Living Donor Whole and Partial Liver Grafts, Deceased Donor Whole Liver and SPLIT: Outcome Comparison

BACKGROUND

Currently, graft options for pediatric liver transplantation (PLT) include whole (WL) and partial (P) grafts, in the form of either deceased donor transplantation (DD) or living donor liver transplantation (LD). WL transplants from LD are commonly referred to as domino LT. The objective of this manuscript is to compare the outcomes of PLT performed with each of the available graft options.

METHODS

Retrospective cohort study from Jan. 2010 to Dec. 2022. The variables included data on the recipients' preoperative clinical status, intraoperative technical aspects, post-operative complications, and survival studies. There were 4 groups: SPLIT (17), DD-WL (55), LD-WL (824), and LD-P (22).

RESULTS

The median age and BW of the recipients was smaller in SPLIT, LD-P, and LD-WL compared to DDT-WL groups. HVOO (HR 15.87, 95% CI 1.89-133.06, P = 0.01), retransplantation (HR 7.94, 95% CI 2.63-24.02, P < 0.01), and malignancies (HR 3.08, 95% CI 1.29-7.37, P = 0.01) were independently associated with decreased patient survival. HAT (HR 27.54, 95% CI 10.44-72.68, P < 0.01) and malignancies (HR 2.42, 95% CI 1.10-5.34, P = 0.03) increased the risk of graft loss. The overall survival in this series was 91.4% (mean follow-up of 74.3 months). Patient and graft survival were not different among groups.

CONCLUSION

HAT and malignancies were associated with reduced graft survival. Whole liver from living donors with MSUD presented 100% patient survival at 120 months. Even without statistical differences in survival among the studied groups, LD-P and LD-WL recipients presented a trend towards better outcomes.

LEVEL OF EVIDENCE

LEVEL III.

SPATIAL AND SOCIAL ASPECTS OF THE 1918-1919 PANDEMIC FLU IN SPLIT

The Spanish flu pandemic is considered the largest and most dangerous epidemic at the beginning of the 20th century affecting most of the world today. The Spanish flu pandemic did not bypass the territory of Croatia (at the time, Croatia was part of the Austro-Hungarian Monarchy), nor its southern coastal region of Dalmatia and the city of Split. Using the example of the city Split, the paper analyses the spatial and demographic determinants of population mortality from the Spanish flu between 1918 and 1919, i.e., from March 1918 to April 1919. The paper is based on the data of the Church Death registers kept in the Archbishop’s Archives in Split and newspaper articles. The analysis of the spatial distribution of mortality within urban settlements showed that the number of deaths per urban settlement

BUILDING THE COVID-19 TESTING CAPACITIES IN CROATIA: ESTABLISHING THE INTERDEPARTMENTAL COVID-19 UNIT AT THE SPLIT UNIVERSITY HOSPITAL CENTRE

This paper presents the chronology, experiences, and challenges in introducing COVID-19 RT-PCR testing in Split, Croatia. We describe the processes from March 12, 2020 to May 26, 2020, starting from the initial knowledge transfer, expert team formation and management, testing implementation, and concluding with the standalone testing facilities, which used automated processes sufficient to meet testing requirements at that time. In the case presented, the COVID-19 unit was organized by joining human and laboratory resources from five clinical departments at the Split University Hospital Centre. Sample preparation procedures and analyses were launched within the restricted time frame while simultaneously training and organizing new laboratory staff and completing equipment requirements. As a result, the process that started with 30 tests per day was constantly improved over time and reached up to 160 tests per day when MagNA Pure was added to automatize RNA extraction at the end of April. At that pace, the cumulative number of samples soon exceeded the first thousand, and by the end of May it exceeded 4000. The case presented provides an example of good practice for crisis response and organization that successfully enabled sufficient COVID-19 testing capacities within the restricted time frame, human and technical resources. Despite limited understanding of COVID-19 at that time, appropriate management, transfer of knowledge, previous experiences in related laboratory and diagnostic work, as well as interdisciplinary and interdepartmental cooperation proved appropriate to overcome the above limitations and ensure adequate healthcare response.

Split appendix Mitrofanoffs have higher risk of complication than intact appendix or monti channels

INTRODUCTION

Many patients with certain conditions require catheterizable channels for bladder and bowel management. There are a variety of accepted techniques for creating these channels; the split appendix technique enables the use of this organ for both procedures, obviating the need for more complex surgical procedures. Studies comparing outcomes across catheterizable channel types are limited.

OBJECTIVE

The aim of this study was to compare the urinary channel complication rates of the split appendix, intact appendix and transverse ileal tube (Monti) channels. We hypothesized that complication rates would be the same across all channel types.

