Cell-specific Extracellular Vesicles and Their miRNA Cargo Released Into the Organ Preservation Solution During Cold Ischemia Storage as Biomarkers for Liver Transplant Outcomes

BACKGROUND

Liver transplantation (LT) is crucial for end-stage liver disease patients, but organ shortages persist. Donation after circulatory death (DCD) aims to broaden the donor pool but presents challenges. Complications like acute rejection, hepatic artery thrombosis, and biliary issues still impact posttransplant prognosis. Biomarkers, including extracellular vesicles (EVs) and microRNAs (miRNAs), show promise in understanding and monitoring posttransplant events. This study explores the role of EVs and their miRNA cargo in LT, including their potential as diagnostic tools.

METHODS

EVs from intrahepatic end-ischemic organ preservation solution (eiOPS) in 79 donated livers were detected using different techniques (nanosight tracking analysis, transmission electron microscopy, and flow cytometry). EV-derived miRNAs were identified by quantitative real time-polymerase chain reaction. Bioinformatics analysis was performed using the R platform.

RESULTS

Different-sized and origin-specific EVs were found in eiOPS, with significantly higher concentrations in DCD compared with donation after brain death organs. Additionally, several EV-associated miRNAs, including let-7d-5p, miR-28-5p, miR-200a-3p, miR-200b-3p, miR-200c-3p, and miR-429, were overexpressed in DCD-derived eiOPS. These miRNAs also exhibited differential expression patterns in liver tissue biopsies. Pathway analysis revealed enrichment in signaling pathways involved in extracellular matrix organization and various cellular processes. Moreover, specific EVs and miRNAs correlated with clinical outcomes, including survival and early allograft dysfunction. A predictive model combining biomarkers and clinical variables showed promise in acute rejection detection after LT.

CONCLUSIONS

These findings provide new insights into the use of EVs and miRNAs as biomarkers and their possible influence on posttransplantation outcomes, potentially contributing to improved diagnostic approaches and personalized treatment strategies in LT.

Intraductal papillary neoplasms of the bile ducts: a comparative study of a rare disease in Europe and Nagoya, Japan

BACKGROUND

Intraductal papillary neoplasm of the bile ducts (IPNB) is a rare disease in Western countries. The aim of this study was to compare tumor characteristics, management strategies, and outcomes between Western and Eastern patients who underwent surgical resection for IPNB.

METHODS

A multi-institutional retrospective series of patients with IPNB undergoing surgery between January 2010 and December 2020 was gathered under the auspices of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA), and at Nagoya University Hospital, Japan.

RESULTS

A total of 85 patients (51% male; median age 66 years) from 28 E-AHPBA centers were compared to 91 patients (64% male; median age 71 years) from Nagoya. Patients in Europe had more multiple lesions (23% vs 2%, P < .001), less invasive carcinoma (42% vs 85%, P < .001), and more intrahepatic tumors (52% vs 24%, P < .001) than in Nagoya. Patients in Europe experienced less 90-day grade >3 Clavien-Dindo complications (33% vs 68%, P < .001), but higher 90-day mortality rate (7.0% vs 0%, P = .03). R0 resections (81% vs 82%) were similar. Overall survival, excluding 90-day postoperative deaths, was similar in both regions.

DISCUSSION

Despite performing more extensive resections, the low perioperative mortality rate observed in Nagoya was probably influenced by a combination of patient-, tumor-, and surgery-related factors.

Endothelial cell activation mediated by cold ischemia-released mitochondria is partially inhibited by defibrotide and impacts on early allograft function following liver transplantation

