Early experience with pure laparoscopic donor hepatectomy: comparison with open donor hepatectomy and non-donor laparoscopic hepatectomy.

BACKGROUND: Pure laparoscopic donor hepatectomy (L-DH) has seen a rise in uptake in recent years following the popularization of minimally invasive modality for major hepatobiliary surgery. Our study aimed to determine the safety and compare the perioperative outcomes of L-DH with open donor hepatectomy (O-DH) and laparoscopic non donor hepatectomy (L-NDH) based on our single institution experience. METHODS: Eighty of 113 laparoscopic hemi-hepatectomies performed between 2015 and 2022 met study inclusion criteria. Of these, 11 were L-DH. PSM in a 1:2 ratio of L-DH versus L-NDH and 1:1 ratio of L-DH versus O-DH were performed, identifying patients with similar baseline clinicopathological characteristics. RESULTS: After 2:1 matching, the L-DH cohort were significantly younger (P < 0.001) and had lower ASA scores (P < 0.001) than the L-NDH cohort. L-DH was associated with a longer median operating time (P < 0.001) and shorter median postoperative stay (P < 0.001) than L-NDH. After 1:1 matching, there were no significant differences in baseline demographic between the L-DH and O-DH cohorts. L-DH was associated with lower median blood loss (P = 0.040) and shorter length of stay compared to O-DH (P = 0.004). There were no significant differences in recipient outcomes for both cohorts. CONCLUSION: L-DH can be adopted safely by surgeons experienced in L-NDH and ODH. It is associated with decreased blood loss and shorter length of stay compared to O-DH.

Management of Spontaneous Aortic Thrombus Following Cisplatin-Based Chemotherapy in Urothelial Cancer: A Case Report.

Spontaneous aortic thrombosis is exceedingly rare, and optimal treatment remains uncertain. We present an unusual case of a spontaneous aortic thrombus at the renal artery level in a patient undergoing active cisplatin treatment for urothelial carcinoma. Management included catheter-directed thrombolysis followed by thrombectomy. An open cutdown was performed on the left common femoral artery (CFA), with right groin access via a 6-Fr sheath. Clamping of the left superficial and deep femoral arteries, along with balloon occlusion of the right common iliac artery, prevented distal embolization. A Coda balloon introduced via direct left CFA puncture with a 20-Fr sheath was positioned above the aortic thrombus. After inflation, clots were trawled to the sheath, "sandwiching" the clots before removal of the balloon and sheath via the left groin. Post-operatively, the patient recovered well and received continued therapeutic anticoagulation.

The neutrophil-to-lymphocyte ratio and lactate dehydrogenase combined in predicting liver metastasis and prognosis of colorectal cancer.

Background: The neutrophil-to-lymphocyte ratio (NLR) and lactate dehydrogenase (LDH) level are inflammatory markers related to tumor growth and metabolism. This study investigated the value of preoperative NLR, LDH and the combination of NLR and LDH (NLR-LDH) for predicting colorectal cancer liver metastasis (CRLM) and tumor prognosis in the early stages of colorectal cancer (CRC). Materials and methods: Three hundred patients undergoing CRC resection were included. Logistic regression analysis was used to estimate the correlation between CRLM time and inflammatory markers, and Kaplan-Meier survival and Cox regression analyses were used to estimate overall survival (OS). Forest plots were prepared based on the multivariate Cox analysis model and evaluated by receiver operating characteristic (ROC) curve analysis. Results: The NLR cut-off value was 2.071 according to the ROC curve. The multivariate analysis showed that the elevated LDH level and a high NLR-LDH level were independent predictors of synchronous CRLM and OS (p < 0.05). The combination of a high NLR and elevated LDH and NLR-LDH levels suggested a poor prognosis and a significantly shorter median survival time than a low NLR and low levels of LDH and NLR-LDH. The ROC curve analysis results illustrated that the predictive value of the NLR-LDH score for synchronous CRLM [area under the curve (AUC) = 0.623, p < 0.001] and OS (AUC = 0.614, p = 0.001) was superior to that of the NLR or LDH score used alone. Conclusion: LDH and NLR-LDH are reliable, easy-to-use, independent biomarkers for predicting synchronous or metachronous CRLM and OS in CRC patients. The NLR is an important monitoring index for CRLM. Preoperative NLR, LDH and NLR-LDH may help to guide the use of therapeutic strategies and cancer surveillance.

