Global parental leave in surgical careers: differences according to gender, geographical regions and surgical career stages.

BACKGROUND: There is a lack of information regarding the provision of parental leave for surgical careers. This survey study aims to evaluate the experience of maternity/paternity leave and views on work-life balance globally. METHODS: A 55-item online survey in 24 languages was distributed via social media as per CHERRIES guideline from February to March 2020. It explored parental leave entitlements, attitude towards leave taking, financial impact, time spent with children and compatibility of parenthood with surgical career. RESULTS: Of the 1393 (male : female, 514 : 829) respondents from 65 countries, there were 479 medical students, 349 surgical trainees and 513 consultants. Consultants had less than the recommended duration of maternity leave (43.8 versus 29.1 per cent), no paid maternity (8.3 versus 3.2 per cent) or paternity leave (19.3 versus 11.0 per cent) compared with trainees. Females were less likely to have children than males (36.8 versus 45.6 per cent, P = 0.010) and were more often told surgery is incompatible with parenthood (80.2 versus 59.5 per cent, P < 0.001). Males spent less than 20 per cent of their salary on childcare and fewer than 30 hours/week with their children. More than half (59.2 per cent) of medical students did not believe a surgical career allowed work-life balance. CONCLUSION: Surgeons across the globe had inadequate parental leave. Significant gender disparity was seen in multiple aspects.

Percutaneous Retroperitoneal Splenorenal Shunt for Symptomatic Portal Vein Thrombosis After Liver Transplantation.

Acute or recurrent bleeding from ectopic varices is a potentially life-threatening condition in rare patients with extrahepatic complete portal vein thrombosis (PVT) after liver transplantation (LT). In this setting, the role of interventional radiology is very limited and surgical shunts, in particular splenorenal shunts are usually used, despite the high associated mortality. We present the first reports of the clinical use of a new minimally invasive technique, percutaneous retroperitoneal splenorenal shunt (PRESS), in two LT recipients with life-threatening variceal hemorrhage secondary to PVT. Both patients had a successful PRESS using a transplenic approach with resolution of bleeding, avoiding the need for a potentially complicated laparotomy. The PRESS procedure is a useful addition to the interventional armamentarium that can be used in cases unsuitable for surgical shunt, and refractory to endoscopic management. In the future, this technique may be an alternative to surgical shunts as the standard procedure in patients with extra-hepatic PVT, just as the transjugular intrahepatic portosystemic shunt (TIPS) procedure has become for the management of portal hypertension in the absence of PVT. Longer-term follow-up will be needed to establish the long-term success of this procedure.

Increasing liver transplantation waiting list mortality: a report from the Australian National Liver Transplantation Unit, Sydney.

BACKGROUND: We aimed to describe the demand for liver transplantation (LTx) and patient outcomes on the waiting list at the Australian National Liver Transplantation Unit, Sydney over the last 20 years. METHODS: We performed a retrospective analysis with the data divided into three eras: 1985-1993, 1994-2000 and 2001-2008. RESULTS: The number of patients accepted for LTx increased from 320 to 372 and 548 (P < 0.001) with the number of LTx being performed increasing from 262 to 312 and 452 respectively (P < 0.001). The median adult recipient age increased from 45 to 48 and 52 years (P < 0.001) while it decreased in children from 4 to 2 and 1 years respectively (P = 0.001). In parallel, the deceased donor offers decreased from 1003 to 720 and 717 (P < 0.001). Methods to improve access to donor livers have been used with the use of split livers, extended criteria and non-heart beating donors, resulting in increased acceptance of deceased donor offers by 65% and 115% in the second and third eras when compared with the first era (P < 0.001). However, the adult median waiting time has increased from 23 to 41 and 120 days respectively (P < 0.001). This was associated with increased adult mortality on the waiting list from 23 to 40 and 122 respectively (P < 0.001). CONCLUSIONS: Despite the increasing proportion of donor offers being used, the waiting list mortality is increasing. A solution to this problem is an increase in organ donation to keep pace with the escalating demand for LTx.

Increased risk of hemorrhagic complications in renal allograft recipients receiving systemic heparin early posttransplantation.

UNLABELLED: The aim of this paper is to document the risk of hemorrhagic complications in renal allograft recipients requiring systemic heparinisation within the first 2 weeks posttransplantation. METHODS: A retrospective chart review of 326 RA recipients from January 1998 to July 2003 was subjected to statistics by SPIDA with P values <.05 considered significant. RESULTS: 16/326 (4.9%) recipients were initiated on intravenous (IV) heparin within the study period. Enoxaparin was subsequently used in 10/16 (62.5%) of these recipients. Intravenous heparin was instituted at a median 8 (1-14) days posttransplantation. Hemorrhagic complications occurred in 10/16 (62.5%) recipients on IV heparin versus 11/310 (3.5%) nonanticoagulated RA recipients (P = .0001). Hemorrhage occurred at a mean 9.75 (2-43) days into the course of IV heparin. The median peak APTT 24 hours prior to hemorrhage in RA recipients on heparin was 68.5 (58-180) versus a median peak APTT of 70 (50-140) among recipients on heparin who did not sustain a hemorrhagic complication (P = .30). A major intervention (predominantly surgery) was required in 6/16 (37%) recipients on IV heparin versus 7/310 (2.2%) nonheparinised RA recipients (P < .0001). Enoxaparin was instituted at a mean 22.5 (4-55) days posttransplantation. Delayed hemorrhage subsequently occurred in 4/10 (40%) recipients on enoxaparin. In conclusion, major and minor hemorrhagic complications occur more commonly among recipients requiring early post transplant IV heparin. Hemorrhage occurred despite APTT monitoring with APTT levels tending to be similar in RA recipients with versus without complications. Delayed hemorrhage was also seen with the subsequent use of enoxaparin.

