Early Hepatoduodenal Ligament Occlusion Versus Classic Technique During Recipient Hepatectomy for Living Donor Liver Transplant.

OBJECTIVES: Intraoperative bleeding is commonly encountered during living donor liver transplant procedures and is associated with greater need for blood transfusion, which increases morbidity. Herein, we hypothesized that early and continuous occlusion ofthe hepatic inflow would have a beneficial effect on the living donor liver transplant procedure regarding intraoperative blood loss and operative time. MATERIALS AND METHODS: This comparative study prospectively included 23 consecutive patients (the experimental group) who had early inflow occlusion during recipient hepatectomy for living donor liver transplant and compared the outcomes versus 29 consecutive patients who had previously received (immediately before the start of our study) living donor liver transplant by the classic technique. Blood loss and time for hepatic mobilization and dissection were compared between the 2 groups. RESULTS: Patient criteria and indication for living donor liver transplant showed no significant difference between the 2 groups. There was a significant decrease in blood loss during hepatectomy in the study group versus the control group (2912 vs 3826 mL, respectively; P = .017). Packed red blood cell transfusion was less in the study group versus the control group (1550 vs 2350 cells, respectively; P < .001). The skin-to-hepatectomy time was not different between the 2 groups. CONCLUSIONS: Early hepatic inflow occlusion is a simple and effective technique to reduce intraoperative blood loss and reduce the need for blood transfusion products during living donor liver transplant.

Outflow Reconstruction in Right Lobe Living Donor Liver Transplant: Middle Hepatic Vein Reconstruction Versus Separate Tributaries to Inferior Vena Cava Anastomosis.

OBJECTIVES: In right lobe living donor liver transplant, proper reconstruction of the segment 5 vein and segment 8 vein is essential. Herein, we compared 2 different techniques for segment 5 vein reconstruction. MATERIALS AND METHODS: This prospective nonrandomized study included all recipients of modified right lobe living donor liver transplant who had reconstruction of the segment 5 vein, with or without segment 8 veins, from October 2018 to October 2021. Patients were grouped into group A (classical technique) and group B (modified technique). For group A, the segment 5 (and segment 8, if present) vein was anastomosed in an end-to-side fashion to a polytetrafluoroethylene synthetic graft positioned parallel to the cut surface of the liver graft; then, during implant, its proximal end was anastomosed to recipient's middle hepatic or middle-left hepatic veins unified orifice. In group B (modified technique), the stumps of segment 5 (and segment 8 if present) were anastomosed in an end-to-end fashion to 2 different polytetrafluoroethylene grafts; then during implant, the other ends of the segment 5 grafts were anastomosed directly to the inferior vena cava. Postoperative segment 5 vein patency and graft recovery were compared. RESULTS: Forty patients were included: 22 in group A and 18 group B. There were no significant differences in the demographic data or characteristics of donors, grafts, and recipients between the groups. There was better patency in segment 5 synthetic grafts in group A at all time points compared with group B, but this difference was statistically significant only at 1 month (18 [81.8%] vs 9 [50%, respectively; P = .046).There was no statistically significant difference in the markers of graft recovery in both groups. CONCLUSIONS: Reconstruction of the segment 5 vein by polytetrafluoroethylene synthetic graft in a fashion to resemble the native middle hepatic vein in modified right lobe living donor liver transplant has better patency than anastomosis of the segment 5 vein in an end-to-end fashion to the synthetic graft and then to the inferior vena cava. Both techniques did not affect graft recovery.

A Case Report of Anti-phospholipid Syndrome With Lower Extremity Arterial Thrombosis That Didn't Respond to Heparin and Direct Oral Anticoagulation: Ultimately, the Patient Agreed to Oral Warfarin.

In the absence of known thrombophilia or factors associated with thrombotic tendency, clinicians are more likely to think of antiphospholipid syndrome in patients presenting with venous thrombosis than in those with arterial thrombosis. We present a case of acute lower extremity arterial ischemia in a female smoker. Despite multiple surgical interventions and treatment with several different anticoagulants, our patient developed bilateral lower extremity thrombi. Ultimately, after developing a pulmonary embolism, she accepted to be on warfarin. She switched to warfarin without recurrence of her arterial thrombosis. We describe the challenging management of her critical limb ischemia and review the pertinent literature on the controversy surrounding optimal anticoagulation in such patients.