Preoperative Predictors of Early Recurrence After Liver Resection for Multifocal Hepatocellular Carcinoma.

BACKGROUND: Liver transplantation remains the optimal treatment for multifocal hepatocellular carcinoma (HCC). However, due to resource constrains, other therapeutic modalities such as liver resection (LR), are frequently utilized. LR, however, has to be balanced against potential morbidity and mortality along with the risks of early recurrence leading to futile surgery. In this study, we evaluated preoperative factors, including inflammatory indices, in predicting early (< 1 year) recurrence in patients who underwent LR for multifocal HCC. METHODS: This was a post hoc analysis of 250 consecutive patients with multifocal HCC who underwent LR. RESULTS: After exclusion of 10 patients with 30-day/in-hospital mortality, 240 were included of which 134 (55.8%) developed early recurrence. Hepatitis B/C aetiology, 3/ > more hepatic nodules and elevated alpha-fetoprotein (AFP) ≥ 200 ng/ml were significant independent preoperative predictors of early recurrence. The early recurrence rate was 72.1% when 2 out of 3 significant predictive factors were present. The conglomerate of all 3 factors predicted early recurrence of 100% with a statistically significant association between number of predictive factors and early recurrence (p < 0.001). CONCLUSION: Better patient selection via the use of preoperative predictive factors of early recurrence such as hepatitis B/C aetiology, ≥ 3 nodules and elevated AFP ≥ 200 ng/ml may assist in identifying patients in whom LR is deemed futile and improve resource allocation.

Treatment of a Delayed Type IIIb Endoleak 20 Years Post EVAR With Inverted Contralateral Limb Custom-Made Device: A Case Report.

PURPOSE: Type III endoleak can be difficult to distinguish from Type I endoleak. Depending on the stent graft anatomy, the use of standard bifurcated endografts may not be technically feasible, and patients may have to be subject to an aorto-uni-iliac repair with femoral-femoral bypass or open surgery. CASE REPORT: We report a case of an 86-year-old male who had a Type IIIb endoleak 20 years post EVAR which was characterized on angiography to be from a hole close to the bifurcation limb origin. The initial Talent (Medtronic, Santa Rosa, California) device had a 50 mm main body common trunk, which was not amenable to treatment with standard devices. He was successfully treated with a custom-made device with an inverted contralateral limb. CONCLUSIONS: Our case highlights the need for lifelong surveillance post EVAR as endoleak may present decades post initial EVAR. It also demonstrates that many Type III endoleak which were otherwise deemed unsuitable for treatment with standard devices may potentially be treatable with custom-made device (CMD). This solution preserves a percutaneous option in a now older person which avoids surgical bypass. Further studies are required to establish the durability of this treatment and survey for recurrence.

Utility of paclitaxel-coated balloons for the treatment of infrainguinal disease in the Asian population - 24-month outcome data from the BIOLUX P-III Global Registry 24-month Asian outcomes of BIOLUX P-III.