DAMPs (danger-associated molecular patterns) are self-molecules of the organism that appear after damage. The endothelium plays several roles in organ rejection, such as presenting alloantigens to T cells and contributing to the development of inflammation and thrombosis. This study aimed to assess whether DAMPs present in the organ preservation solution (OPS) after cold ischemic storage (CIS) contribute to exacerbating the endothelial response to an inflammatory challenge and whether defibrotide treatment could counteract this effect. The activation of cultured human umbilical vein endothelial cells (HUVECs) was analyzed after challenging with end-ischemic OPS (eiOPS) obtained after CIS. Additionally, transwell assays were performed to study the ability of eiOPS to attract lymphocytes across the endothelium. The study revealed that eiOPS upregulated the expression of MCP-1 and IL-6 in HUVECs. Moreover, eiOPS increased the membrane expression of ICAM-1and HLA-DR, which facilitated leukocyte migration toward a chemokine gradient. Furthermore, eiOPS demonstrated its chemoattractant ability. This activation was mediated by free mitochondria. Defibrotide was found to partially inhibit the eiOPS-mediated activation. Moreover, the eiOPS-mediated activation of endothelial cells (ECs) correlated with early allograft dysfunction in liver transplant patients. Our finding provide support for the hypothesis that mitochondria released during cold ischemia could trigger EC activation, leading to complications in graft outcomes. Therefore, the analysis and quantification of free mitochondria in the eiOPS samples obtained after CIS could provide a predictive value for monitoring the progression of transplantation. Moreover, defibrotide emerges as a promising therapeutic agent to mitigate the damage induced by ischemia in donated organs.

Minimally invasive surgery and liver transplantation: is it a safe, feasible, and effective approach?

The minimally invasive approach (MIS) is undoubtedly one of the most important breakthroughs in surgery in recent decades. Consequently, MIS has been increasingly in the field of liver transplantation (LT). The objective of the present review was to determine the current status of MIS with respect to liver transplantation (LT) and what would be the indications for an MIS in this context today. The literature was searched for publications reporting the MIS in LT. Only those articles that described the results according to whether the MIS had been performed to treat transplant complications (urgent or late), another pathology not related to the LT, or to perform the liver explantation and graft implantation were included. From 2000 to 2022, 33 studies and 261 patients were included. Most frequent indications were incisional hernias secondary to LT followed by the treatment of other pathologies not related with the LT and treatment of LT complications. Only a 12% were urgent interventions. Few studies describe conversions with an average rate of 2.5%. Morbidity do not differ significantly from open surgery. No case of mortality or graft loss was described. Purely laparoscopic liver explants in 9 patients with 2 conversions and 3 cases of graft implantation with a higher warm ischemia in the MIS implants grafts were described. The limitations of MIS in LT are relative and probably depend more on training, experience, and skills of the surgeons. This approach could be safety and feasibility to solved complications or in other individualized indications in LT patients. The initial experiences in liver explant and graft implantation need further investigations.

Intraductal papillary neoplasms of the bile duct: a European retrospective multicenter observational study (EUR-IPNB study)

BACKGROUND/PURPOSE

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare disease in Western countries. The main aim of this study was to characterize current surgical strategies and outcomes in the mainly European participating centers.

METHODS

A multi-institutional retrospective series of patients with a diagnosis of IPNB undergoing surgery between 1 January 2010 and 31 December 2020 was gathered under the auspices of the European-African Hepato-Pancreato-Biliary Association. The textbook outcome (TO) was defined as a non-prolonged length of hospital stay plus the absence of any Clavien-Dindo grade at least III complications, readmission, or mortality within 90 postoperative days.

RESULTS

A total of 28 centers contributed 85 patients who underwent surgery for IPNB. The median age was 66 years (55-72), 49.4% were women, and 87.1% were Caucasian. Open surgery was performed in 72 patients (84.7%) and laparoscopic in 13 (15.3%). TO was achieved in 54.1% of patients, reaching 63.8% after liver resection and 32.0% after pancreas resection. Median overall survival was 5.72 years, with 5-year overall survival of 63% (95% CI: 50-82). Overall survival was better in patients with Charlson comorbidity score 4 or less versus more than 4 ( P =0.016), intrahepatic versus extrahepatic tumor ( P =0.027), single versus multiple tumors ( P =0.007), those who underwent hepatic versus pancreatic resection ( P =0.017), or achieved versus failed TO ( P =0.029). Multivariable Cox regression analysis showed that not achieving TO (HR: 4.20; 95% CI: 1.11-15.94; P =0.03) was an independent prognostic factor of poor overall survival.

CONCLUSIONS

Patients undergoing liver resection for IPNB were more likely to achieve a TO outcome than those requiring a pancreatic resection. Comorbidity, tumor location, and tumor multiplicity influenced overall survival. TO was an independent prognostic factor of overall survival.

