediatric Patients with Prolonged Activated Partial Thromboplastin Time and Factor XII Deficiency

Objective

To evaluate the safety and feasibility of tonsillectomy and/or adenoidectomy (T&A) in pediatric patients with prolonged activated partial thromboplastin time (APTT) and coagulation factor deficiency.

Methods

A prospective study was admitted to the children undergoing T&A at our institution between October 2019 and January 2020, specifically focusing on preoperative coagulation function. Within this group, we identified 5 patients exhibiting prolonged APTT and coagulation factor deficiencies, constituting the experimental group, and 10 patients matched by gender and age with normal blood coagulation function were selected as the control group. Comparative analyses between the two groups were conducted, focusing on surgical duration, intraoperative bleeding volume, duration of hospital stay, and postoperative complications such as active bleeding across the groups. At the six-month postoperative mark, a reassessment of coagulation functions and factor assays was conducted within the experimental group.

Results

No statistically significant differences were discovered in terms of surgical duration or bleeding volume when comparing the experimental subgroups with their respective control counterparts. Furthermore, there were no incidences of postoperative active bleeding observed in any of the groups. Notably, postoperative APTT values (32.7 ± 1.7s) exhibited a significant disparity compared to preoperative levels (43.7 ± 1.8s, p < 0.01). Coagulation factors demonstrated normalization, evidenced by a significant difference in postoperative Factor XII levels (40.2 ± 5.4%) compared to preoperative levels (63.1 ± 5.9%, p < 0.01).

Conclusion

Prolonged APTT with FXII factor deficiency does not show a significant bleeding tendency and is not a contraindication for T&A surgery. Post T&A surgery, children with abnormal coagulation function and deficient clotting factors show significant improvement compared to pre-surgery. It is important to consider that chronic inflammation in adenoids and tonsils may contribute to the prolongation of APTT and the manifestation of Factor XII deficiency.

Comparison of Clinical, Pathological, and Procedural Characteristics of Adult and Pediatric Acute Appendicitis before and during the COVID-19 Pandemic

BACKGROUND

This study aims to analyze the impact of the COVID-19 pandemic on the clinical, pathological, and surgical characteristics of acute appendicitis (AA) at the University Hospital Centre (UHC) Zagreb.

METHODS

This retrospective study analyzed demographic, clinical, and surgical data from consecutive AA patients. Data were collected from an electronic database for two periods: 1 January to 31 December 2019 (pre-COVID-19), and 11 March 2020, to 11 March 2021 (COVID-19 pandemic).

RESULTS

During the two study periods, 855 appendectomies were performed, 427 in the pre-pandemic, and 428 during the pandemic. Demographic data were comparable between groups. There was statistically no significant difference in the type of appendectomy (p = 0.33) and the median hospital length of stay (3; (2-5) days, p = 0.08). There was an increase in the conversion rate during the pandemic period (4.2% vs. 7.7%, p = 0.03). The negative appendectomy rate and the incidence of perforated AA did not differ significantly (p = 0.34 for both).

CONCLUSIONS

We did not observe a significant increase in the rate of AA complications during the COVID-19 pandemic at the UHC Zagreb. This may be attributed to two factors: (1) AA was diagnosed and treated as an emergency, which remained available during the pandemic, and (2) diagnostic and therapeutic protocols remained unaltered. We recommend a laparoscopic approach even during the COVID-19 pandemic.

Cholangiocarcinoma: The Current Status of Surgical Options including Liver Transplantation

Cholangiocarcinoma (CCA) poses a substantial threat as it ranks as the second most prevalent primary liver tumor. The documented annual rise in intrahepatic CCA (iCCA) incidence in the United States is concerning, indicating its growing impact. Moreover, the five-year survival rate after tumor resection is only 25%, given that tumor recurrence is the leading cause of death in 53-79% of patients. Pre-operative assessments for iCCA focus on pinpointing tumor location, biliary tract involvement, vascular encasements, and metastasis detection. Numerous studies have revealed that portal vein embolization (PVE) is linked to enhanced survival rates, improved liver synthetic functions, and decreased overall mortality. The challenge in achieving clear resection margins contributes to the notable recurrence rate of iCCA, affecting approximately two-thirds of cases within one year, and results in a median survival of less than 12 months for recurrent cases. Nearly 50% of patients initially considered eligible for surgical resection in iCCA cases are ultimately deemed ineligible during surgical exploration. Therefore, staging laparoscopy has been proposed to reduce unnecessary laparotomy. Eligibility for orthotopic liver transplantation (OLT) requires certain criteria to be granted. OLT offers survival advantages for early-detected unresectable iCCA; it can be combined with other treatments, such as radiofrequency ablation and transarterial chemoembolization, in specific cases. We aim to comprehensively describe the surgical strategies available for treating CCA, including the preoperative measures and interventions, alongside the current options regarding liver resection and OLT.