BACKGROUND: Results from the BIOLUX P-III registry have demonstrated favourable outcomes of Passeo-18 Lux™ (Biotronik®, Buelach, Switzerland) drug-coated balloon in treating obstructive infrainguinal peripheral artery disease, but it has not been established if Asians would benefit to the same extent as non-Asians. METHODS: A subgroup analysis was performed on the 24-month data comparing the Asian cohort (AC) to non-Asian cohort (NAC). RESULTS: AC included 49 patients with 77 lesions. AC was significantly younger (65.6 vs 70.3 years, p < 0.05), had more diabetes (87.8% vs 45.3%, p < 0.05), and was more likely to present with CLTI (73.5% vs 35.3%, p < 0.001) compared to NAC. They had significantly longer mean target lesions (115 vs 86.9 mm, p = 0.006), and received significantly higher paclitaxel doses (10.7 vs 7.2 mg, p = 0.0005). Device, technical and procedural successes were 125/125(100%), 95/97(97.5%) and 45/49(91.8%), respectively. There was no significant difference in target lesion revascularization rates between groups (10.5% vs 12%, p = 0.91). However, the AC had more major adverse events (30.2% vs 16.1%, p = 0.001), amputations (26.3% vs 6.2%, p < 0.05) and mortality (37.9% vs 10.6%, p < 0.05) at 24 months. CONCLUSION: Passeo-18 Lux™ use was efficacious in Asians, but was associated with higher adverse events, amputations and mortality rates, likely attributable to poorer patient comorbidities and more extensive PAD.

Systematic review and meta-analysis of difficulty scoring systems for laparoscopic and robotic liver resections.

INTRODUCTION: The ability to stratify the difficulty of minimally invasive liver resection (MILR) allows surgeons at different phases of the learning curve to tackle cases of appropriate difficulty safely. Several difficulty scoring systems (DSS) have been formulated which attempt to accurately stratify this difficulty. The present study aims to review the literature pertaining to the existing DSS for MILR. METHODS: We performed a systematic review and metanalysis of the literature reporting on the formulation, supporting data, and comparison of DSS for MILR. RESULTS: A total of 11 studies were identified which reported on the formulation of unique DSS for MILR. Five of these (Ban, Iwate, Hasegawa, Institut Mutaliste Montsouris [IMM], and Southampton DSS) were externally validated and shown to predict difficulty of MILR via a range of outcome measures. The Ban DSS was supported by pooled data from 10 studies (9 LLR, 1 RLR), Iwate by 10 studies (8 LLR, 2 RLR), Hasegawa by four studies (all LLR), IMM by eight studies (all LLR), and Southampton by five studies (all LLR). There was no clear superior DSS. CONCLUSION: The existing DSS were all effective in predicting difficulty of MILR. Present studies comparing between DSS have not established a clear superior system, and the five main DSS have been found to be predictive of difficulty in LLR and two of these in RLR.

The Functional, Psychological and Economic Impacts 6 Months Post Major Trauma

Purpose@#The consequences of severe traumatic injury extend beyond hospital admission and have the potential for long-term functional, psychological, and economic sequalae. This study investigated patient outcomes 6 months following major trauma. @*Methods@#Using the National Trauma Registry, database of patients who were admitted between 2016-18 in a tertiary trauma hospital for major trauma [Injury Severity Score (ISS) ≥ 16] a review was performed on 6-month outcomes [including functional outcomes, self-reported state of health and outcome scores (EuroQol-5 Dimension score and Glasgow Outcome Scale Extended)].Result: There were 637 patients who were treated for major trauma (ISS ≥ 16); the median age was 64 years (range 16-100) and 435 (68.3%) patients were male. The most common injury mechanisms included falling from height (56.5%) and motor vehicle accident (27.0%). The median ISS was 24 (range 16-75). After 6 months, 87.6% of responders were living at home, 25.0% were back to work, and 55.1% were ambulating independently. The median self-rated state of health was 73 at baseline and 64 at 6 months. Age and length of stay were independent predictors of return to ambulation using multivariate analysis. Age, Abbreviated Injury Scale external, Glasgow Coma Scale on Emergency Department arrival, heart rate, and need for transfusion were independent predictors of failure to return to work at 6 months using multivariate analysis. Charlson Comorbidity Index, Glasgow Coma Scale on arrival, temperature, pain and need for inpatient rehabilitation were independent predictors of mortality at 6 months. @*Conclusion@#Recovery from major trauma is multi-faceted and requires a team-based approach well beyond discharge.