Danger signals released during cold ischemia storage activate NLRP3 inflammasome in myeloid cells and influence early allograft function in liver transplantation

BACKGROUND

Innate immunity plays a fundamental role in solid organ transplantation. Myeloid cells can sense danger signals or DAMPs released after tissue or cell damage, such as during ischemia processes. This study aimed to identify DAMPs released during cold ischemia storage of human liver and analyze their ability to activate the inflammasome in myeloid cells and the possible implications in terms of short-term outcomes of liver transplantation.

METHODS

79 samples of organ preservation solution (OPS) from 79 deceased donors were collected after cold static storage. We used different analytical methods to measure DAMPs in these end-ischemic OPS (eiOPS) samples. We also used eiOPS in the human macrophage THP-1 cell line and primary monocyte cultures to study inflammasome activation.

FINDINGS

Different DAMPs were identified in eiOPS, several of which induced both priming and activation of the NLRP3 inflammasome in human myeloid cells. Cold ischemia time and donation after circulatory death negatively influenced the DAMP signature. Moreover, the presence of oligomeric inflammasomes and interleukin-18 in eiOPS correlated with early allograft dysfunction in liver transplant patients.

INTERPRETATION

DAMPs released during cold ischemia storage prime and activate the NLRP3 inflammasome in liver macrophages after transplantation, inducing a pro-inflammatory environment that will complicate the outcome of the graft. The use of pharmacological blockers targeting DAMPs or the NLRP3 inflammasome in liver ischemia during static cold storage or through extracorporeal organ support could be a suitable strategy to increase the success of liver transplantation.

FUNDING

Fundación Mutua Madrileña and Instituto de Salud Carlos III, Madrid, Spain.

Lymphoepithelioma-like carcinoma of the duodenum: a very infrequent tumor

Lymphoepithelioma-like carcinoma (LELC) is a type of tumor that is histologically characterized by wide lymphoplasmacytic infiltration in the stroma. This type of carcinoma is usually found in the airway and is extremely infrequent in the gastrointestinal tract. We present the case of a 77-year-old male, under follow-up for refractory anemia, who was diagnosed with a cavum type lymphoepithelioma-like carcinoma in the third duodenal portion. After diagnosis, he was treated surgically via a duodenal resection, without adjuvant oncological treatment due to the early diagnosis and surgical pathology features. Today, 12 months after surgery, the patient is free of disease. Cases of LELC have been described in other organs of the gastrointestinal tract. However, after an extensive review of the literature, this is the first case of LELC in the duodenum. A review of the available literature about LELC in the digestive tract and its management was also included.

Management of hepatic artery aneurysms

We have read with interest the case published by Plua-Muñiz as an example of how endovascular treatment may be an acceptable and safe option even in an emerging situation as long as swift action is taken and the patient is stabilized previously. Hepatic artery aneurysms are an infrequent entity and their management is a great challenge. In the following letter we show our point of view and what the literature says about its management.

Assessing tumor response to neoadjuvant chemoradiation in rectal cancer with rectoscopy and 18F-FDG PET/CT: results from a prospective series

INTRODUCTION

rectoscopy and 18F-FDG PET/CT as a diagnostic algorithm for the assessment of tumor response in rectal cancer after neoadjuvant chemoradiation therapy (CRT) is very useful.

MATERIAL AND METHODS

this was a prospective longitudinal study in patients with locally advanced rectal cancer treated with neoadjuvant CRT. Patients were assessed after CRT completion with a digital rectal examination, proctoscopy and 18F-FDG PET/CT. Patients were subdivided as clinical (cCR) or radiologic (rCR) responders and non-responders according to tumor response. Clinical and radiological re-assessment was compared with the surgical specimen. Pathological tumor regression (pCR) grade was determined according to Mandard's classification. Of the 68 patients included, 15 (22 %) presented pCR in the surgical specimen and tumor persistence (non-PCR) was detected in the remaining 53 (78 %). Clinical assessment (DRE+ rectoscopy) identified 15 patients as cCR and 53 as non-cCR, two were false positives and two were false negatives. The overall accuracy was 94 %. 18F-FDG PET/CT identified 18 patients as rCR and 50 as non-rCR, one was a false positive and four were false negatives. The overall accuracy was 92 %. A combination of clinical findings and 18F-FDG PET/CT resulted in an accuracy of 96 %. The combination of clinical findings + 18F-FDG PET/CT was able to correctly identify all cases of pCR, with the exception of one case that presented a tumor regression of 80 %. In this series, 18F-PET-CT and clinical assessment had excellent accuracies in differentiating PCR from non-PCR after CRT completion. PET-CT combined with clinical assessment had a better accuracy than both modalities independently. 18F-FDG PET/CT is a valid tool that complements the clinical assessment of tumor response.