Pancreaticoduodenectomy for pancreatic adenocarcinoma in a patient with situs inversus abdomenalis, a case report.

INTRODUCTION AND IMPORTANCE: Situs Inversus (SI) is a rare congenital condition in which the abdominal and thoracic organs are located in a mirror image of the normal position in the sagittal plane. Although this condition does not affect normal health or longevity, its recognition is very important for treating many diseases, particularly those requiring surgical intervention. The relationship between situs inversus and cancer remain inconspicuous. CASE PRESENTATION: We report a 64-year old male with Situs Iinversus Abdominalis with Pancreatic Adenocarcinoma. Radiographic modalities were very important in preoperative assessment of the patient. The patient was managed by pyloric preserving pancreaticoduodenectomy. The patient received adjuvant chemotherapy and free of recurrence for one year after operation. CONCLUSION: Surgeons must recognize the complexity of operative intervention with respect to aberrant anatomy. The occurrence of Situs Inversus in a patient with pancreatic cancer must not deter the surgeon from sound oncologic principles of pancreatic surgery. Referral to these cases to tertiary level center is of utmost importance.

Architectural distortion outcome: digital breast tomosynthesis-detected versus digital mammography-detected.

OBJECTIVES: To compare the outcome for DBT-detected and DM-detected suspicious AD, to evaluate the risk of malignancy and if is affected by the US or MRI imaging correlation. METHODS: All cases with suspicious AD (ultimately assigned BI-RADS 4 or 5 categories) were retrospectively included. Two radiologists independently reviewed DM and DBT images in two sessions for detection (DM vs. DBT). US and MRI imaging correlation findings were recorded. Pathologic results were compared between DBT-detected and DM-detected AD. RESULTS: Among 137 detected ADs, 103 (75.2%) were DM-detected, and 34 (24.8%) were only DBT-detected (p = 0.01). The malignancy rate was lower for DBT-detected than DM-detected AD (14.7% vs. 45.6%) (p = 0.01). Malignancy rate was higher with US-positive than US-negative correlation at DM-detected AD (49.4% vs. 27.8%) (p = 0.01). Malignancy rate was not different for DBT-detected AD with (16.7%) or without (12.5%) sonographic correlation. NPV based on radiologists' level of suspicion was high (86.2%-97.2%) but not sufficient enough to forgo biopsy. Of 34 sonographically occult ADs, a positive-MRI correlation was identified in 19 (55.9%) ADs (7 were malignant, 12 were benign). A negative-MRI correlation was identified in 15 (44.1%) ADs; all had a benign outcome (p = 0.01). CONCLUSIONS: DBT-detected AD is less likely to represent malignancy than does DM-detected; however, the risk of malignancy is not low enough to forgo biopsy. MRI-negative correlation in sonographically occult AD was significantly associated with benign outcomes and can avoid unnecessary interventions.

The utility of Multi-Detector Computed Tomography criteria after neoadjuvant therapy in Borderline Resectable Pancreatic cancer: Prospective, bi-institutional study.

OBJECTIVES: To evaluate the utility of MDCT criteria for the determination of resectability and tumor response in borderline resectable pancreatic cancer (BRPC) following neoadjuvant therapy (NAT). METHODS: This prospective study includes 90 consecutive BRPC patients who underwent surgery following NAT. Two radiologists assessed baseline and pre-surgical CTs for (largest tumor axis, size, attenuation, and vascular criteria). Logistic regression was used to determine which CT criteria independently associated with R0 resection and pathologic major response (pMR). Median survival and overall survival (OS) were calculated. RESULTS: Seventy-three/90 (81.1 %) patients had R0 resection, and 11/90 (12.2 %) had pMR. After NAT, there were significant interval changes in the largest tumor axis, size, attenuation, and venous burden index (VBI) (P < 0.02). On the multivariable analysis, regression of the VBI and low VBI at the pre-surgical CT were independently associated with an increased likelihood of R0 resection (OR 1.82; 95 % CI 1.44-5.33) (OR 1.91; 95 % CI 1.83-6.14). The assessment of VBI at the pre-surgical CT showed moderate reproducibility (k-value, 0.56 - 0.60). On the multivariable analysis, partial response (PR) was found to be independently associated with an increased likelihood of pMR (OR 1.71; 95 % CI 1.31-3.45). The median survival was longer in patients who had R0 (P = 0.01). The overall survival was longer in patients who had pMR compared to those who did not (P = 0.02). CONCLUSION: Surgical exploration could be indicated in patients who had regression of the VBI and low VBI at the pre-surgical CT. PR response is associated with pMR.