Effect of clinical pharmaceutical care on our outpatient service of Traditional Chinese Medicine pharmacy / 药学实践杂志

Objective To explore the role of clinical pharmaceutical care in outpatient service of traditional Chinese medicine. Methods Two hundred patients who were not taking medicines for the first time (had received routine medication explanations) and had made an appointment for the next outpatient TCM service were randomly selected for questionnaire survey during July to October, 2021. After the intervention of clinical pharmacy care, the questionnaire survey was conducted again, and the results of the questionnaire survey of patients before and after the clinical pharmacy care were compared. Results After clinical pharmacy intervention, the scores of eight questions in the questionnaire were significantly improved (except for the awareness of taking drugs, P values of the other seven items were all <0.05). Conclusion The development of TCM clinical pharmaceutical care could effectively improve patients' safety awareness of medication safety. The patients' awareness of the use of Traditional Chinese Medicine and medication compliance had also been significantly improved. The awareness of pharmacists role in patients was enhanced. The outpatient pharmaceutical care of Traditional Chinese Medicine was effectively improved, which is important to rational drug use.

Research Status and Prospects of Non-Traumatic Fat Embolism in Forensic Medicine.

In the practice of forensic pathology, fat embolism is one of the common causes of death, which can be divided into two categories: traumatic and non-traumatic. Non-traumatic fat embolism refers to the blockage of small blood vessels by fat droplets in the circulatory blood flow caused by non-traumatic factors such as underlying diseases, stress, poisoning and lipid metabolism disorders. At present, it is believed that the production of non-traumatic fat embolism is related to the disturbance of lipid metabolism, C-reactive protein-related cascade reaction, the agglutination of chylomicron and very low-density lipoprotein. The forensic identification of the cause of death of non-traumatic fat embolism is mainly based on the case, systematic autopsy, HE staining and fat staining, but it is often missed or misdiagnosed by forensic examiners because of its unknown risk factors, hidden onset, the difficulty of HE staining observation and irregular implementation of fat staining. In view of the lack of attention to non-traumatic fat embolism in forensic identification, this paper reviews the concepts, pathophysiological mechanism, research progress, existing problems and countermeasures of non-traumatic fat embolism, providing reference for forensic scholars.

Laparoscopic versus open caudate lobe liver resections: a 1:2 propensity score-matched controlled study based on a single institution experience.

BACKGROUND: Despite the wide use of laparoscopy for liver resection, laparoscopic caudate lobe resections(L-CLR) remain technically challenging, only attempted by experts in the field. The primary objective of this study was to determine the safety and compare the perioperative outcomes of L-CLR with O-CLR based on our single institution experience in a 1:2 propensity score-matched controlled study based on our single institution experience. METHODS: Between 2004 and 2020, 67 consecutive patients who underwent CLR at Singapore General Hospital were identified. Propensity score matching (PSM) of laparoscopic versus open caudate lobe resections(O-CLR) was performed in a 1:2 ratio with no replacements using nearest neighbour matching method. RESULTS: L-CLR was associated with a significantly decreased median blood loss (150 mL versus 500 mL, P = 0.001) and a decreased median post-operative stay (3 days versus 7.5 days, P = <0.01) in the unmatched cohorts. After 1:2 propensity score matching, these results were again demonstrated with a significantly lower blood loss (150 mL versus 400 mL, P = 0.016) and a shorter postoperative stay (3 days versus 7 days, P = <0.01) in favour of L-CLR. 30-day readmission and major morbidity (Clavien-Dindo grade > 2) rates were all in favour of L-CLR as well but could not reach statistical significance. CONCLUSION: L-CLR can be safely performed by experienced surgeons. It is associated with decreased blood loss and shorter perioperative stay compared to O-CLR.

Comparison of the use of allogenic acellular dermal matrix on rates of Frey syndrome post parotidectomy: A systematic review and meta-analysis.