STUDY DESIGN

We retrospectively reviewed consecutive patients who underwent surgical creation of a urinary continent catheterizable channel. We recorded demographics, underlying diagnosis, body mass index, stoma location, surgical techniques, and surgical revisions. The primary outcome was complication (stenosis, leakage, or both) with or without surgical revision, and to compare the three different catheterizable channel types using time to event analysis.

RESULTS

From January 2014-July 2018, 107 patients underwent creation of a continent catheterizable urinary channel; 86 (80.4%) patients also underwent simultaneous procedure for antegrade bowel management. The mean age was 7 years; 66 (60.8%) were females. Intact appendices were used in 46 (43.0%), Monti channel in 25 (23.4%), and split appendix technique in 36 (33.6%). The corresponding complication rates with or without surgical revision was 21.7%, 36.0%, and 47.2%, respectively. The only independent factor associated with increased risk of complication was the split appendix technique; these channels were more than twice as likely to require surgical revision with an adjusted hazard ratio of 2.32 (Table 4). The majority of revisions in all groups were skin level (58.3%). The most common indication for surgical revision was stenosis (55.6%).

DISCUSSION

This analysis shows a statistically significant increase in risk of all complications, including an increase in need for surgical revision, in patients who underwent split appendix technique for simultaneous bladder and bowel catheterizable channels. This finding should be balanced with the fact that a bowel anastomosis is not required in cases where individuals need both a bowel and bladder catheterizable channel. This study is unique in its separation of split and intact appendix channels, and inclusion of patients experiencing complications that have not yet required surgical revision. Limitations of this study include its retrospective design, inclusion of a single institution, and the lack of consistency in documenting baseline appendiceal length.

CONCLUSION

Split appendix catheterizable channels have a higher rate of channel complications than other techniques. The authors acknowledge that the split appendix technique has been proven feasible and effective, however recognize that it may not be appropriate for all patients and include counseling of the risks of its use.

Split difference method to determine the polynomial function that models the first few given terms of a sequence

When looking at a sequence of numbers, one that can be defined by a polynomial function of a natural number degree, one most commonly would use a difference table to find the degree followed by a system of equations to find the equation that models the sequence. This method can prove to be very time consuming as solving a system of equations can become tedious at higher degrees. Alternately, some people would use a method where they use the difference table to find the leading coefficient in addition to the degree to give the first term. Then they would subtract this term from the function and repeat this process. However, this can be unnecessarily complicated as this method requires one to create a difference table numerous times only to need the last difference. This method uses a simple pattern triangle and only the first difference table of the sequence. It is already necessary to create the first difference table and this pattern triangle can be used to improve upon the second method. The pattern triangle allows us to walk through the difference table of the lower degree polynomials quite easily, removing the need for multiple difference table. This method differs from existing methods in that:•

It is much faster

•

It uses a unique pattern triangle.

Supermicrosurgery in fingertip defects-split tibial flap of the second toe to reconstruct multiple fingertip defects: A case report

BACKGROUND

Injuries to multiple fingertips pose a significant treatment dilemma. Numerous reconstructive options exist, all with the ultimate goal of restoring function and sensibility to the injured fingertips.

CASE SUMMARY

A 24-year-old male suffered injury to multiple fingertips of the right hand, resulting in exposed distal phalanges of the middle, ring, and small fingers. The amputated distal stumps were not possible for replantation. Free flap coverage was selected in order to achieve better functional outcome. The fingertip defects were covered by performing a right second toe split tibial flap using local anesthesia at the harvest site and brachial plexus nerve block for the right upper extremity. At 6-month follow-up, all three of the reconstructed fingertips had some preserved nail growth, Semmes-Weinstein Monofilaments testing was equal to the contralateral side and the Static Two-Point Discrimination were comparable to the contralateral side.

CONCLUSION

This report provides a novel reconstructive option for the management of multiple fingertip injuries and demonstrates the utility of supermicrosurgery in management of these injuries.

Split-specific bootstrap measures for quantifying phylogenetic stability and the influence of taxon selection

Assessing the robustness of an inferred phylogeny is an important element of phylogenetics. This is typically done with measures of stabilities at the internal branches and the variation of the positions of the leaf nodes. The bootstrap support for branches in maximum parsimony, distance and maximum likelihood estimation, or posterior probabilities in Bayesian inference, measure the uncertainty about a branch due to the sampling of the sites from genes or sampling genes from genomes. However, these measures do not reveal how taxon sampling affects branch support and the effects of taxon sampling on the estimated phylogeny. An internal branch in a phylogenetic tree can be viewed as a split that separates the taxa into two nonempty complementary subsets. We develop several split-specific measures of stability determined from bootstrap support for quartets. These include BPtaxon_split (average bootstrap percentage [BP] for all quartets involving a taxon within a split), BPsplit (BPtaxon_split averaged over taxa), BPtaxon (BPtaxon_split averaged over splits) and RBIC-taxon (average BP over all splits after removing a taxon). We also develop a pruned-tree distance metric. Application of our measures to empirical and simulated data illustrate that existing measures of overall stability can fail to detect taxa that are the primary source of a split-specific instability. Moreover, we show that the use of many reduced sets of quartets is important in being able to detect the influence of joint sets of taxa rather than individual taxa. These new measures are valuable diagnostic tools to guide taxon sampling in phylogenetic experimental design.