A giant multiacinar macroregenerative nodule in an explanted liver.

Macroregenerative nodules (MRN) have been detected with increased incidence in explanted livers since orthotopic liver transplantation (OLTx) has become a routine treatment for end-stage liver disease. Autopsy series suggest that MRN may be more common than once thought, and several studies point to the malignant potential of these lesions. With increasing waiting times for OLTx, the propensity for these premalignant lesions to arise in cirrhotic livers has important implications for the supervision of patients on OLTx waiting lists. We present here a striking example of a MRN and review a topic that is generating considerable interest.

Inferior liver allograft survival from cadaveric donors >50 years of age?

The growing imbalance between the number of cadaveric organ donors and recipients has led to an increasing use of high-risk donors as an option to expand the donor pool. The aim of this study was to evaluate our experience with the use of older liver (donor>50 yr of age) allografts. The medical records, postreperfusion biopsies and laboratory results were reviewed of the 393 patients who underwent orthotopic liver transplantation between 1986 and 1997. The outcome of the 61 patients who received older livers (OL) was compared to that of the other 332 recipients. Increasing use of OL was evident from 1992 onwards. Recipients of OL were older than recipients of younger livers (YL, p<0.001) and more commonly had underlying chronic viral hepatitis (CVH) or fulminant hepatic failure (p<0.05). Patient and allograft survival were only slightly less in recipients of OL versus YL (p=NS). Although postperfusion biopsies showed more damage in OL than YL allografts (p<0.05), this was not associated with increased primary graft failure. OL allografts can be transplanted with acceptable results into recipients without the concern of early allograft loss. SUMMARY OF ARTICLE: This report of one centre's experience with 61 recipients of older donor liver allografts identifies recipient factors that may also have a negative impact on allograft outcome. These factors include a diagnosis of either CVH or fulminant hepatic failure at the time of transplantation. Postreperfusion biopsies of older donor allografts tend to show more damage, but this is not associated with primary non-function.

Factors in older cadaveric organ donors impacting on renal allograft outcome.

Transplantation of renal allografts (RA) from older donors has become more common, despite conflicting data on outcome between reports from large series versus individual centres. Factors other than donor age per se may contribute to RA outcome. The outcome of RA procured from 114 older donors over 55 yr of age in NSW, between 1990 and 1997, was analysed. Corresponding donor factors, including demographics, medical history, inotrope use, major hypotension and findings at procurement, were also analysed. Of the potential RA, 8% were discarded and the remainder transplanted. Factors significantly associated with renal discard were pre-transplantation donation biopsy abnormality (p < 0.001) and a history of cardiovascular (CV) disease in the donor (p < 0.02). Donor aortorenal atherosclerosis (AS; p < 0.09) and a donor age of 65 yr or older (p < 0.08) were common in the discard group. The never function rate was 7.6% and was associated with a history of a discarded partner kidney (p < 0.05). The delayed graft function rate was 33% and was associated with a history of donor CV disease. At a median follow up of 5 yr, the death censored allograft failure rate was 24%. Allograft failure was associated with a history of donor hypertension (p < 0.05). Donor AS (p < 0.7) tended to have been more common in the allograft failure group. A number of cadaveric organ donor factors documented at procurement may be associated with inferior outcome of RA. These include biopsy abnormality, history of donor CV disease and history of donor hypertension. A donor age of 65 yr or older or significant visible aortorenal AS may also be factors. This retrospective review of kidneys procured from 114 older cadaveric organ donors identifies factors apart from donor age, which may have a negative impact on both allograft utilisation and outcome. Theses factors include renal biopsy abnormality, history of donor CV disease, discard of a partner kidney and donor hypertension. Visible AS in the donor aorta documented at renal procurement may also be a factor.

Analysis of postrevascularization syndrome after orthotopic liver transplantation: the experience of an Australian liver transplantation center.

BACKGROUND/PURPOSE: We investigated the causes and examined patient outcomes following the postrevascularization syndrome (PRS) during orthotopic liver transplantation (OLTx). METHODS: PRS was defined as a fall in the mean arterial pressure at 5 min after revascularization to less than 70% of the baseline and lasting for 5 min. Data from 100 adult patients who underwent OLTx between January 1998 and September 2000 were analyzed. Analyzed data included donor and recipient demographic data, recipient operative and postoperative courses, and recipient outcome. RESULTS: Twenty-nine patients (29%) exhibited PRS during OLTx (PRS group). There was a higher incidence of older donors (>50 years) in the PRS group (48% vs 23%; P < 0.05). Postrevascularization hyperkalemia and metabolic acidosis were observed in both the PRS and non-PRS groups. Transaminase and lactate levels after revascularization were significantly higher in the PRS group ( P < 0.05). Alkaline phosphatase and gamma-glutamyl transpeptidase levels on day 7 tended to be higher in the PRS group; although the difference was not significant (p > or = 0.05). Serum creatinine was significantly elevated on day 7 in the PRS group ( P < 0.01). CONCLUSIONS: Our results indicate that PRS following OLTx tended to be more common in liver allografts from older donors and was associated with posttransplantation liver and renal dysfunction.