OBJECTIVE: The aim of this study was to evaluate the efficacy of acellular dermal matrix (ADM) use in reducing Frey syndrome (FS) rates in patients postparotidectomy. STUDY DESIGN: We performed a systematic review and meta-analysis of existing literature comparing rates of FS with and without ADM use. RESULTS: Eight studies were shortlisted for qualitative study, of which 7 compared rates of FS with and without the use of ADM. A total of 211 patients underwent parotidectomy with the use of ADM. Of these, mean patient age was 44.7 (SD ± 7.2); 89 of 159 were pleomorphic adenoma (55.9%), 29 of 159 with histological diagoses stated were Warthin's tumor (18.2%), and 159 of 211 were other histologic diagnoses (25.7%). Subjective and objective incidence rates for FS were 23 of 211 (10.9%) and 7 of 211 (3.3%), respectively. Patients in whom ADM barriers were used had significantly lower rates of subjective and objective FS (relative risk = 0.22; 95% confidence interval, 0.09-0.57; P = .002; and relative risk = 0.07; 95% confidence interval, 0.07-0.33; P < .001), respectively, compared to patients with no ADM. CONCLUSION: The use of ADM was associated with lower FS rates compared to no ADM and should be considered in routine use to prevent this condition.

Breast metastasis presenting as swelling with calcification - A case report and review of the literature.

Primary breast carcinomas often present as ill-defined, infiltrative lesions which may contain calcifications, whereas metastatic cancers from non-mammary sites are often more well-circumscribed, sharply demarcated from the adjacent breast tissue and are usually not associated with calcifications, although there are exceptions. We report an atypical case of a lady with lung adenocarcinoma with pleural involvement, who presented with diffuse breast swelling with calcifications on imaging from metastatic lung adenocarcinoma, the first of its kind in the literature. We postulate that the pathophysiology of this was due to lymphatic spread of the tumour from the pleura resulting in retrograde lymphovascular congestion of the breast, resulting in swelling and dystrophic calcification.

Minimally Invasive vs Open Major Hepatectomies for Liver Malignancies: a Propensity Score-Matched Analysis.

BACKGROUND: The majority of evidence with regards to minimally invasive liver resection (MILR) favors its application in minor hepatectomies. We conducted a propensity score-matched (PSM) analysis to determine its feasibility and safety in major hepatectomies (MIMH) for liver malignancies. METHODS: Retrospective review of 130 patients who underwent MIMH and 490 patients who underwent open major hepatectomy (OMH) for malignant pathologies was performed. PSM in a 1:1 ratio identified two groups of patients with similar baseline clinicopathological characteristics. Perioperative outcomes were then compared. Major hepatectomies included traditional major (>3 segments) and technical major hepatectomies (right anterior and right posterior sectionectomies). RESULTS: Both cohorts were well-matched for baseline characteristics after PSM. Of 130 MIMH cases, there were 12 conversions to open. Comparison of perioperative outcomes demonstrated a significant association of MIMH with longer operation time and more frequent application of Pringle's maneuver (PM), but decreased postoperative stay. These results were consistent on a subgroup analysis that only included patients undergoing traditional major hepatectomies. A second subgroup analysis restricted to cirrhotic patients demonstrated that while perioperative outcomes were equivalent, MIMH was similarly associated with a longer operative time. Subset analyses of resections performed after 2015 demonstrated that MIMH was additionally associated with a lower postoperative morbidity compared to OMH. CONCLUSION: Comparison of perioperative and short-term oncological outcomes between MIMH and OMH for malignancies demonstrated that MIMH is feasible and safe. It is associated with a shorter hospital stay at the expense of a longer operation time compared to OMH.

Endoleak Complicated by communicating psoas abscess and aorto-enteric fistula in an immunocompromised patient.