Living donor liver transplantation in septuagenarians: Better late than never.

BACKGROUND: The coupling of increased life expectancy and improvements in both quality and access to chronic liver disease care, is culminating in an expanding population of septuagenarians (≥70 years) in need of liver transplantation (LT). The objective of this study is to partially alleviate this knowledge deficit and to add clarity to the current status and role of LDLT in this recipient population. METHODS: Of 295 adult patients underwent LDLT between January 1, 2011 and December 31, 2016. Twelve (4%) of these patients were septuagenarians and this group was compared to younger cohort (n = 283). RESULTS: Comorbidity profiles between the two groups were similar and no statistically significant differences were noted in warm/cold ischemia times, operative duration, or blood product utilization. ICU and total hospital stays were comparable. Septuagenarian 1-and 5-year graft and patient survivals were identical at 91.7%. Their younger counterparts had 1-and 5-year patient survivals of 91.1% and 84.0 % accompanied by 1-and 5-year graft survivals of 89.8% and 82.7%, respectively. CONCLUSION: Our study highlights a recognition that LDLT can afford highly-selected elderly patients to access to transplant with equivalent outcomes to those realized by younger recipients.

Preoperative CT staging of borderline pancreatic cancer patients after neoadjuvant treatment: accuracy in the prediction of vascular invasion and resectability.

OBJECTIVES: To assess the utility of MDCT tumor-vascular interface criteria for predicting vascular invasion and resectability in borderline pancreatic cancer (BRPC) patients after neoadjuvant therapy (NAT). METHODS: This prospective study included 90 patients with BRPC who finished NAT, showed no progression in preoperative CTs and underwent surgery. Two radiologists independently assessed preoperative vessel-tumor interface criteria. The area under the ROC curve (AUC) was used to evaluate the diagnostic performance for predicting vascular invasions and resectability using surgical and pathological results as the gold standard. Inter-reader agreement was assessed using the κ coefficient. RESULTS: Pathologic vascular invasion was confirmed in 47 (54.7%) veins and 14 (16.3%) arteries. R0 resection was achieved in (82.6%71/86) pancreatic resection. Using criteria of circumferential interface ≥ 180 degrees with contour deformity ≥ grade 3 and/or length of tumor contact > 2 cm to predict vascular invasion, the AUCs for the two readers were 0.85-0.88 for arterial invasion and 0.92-0.87 for venous invasion. Using criteria of circumferential interface ≤ 180° with contour deformity ≤ grade 2 and/or length of tumor contact < 2 cm to predict R0 resection, the AUCs was 0.85-0.86 for the two readers. The overall inter-reader agreement was good (κ = 0.75-0.80). The κ values for venous invasion, arterial invasion and R0 resection were 0.76, 0.78, and 0.80. CONCLUSION: Tumor-vessel criteria demonstrated good diagnostic performance and reproducibility in the prediction of vascular invasion after NAT in BRPC. These criteria could be helpful in the prediction of R0 resection in cases with only venous involvement.

Effects of terlipressin infusion during hepatobiliary surgery on systemic and splanchnic haemodynamics, renal function and blood loss: a double-blind, randomized clinical trial.

BACKGROUND: Terlipressin, in general, is a vasopressor which acts via V1 receptors. Its infusion elevates mean blood pressure and can reduce bleeding which has a splanchnic origin. The primary outcome was to assess the impact of intraoperative terlipressin infusion on portal venous pressure during hepatobiliary surgery; the 2ry outcomes included effects upon systemic hemodynamics, estimated blood loss, and postoperative renal functions. METHODS: This prospective randomized study involved 50 patients undergoing hepatobiliary surgery who were randomly and equally allocated into terlipressin group, or a control group. The terlipressin group received an initial bolus dose of (1 mg over 30 min) followed by a continuous infusion of 2 µg/kg/h throughout the procedure and gradually weaned over the first four postoperative hours, whereas the control group received the same volumes of normal saline. The portal venous pressure changes were measured directly through a portal vein angiocatheter. RESULTS: Portal pressure was significantly reduced over time in the terlipressin group only (from 17.88 ± 7.32 to 15.96 ± 6.55 mmHg, p < .001). Mean arterial blood pressure was significantly higher in the terlipressin group. Estimated blood loss was significantly higher in the control group than the terlipressin group (1065.7 ± 202 versus 842 ± 145.5 ml; p = 0.004), and the units of packed RBCs transfused were significantly higher in the control group ((0-2) versus (0-4) p = 0.003). There was no significant difference between groups as regards the incidence of acute kidney injury. CONCLUSION: Intraoperative infusion of terlipressin during hepatobiliary surgery was shown to improve intraoperative portal hemodynamics with subsequent reduction in blood loss. TRIAL REGISTRATION: Clinical trial number and registry URL: Trial registration number: NCT02718599 . Name of registry: ClinicalTrials.gov. URL of registry: https://clinicaltrials.gov/ct2/show/NCT02718599 . Date of registration: March 2016. Date of enrolment of the first participant to the trial: April 2016.