Case report of Tourniquet ALPPS and simultaneous sleeve gastrectomy: A valuable association to achieve an adequate future liver remnant in obese patients

INTRODUCTION

Obesity represents a risk factor in case of major hepatectomy, because the future liver remnant (FLR) must be proportional with body weight. To avoid post-hepatectomy liver failure, and further increase the ratio between FLR and body weight, we performed a bariatric procedure in the first stage of the ALPPS technique.

PATIENT CONCERNS

Fifty-four-year-old woman, with morbid obesity (BMI 58.5) and type II diabetes mellitus, was scheduled for a major hepatectomy due to multiple colorectal liver metastases DIAGNOSIS:: Six months before, the patient was diagnosed with colorectal cancer and synchronous liver metastases. She was initially treated with sigmoidectomy and chemotherapy. After partial response of the liver metastases, we considered a liver resection but the FLR was very low, especially in relation to her BMI.

INTERVENTION

We planned a novel approach and, for the first time, we performed a sleeve gastrectomy during the first stage of Tourniquet ALPPS (T-ALPPS). After achieving an adequate FLR, we successfully completed the major hepatectomy during the second stage of T-ALPPS.

OUTCOME

The association between sleeve gastrectomy and T-ALPPS produced an increase of FLR/body weight ratio up to 0.8 that allowed completing a right trisectionectomy in the second stage of ALPPS. The major hepatectomy was performed without severe complications, and several months after surgery the patient is still alive without any recurrence Conclusion: Despite obesity represents a risk factor involved in the carcinogenesis, the role of the bariatric surgery in the oncological setting is not well established. In this clinical case, we benefited from the weight loss produced by bariatric surgery combined with an effective hypertrophy technique and chemotherapy. These findings suggest that bariatric surgery could be useful for obese patients with liver malignancy and need for extended hepatectomy.

Psoas Muscle Index Does Not Predict Post-Transplant Outcomes: A Series of 57 Liver Transplant Recipients

BACKGROUND

Sarcopenia is defined as the loss of muscle mass and function. Our aim is to evaluate the degree of sarcopenia by measuring the patients on the waiting list for liver transplantation and its influence on the different post-liver transplant outcomes in our group.

METHODS

The psoas muscle index (PMI, cm²/m²) was calculated (right psoas muscle area [cm²]/the square of the body height [m²]) in 57 patients on the waiting list for liver transplantation in our center, and the post-transplant variables relevant to our study were collected.

RESULTS

The 57 recipients had a mean age of 57 years (range, 35-73) and had a mean of 7.4 months (range, 0-39) on the liver transplant waiting list. The mean psoas muscle index was 2.39 (range, 1-4), and the mean body mass index was 28.01kg/m² (range, 22-36). After multivariate analysis we found a positive correlation between the PMI and the body mass index of the recipients (r = 0.320, P = .017), intensive care unit length of stay, and donor age (r = 0.319, P = .042), and between cold ischemia time and graft survival (r = 0.366, P = .009). We found no correlation in our sample between PMI and post-liver transplant complications either in terms of graft or patient survival.

CONCLUSION

PMI is not representative of total muscle mass and sarcopenia and is not effective in adequately predicting the survival of patients on the waiting list for liver transplantation.

Long-Term Outcome After Conventional Two-Stage Hepatectomy Versus Tourniquet-ALPPS in Colorectal Liver Metastases: A Propensity Score Matching Analysis

BACKGROUND

To compare the overall survival (OS) and disease-free survival (DFS) of Tourniquet-ALPPS (T-ALPPS) and conventional two-stage hepatectomy (TSH) in patients with colorectal liver metastases (CRLM).