Split-graft technique in neonatal heart transplant for aortic atresia

We describe a neonate with aortic atresia and hypoplastic aorta, listed for heart transplant after extracorporeal membrane oxygenation resuscitation and ductal stenting. The donor aorta was detached from the graft, after an isolated arch reconstruction prior to the transplant itself in a routine fashion. To the best of our knowledge, this is the first reported case of neonatal arch reconstruction before transplantation performed with grafts from the same donor in a split-way strategy.

Granulocyte transfusion experience in pediatric neutropenic fever: Splitted product can be an alternative?

The granulocyte transfusion (GTX) has been used for a long time due to uncontrolled neutropenic fever with antimicrobial agents. In some cases, the product needs to be splitted for using in the next 12 hours. The aim of this study is to evaluate the efficacy of splitted product and clinical response to GTX. In this study, 15 patients with malignancy with 19 neutropenic fever, who had received 56 GTX, were included. Seventeen of 56 GTX were splitted and used in maximum 12 hours during infections which did not respond to antibacterial and antifungal therapy in 7 days. The patients were divided in to response groups as a complete, partial and progressive. The predictive factors for response group were evaluated. GTX were well tolerated in all patients. The median granulocyte dose was 1.26 (0.38-5.22) × 10(9)/kg. Total response rate was 89.5%. The infection-related mortality rate was 10.5%. Although the granulocyte doses are the same in both of the product groups, an hour later ANC increment of primer product was higher than that of splitted product (p = 0.001). Among the products, 48.7% of primer product and 17.6% of splitted product had induced ≥ 1000/mm(3) ANC increment after an hour (p = 0.039). Granulocyte transfusion is safe and effective in controlling the febrile neutropenia attack. GTX should be applied in a short time to provide effective ANC increment. For now, main granulocyte product instead of splitted product should be preferred in case of uncontrolled neutropenic fever with antibacterial/antifungal agents.

Associating liver partition and portal vein ligation for staged hepatectomy in a hepatocellular carcinoma patient with severe liver cirrhosis

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel method for treating metastatic hepatocellular carcinoma (HCC) with tremendous or multiple tumors without liver cirrhosis. Here we report that ALPPS was used successfully in a man with huge HCC in the left lobe of the liver complicated with severe liver cirrhosis. Absorbable antistick film around remnant liver was inserted and drug delivery systems (DDS) to proper hepatic artery and portal vein were respectively embedded in the second step to reduce HCC relapse by chemoembolization with emulsion including Endostar through the two DDS. Relapse of HCC was not found three months after surgery.

Surgical experience in splitting donor liver into left lateral and right extended lobes

AIM: To outline the surgical experience with donor liver splitting in split liver transplantation.

METHODS: From March 1 to September 1 in 2004, 10 donor livers were split ex situ into a left lateral lobe (segments II and III) and a right extended lobe (segments I, IV - VIII) in Medical School of Hannover, and thereafter split liver transplantation was performed successfully in 19 cases. The average age, weight and ICU staying period of the donors were 32.7 years (15 - 51 years), 64.5 kg (45 - 75 kg) and 2.4 d (1 - 8 d) respectively.

RESULTS: The average weight of the whole graft and the left lateral lobe was 1 322.6 g (956 - 1 665 g) and 281.8 g (198 - 373 g) respectively, and the average ratio of left lateral lobe to the whole graft was 0.215 (0.178 - 0.274). The average graft to recipient weight ratio (GRWR) of the left lateral lobe and the right extended lobe reached 2.44% (1.22 - 5.41%) and 1.73% (1.31 - 2.30%) respectively. On average it took approximately 105 min (85 - 135 min) to split the donor liver. Five donor organs showed anatomic variation including the left hepatic vein variation in two cases, the left hepatic artery variation in two cases and the bile duct variation in one case.

CONCLUSION: Split liver transplantation has become a mature surgical technique to expand the donor pool with promising results. In the process of graft splitting, close attention needs to be paid to potential anatomic variations, especially to variations of the left hepatic vein, the left hepatic artery, and the bile duct.