Failure on the American Board of Surgery Examinations of General Surgery Residency Graduates Correlates Positively with States' Malpractice Risk.

It has been suggested that in environments where there is greater fear of litigation, resident autonomy and education is compromised. Our aim was to examine failure rates on American Board of Surgery (ABS) examinations in comparison with medical malpractice payments in 47 US states/territories that have general surgery residency programs. We hypothesized higher ABS examination failure rates for general surgery residents who graduate from residencies in states with higher malpractice risk. We conducted a retrospective review of five-year (2010-2014) pass rates of first-time examinees of the ABS examinations. States' malpractice data were adjusted based on population. ABS examinations failure rates for programs in states with above and below median malpractice payments per capita were 31 and 24 per cent (P < 0.01) respectively. This difference was seen in university and independent programs regardless of size. Pearson correlation confirmed a significant positive correlation between board failure rates and malpractice payments per capita for Qualifying Examination (P < 0.02), Certifying Examination (P < 0.02), and Qualifying and Certifying combined index (P < 0.01). Malpractice risk correlates positively with graduates' failure rates on ABS examinations regardless of program size or type. We encourage further examination of training environments and their relationship to surgical residency graduate performance.

Immediate Auditory Feedback is Superior to Other Types of Feedback for Basic Surgical Skills Acquisition.

OBJECTIVE: We examined the effect of timing and type of feedback on medical students' knot-tying performance using visual versus auditory and immediate versus delayed feedback. We hypothesized that participants who received immediate auditory feedback would outperform those who received delayed and visual feedback. METHODS: Sixty-nine first- and second-year medical students were taught to tie 2-handed knots. All participants completed 3 pretest knot-tying trials without feedback. Participants were instructed to tie a knot sufficiently tight to stop the "blood" flow while minimizing the amount of force applied to the vessel. Task completion time was not a criterion. Participants were stratified and randomly assigned to 5 experimental groups based on type (auditory versus visual) and timing (immediate versus delayed) of feedback. The control group did not receive feedback. All groups trained to proficiency. Participants completed 3 posttest trials without feedback. RESULTS: There were fewer trials with leak (p < 0.01) and less force applied (p < 0.01) on the posttest compared to the pretest, regardless of study group. The immediate auditory feedback group required fewer trials to achieve proficiency than each of the other groups (p < 0.01) and had fewer leaks than the control, delayed auditory, and delayed visual groups (p < 0.02). CONCLUSIONS: In a surgical force feedback simulation model, immediate auditory feedback resulted in fewer training trials to reach proficiency and fewer leaks compared to visual and delayed forms of feedback.

Common hepatic artery thrombosis after iatrogenic injury in pancreaticodudenectomy operation, unexpected course.

INTRODUCTION: Pancreatic resection is the only effective treatment with prolonged survival in operable pancreatic cancer and peri-ampullary cancer; it is also a procedure of significant morbidity and complications. Vascular injury is one of the most serious intraoperative complications. PRESENTATION OF CASE: We report here a case of common hepatic artery injury during pancreaticodudenectomy followed by complete thrombosis after its repair. As common hepatic artery is the only arterial blood supply of the liver, acute liver failure and necrosis were the usual course. Surprisingly liver enzymes and bilirubin start to improve in post operatively due to small hardly detected accessory left and middle hepatic artery. DISSCUSSION AND CONCLUSION: Although hepatic artery is the only arterial supply of the liver, occasionally small accessory arteries may give significant arterial blood supply. In such a situation liver enzymes act as surrogate markers to assess the sufficiency of this flow to the liver.