METHODS

A retrospective study from a prospectively collected database was performed between October 2000 and July 2016. TSH was performed before September 2011, after which time T-ALPPS became the technique of choice. A propensity score matching (PSM) was performed based on a 1:1 ratio with consideration of the following variables: number and size of metastases, bilobar disease presence, and chemotherapy received.

RESULTS

Thirty-four patients received T-ALPPS; 41 patients received TSH. After PSM, 21 patients remained in each group, with 100% resectability in the T-ALPPS group and 90.5% resectability in the TSH group. The median OS for TSH was 41 months; for T-ALPPS, the median OS was 36 months (P = 0.925). The median DFS was 16 months in the TSH group; the median DFS was 9 months in the T-ALPPS group (P = 0.930). The 1-, 3-, and 5-year OS for TSH was 81%, 66.7%, and 23.8% vs. 76.2%, 57.1%, and 22.9% for T-ALPPS, respectively. The 1-, 3-, and 5-year DFS for TSH was 66.7%, 9.5%, and 5% vs. 44.6%, 11.1%, and 11.1% for T-ALPPS, respectively. The volume increase with T-ALPPS was superior to that with TSH (68% vs. 39%; P = 0.018). There were no differences in morbidity and mortality after stages 1 and 2.

CONCLUSIONS

T-ALPPS produces a similar outcome to TSH, indicating that it could be a safe and effective alternative for curative hepatectomy for all patients.

Liver transplantation as a rescue surgery after failure of embolization of a giant hepatic artery pseudoaneurysm

We present the case of a male diagnosed with a giant hepatic artery aneurysm, which first presented with pain and hemorrhage due to a partial rupture of the aneurysm. After discarding treatment with a stent or surgery due to the wide extension, we chose to embolize the hepatic artery with coils. However, the progress was unfavorable after the procedure, with the appearance of liver failure that was resolved by an urgent liver transplantation. Giant hepatic artery pseudoaneurysms are an infrequent entity and their management is a great challenge. The diagnosis is usually delayed due to non-specific clinical signs and the life of the patient may be threatened in the case of rupture. Thus, endovascular or surgical treatment is recommended. Aneurysm embolization or ligation has been described in the literature as a valid treatment option in cases where revascularization by stent or bypass is not possible, as it preserves the viability of the liver due to the portal flow and collateral arteries. However, in the case of the failure of these treatments, liver transplantation is a rescue option.

Effect of Paclitaxel-based Hyperthermic Intraperitoneal Chemotherapy (HIPEC) on colonic anastomosis in a rat model

BACKGROUND

Paclitaxel has been used frequently for Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for ovarian carcinomatosis. Cytoreductive surgery and HIPEC are associated with high rates of morbidity being anastomotic dehiscence one of the most frequent. The objective of this study is to quantify the effect of Paclitaxel-based HIPEC on colonic anastomosis in an experimental rat model.

METHODS

After left colon resection and anastomosis, animals were randomized into four groups: Controls (C); Hyperthermia (H); Normothermic Intraperitoneal Paclitaxel (CP) and Paclitaxel-based HIPEC (HP). On postoperative day four, animals' peritoneal cavities were examined macroscopically, colon anastomosis burst pressures measured and specimens analyzed histologically.

RESULTS

Thirty-nine animals were randomized and 36 were included in the analysis. H group presented the highest burst pressure 105.11 ± 22.9 mmHg, which was 27% higher than C (77.89 ± 27.6 mmHg). On the other hand, HP presented the lowest burst pressure 64 ± 26 mmHg, 16% lower than C group and 39% lower than H, being this latter difference statistically significant (p = 0.004). There were no significant differences regarding weight loss, adhesion scores, perianastomotic abscesses and histological findings (inflammation, fibroblasts, neoangiogenesis, and collagen among groups).

CONCLUSION

Strength of colonic anastomosis was improved by isolated hyperthermia and negatively affected by Paclitaxel-based HIPEC.