PURPOSE: While endovascular repair of aortic aneurysm (EVAR) has become the mainstay treatment for abdominal aortic aneurysm (AAA), it is not without its disadvantages. Feared complications include graft infections, fistulation and endoleak, the outcomes of which may be life limiting. CASE REPORT: We present a case of a 57 year-old patient with human immunodeficiency virus (HIV) previously treated with EVAR for AAA complicated by endoleak post treatment. He developed an aorto-psoas abscess 2 years later which harboured Mycobacterium avium complex, and medical therapy was unsuccessful. He eventually underwent an extra-anatomical bypass and graft explant, for which an aortoenteric fistula was also discovered and repaired. CONCLUSION: Infection of endografts post EVAR is relatively rare, and there are presently no guidelines concerning its management. The concomittance of aorto-psoas abscess and aortoenteric fistula is even more uncommon, and necessitated surgical explant for source control purposes in our patient. Lifelong surveillance is required for complications of the aortic stump and bypass patency.

Microbial spectrum and drug resistance of pathogens cultured from gallbladder bile specimens of patients with cholelithiasis: A single-center retrospective study.

BACKGROUND: Bacterial infection is an important cause of cholelithiasis or gallstones and interferes with its treatment. There is no consensus on bile microbial culture profiles in previous studies, and identified microbial spectrum and drug resistance is helpful for targeted preventive and therapeutic drugs in the perioperative period. AIM: To analyze the bile microbial spectrum of patients with cholelithiasis and the drug susceptibility patterns in order to establish an empirical antibiotic treatment for cholelithiasis-associated infection. METHODS: A retrospective single-center study was conducted on patients diagnosed with cholelithiasis between May 2013 and December 2018. RESULTS: This study included 185 patients, of whom 163 (88.1%) were diagnosed with gallstones and 22 (11.9%) were diagnosed with gallstones and common bile duct stones (CBDSs). Bile culture in 38 cases (20.5%) was positive. The presence of CBDSs (OR = 5.4, 95%CI: 1.3-21.9, P = 0.03) and longer operation time (> 80 min) (OR = 4.3, 95%CI: 1.4-13.1, P = 0.01) were identified as independent risk factors for positive bile culture. Gram-negative bacteria were detected in 28 positive bile specimens, and Escherichia coli (E. coli) (19/28) and Klebsiella pneumoniae (5/28) were the most frequently identified species. Gram-positive bacteria were present in 10 specimens. The resistance rate to cephalosporin in E. coli was above 42% and varied across generations. All the isolated E. coli strains were sensitive to carbapenems, with the exception of one imipenem-resistant strain. K. pneumoniae showed a similar resistance spectrum to E. coli. Enterococcus spp. was largely sensitive to glycopeptides and penicillin, except for a few strains of E. faecium. CONCLUSION: The presence of common bile duct stones and longer operation time were identified as independent risk factors for positive bile culture in patients with cholelithiasis. The most commonly detected bacterium was E. coli. The combination of ß-lactam antibiotics and ß-lactamase inhibitors prescribed perioperatively appears to be effective against bile pathogens and is recommended. Additionally, regular monitoring of emerging resistance patterns is required in the future.

Research Status and Prospects of Non-Traumatic Fat Embolism in Forensic Medicine / 法医学杂志

In the practice of forensic pathology, fat embolism is one of the common causes of death, which can be divided into two categories: traumatic and non-traumatic. Non-traumatic fat embolism refers to the blockage of small blood vessels by fat droplets in the circulatory blood flow caused by non-traumatic factors such as underlying diseases, stress, poisoning and lipid metabolism disorders. At present, it is believed that the production of non-traumatic fat embolism is related to the disturbance of lipid metabolism, C-reactive protein-related cascade reaction, the agglutination of chylomicron and very low-density lipoprotein. The forensic identification of the cause of death of non-traumatic fat embolism is mainly based on the case, systematic autopsy, HE staining and fat staining, but it is often missed or misdiagnosed by forensic examiners because of its unknown risk factors, hidden onset, the difficulty of HE staining observation and irregular implementation of fat staining. In view of the lack of attention to non-traumatic fat embolism in forensic identification, this paper reviews the concepts, pathophysiological mechanism, research progress, existing problems and countermeasures of non-traumatic fat embolism, providing reference for forensic scholars.