Preservation of Pancreatic Function Should Not Be Disregarded When Performing Pancreatectomies for Pancreatoblastoma in Children

Complete surgical resection in the context of a multimodal approach has been associated with excellent long-term survival in children diagnosed with pancreatoblastoma (PB). Traditionally, curative intent surgery for PB implies standard pancreatic resections such as pancreaticoduodenectomies and distal pancreatectomies with splenectomies, surgical procedures that may lead to significant long-term pancreatic functional deficiencies. Postoperative pancreatic functional deficiencies are particularly interesting to children because they may interfere with their development, considering their long life expectancy and the significant role of pancreatic functions in their nutritional status and growth. Thus, organ-sparing pancreatectomies, such as spleen-preserving distal pancreatectomies and central pancreatectomies, are emerging in specific tumoral pathologies in children. However, data about organ-sparing pancreatectomies' potential role in curative-intent PB surgery in children are scarce. Based on the literature data, the current review aims to present the early and late outcomes of pancreatectomies in children (including long-term deficiencies and their potential impact on the development and quality of life), particularly for PB, and further explore the potential role of organ-sparing pancreatectomies for PB. Organ-sparing pancreatectomies are associated with better long-term pancreatic functional outcomes, particularly central pancreatectomies, and have a reduced impact on children's development and quality of life without jeopardizing their oncological safety. The long-term preservation of pancreatic functions should not be disregarded when performing pancreatectomies for PB in children. A subset of patients with PB might benefit from organ-sparing pancreatectomies, particularly from central pancreatectomies, with the same oncological results as standard pancreatectomies but with significantly less impact on long-term functional outcomes.

Algorithmic Approach to Deranged Liver Functions After Transplantation

Liver transplant (LT) recipients require close follow-up with regular monitoring of the liver function tests (LFTs). Evaluation of deranged LFT should be individualized depending upon the time since LT, peri-operative events, clinical course, and any complications. These derangements can range from mild and asymptomatic to severe and symptomatic elevations requiring expedited personalized assessment and management. Pattern of LFT derangement (hepatocellular, cholestatic, or mixed), donor-recipient risk factors, timing after LT (post-operative, 1-12 months, and >12 months since LT) along with clinical context and symptomatology are important considerations before proceeding with the initial evaluation. Compliance to immunosuppression and drug interactions should be ascertained along with local epidemiology of infections. Essential initial evaluation must include an ultrasound abdomen with Doppler to rule out any structural causes such as biliary or vascular complications apart from focussed laboratory evaluation. Early allograft dysfunction, ischemia reperfusion injury, small-for-size syndrome, biliary leaks, hepatic artery, and portal vein thrombosis are usual culprits in the early post-operative period whereas viral hepatitis (acute or reactivation), opportunistic infections, and recurrence of the primary disease are more frequent in the later period. Graft rejection, biliary strictures, sepsis, and drug induced liver injury remain possible etiologies at all times points after LT. Initial evaluation algorithm must be customized based on history, clinical examination, risk factors, and pattern and severity of deranged LFT. Allograft rejection is a diagnosis of exclusion and requires liver biopsy to confirm and assess severity. Empirical treatment of rejection sans liver biopsy is discouraged.

Basics and Art of Immunosuppression in Liver Transplantation

Liver transplantation is one of the most challenging areas in the medical field. Despite that, it has already been established as a standard treatment option, especially in decompensated cirrhosis and selected cases of hepatocellular carcinoma and acute liver failure. Complications due to graft rejection, including mortality and morbidity, have greatly improved over time due to better immunosuppressive agents and management protocols. Currently, immunosuppression in liver transplant patients makes use of the best possible combinations of effective agents to achieve optimal immunosuppression for long-term graft survival. Induction agents are no longer used routinely, and the aim is to provide minimal immunosuppression in the maintenance phase. Currently available immunosuppressive agents are mainly classified as biological and pharmacological agents. Though the protocols may vary among the centers and over time, the basics of effective use usually remain similar. Most protocols use the combination of multiple agents with different mechanisms of action to reduce the dose and minimize the side effects. Along with the improvement in operative and perioperative techniques, this art of immunosuppression has contributed to the recent progress made in the outcomes of liver transplants. In this review, we will discuss the various types of immunosuppressive agents currently in use, the different protocols of immunosuppression used, and the art of optimal use for achieving maximum immunosuppression without increasing toxicity. We will also discuss the practical aspects of various immunosuppression regimens, including drug monitoring, and briefly discuss the concepts of immunosuppression minimization and withdrawal.