Utility of neoadjuvant therapy in rectal GIST

Neoadjuvant therapy with Imatinib is the preferred treatment for rectal GISTs in order to reduce the aggressiveness of a surgical resection. At present, surgical resection does not require wide surgical margins. There is also a lot of controversy with regard to the need for a broad anatomical resection or if a local resection is sufficient and maintains maximum oncological safety and minimum morbidity and mortality. We present a case report of a rectal GIST with a good response to neoadjuvant treatment which allowed a transanal resection.

Hyperthermic intraperitoneal chemotherapy with paclitaxel or cisplatin in patients with stage III-C/IV ovarian cancer. Is there any difference?

OBJETIVE

To compare the results of the administration of HIPEC with Paclitaxel or Cisplatin after cytoreduction in patients with stage IIIC-IV ovarian cancer, especially focused on disease-free survival.

PATIENTS

We retrospectively analyzed a consecutive series of patients operated after being diagnosed with stage III-C/IV serous epithelial ovarian carcinoma. Patients included in the study were treated between January 2008 and March 2015. After cytoreduction, Paclitaxel (doses of 60 mg/m(2)O or Cisplatin (doses of 75 mg/m(2)) were used.

RESULTS

A total of 111 patients were included. Median age was 61 years. In 60 of them (54%) Paclitaxel was used during HIPEC treatment and 51 patients (46%) were treated with Cisplatin. PCI was similar between groups (PCI = 11 in both cases). Median follow up was 34 months (12-96 months). The median disease free survival in Paclitaxel Group was 27 months and 33 months in Cisplatin Group (p = 0.551). In patients treated with Paclitaxel disease free survival rates at 1, 2, and 3 years were 79%, 60% and 46%. In patients treated with Cisplatin disease free survival at 1, 2, and 3 years were 64%, 50% and 40% respectively. After a multivariate analysis, incomplete cytoreduction (HR: 6.54, 95% CI 2.98-10.17, p < 0.01) and PCI >11 (HR: 2.15, 95% CI 1.42-6.68, p < 0.05) were identified as independent factors associated with a reduced disease-free survival. Cystotatic used was not relevant regarding disease free survival analysis.

CONCLUSION

HIPEC with paclitaxel or cisplatin after cytoreduction in patients with ovarian cancer IIIC-IV has not shown different results in disease-free survival outcomes.

Morbidity and mortality outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients aged 75 years and over: Spanish group of peritoneal cancer surgery (GECOP) multicenter study

BACKGROUND

The aim of this study is to report the perioperative outcomes of cytoreductive surgery and hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) in patients ≥75 years from a Spanish multi-institutional experience.

METHODS

This multi-institutional retrospectively analyzed a prospectively collected clinical data from 10 Spanish hospitals that are part of the Spanish Group Peritoneal Cancer Surgery (GECOP). We assessed postoperative morbidity rates and performed univariate and multivariate analyses of factors associated with overall (grade I-IV) and major (grade III-IV) postoperative morbidity.

RESULTS

A total of 85 patients aged ≥75 years were included. Forty six postoperative adverse events were detected in 37 patients (43.5%). Twenty five complications in 20 patients (23.5%) were mild (grade I-II) and 16 complications in 12 patients (14.1%) were moderate-severe (grade III-IV). Five patients died in the first 90 days after the procedure (5.9%). After multivariate analysis, independent factors associated with postoperative complications were: PCI> 12 (OR: 4.14, 95% CI 1.22-14.12, p = 0.043) and the need for perioperative blood transfusion (OR: 14.91, 95% CI 3.87-57.46, p < 0.001). Regarding grade III-IV complications, after multivariate analysis, the presence of preoperative albumin levels <3.5 mgr/dl (OR: 9.15, 95% CI 1.38-60.57, p = 0.017), need for diaphragmatic peritonectomy procedures (OR: 11.32, 95% CI 1.40-91.32, p = 0.023) and perioperative blood transfusion (OR: 8.58, 95% CI 1.44-51.16, p = 0.018) were independent factors.

CONCLUSIONS

Cytoreductive surgery and performing HIPEC by experienced groups in selected patients aged ≥75 years can be performed with morbidity and mortality similar to that described in the literature.