Abdominal Transplantation Research Articles

Acuity circles allocation policy impact on waitlist mortality and donation after circulatory death liver transplantation: A nationwide retrospective analysis.

Acuity circles allocation policy impact on waitlist mortality and donation after circulatory death liver transplantation: A nationwide retrospective analysis.

Abdominal transplantation of pancreatic islets to protect against type 1 diabetes.

Abdominal transplantation of pancreatic islets to protect against type 1 diabetes.

CYP3A5 Polymorphisms Leading to Tacrolimus Toxicity Following an Adult Renal Transplant.

Tacrolimus is one of the calcineurin inhibitors used for maintaining immuno-suppression in thoracic and abdominal transplantations including heart, lung, liver, intestine, pancreas, and renal transplants. It has a narrow therapeutic window requiring therapeutic drug monitoring (TDM). Genetic polymorphism in the expression of cytochrome P3A5 enzyme plays a significant role in the bioavailability of tacrolimus in patients, leading to toxicity or rejection. In this case, we studied a renal transplant patient who received a standard dose of tacrolimus and experienced toxicity related to the poor expression of cytochrome P450 3A5 (CYP3A5), which required the withholding of tacrolimus and cutting the dose for several days with more frequent TDM. Similar cases have been reported before, yet there is no consensus on the appropriate dosage. The projected cost of additional TDM and hospitalization significantly exceeds the one-time cost of genetic CYP3A5 testing. In high-risk renal transplant recipients, pharmacogenetic testing must be considered to cut the time to limit TDM, prevent extended hospitalization, and reduce the total cost of transplantation.

Cross-fellowship inter-institutional exchange: A new paradigm in hepatobiliary surgery training

Background: Surgeons performing complex hepatobiliary surgery come from diverse training pathways, including hepatobiliary, surgical oncology and abdominal transplant fellowships. Although focused on similar pathologies, each fellowship emphasizes different technical and didactic aspects of training. Additionally, as treatment of hepatobiliary malignancies require multidisciplinary care, each fellowship only exposes trainees to a single institutional paradigm. This abstract evaluates an annual inter-institutional exchange between a surgical oncology and transplant program, a unique and replicable training experience.

Establishing an open and robotic pancreatic surgery program in a level 1 trauma center community teaching hospital and comparing its outcomes to high-volume academic center outcomes: a retrospective review

BackgroundThe debate of whether to centralize hepato-pancreato-biliary surgery has been ongoing. The principal objective was to compare outcomes of a community pancreatic surgical program with those of high-volume academic centers.MethodsThe current pancreatic surgical study occurred in an environment where (1) a certified abdominal transplant surgeon performed all surgeries; (2) complementary quality enhancement programs had been developed; (3) the hospital’s trauma center had been verified; and (4) the hospital’s surgical training had been accredited. Pancreatic surgical outcomes at high-volume academic centers were obtained through PubMed literature searches. Articles were selected if they described diverse surgical procedures. Two-tailed Fisher exact and mid-P tests were used to perform 2 × 2 contingency analyses.ResultsThe study patients consisted of 64 consecutive pancreatic surgical patients. The study patients had a similar pancreaticoduodenectomy proportion (59.4%) when compared to literature patients (66.8%; P = 0.227). The study patients also had a similar distal pancreatectomy proportion (25.0%) when compared to literature patients (31.9%; P = 0.276). The study patients had a significantly higher American Society of Anesthesiologists physical status ≥ 3 proportion (100%) than literature patients (28.1%; P < 0.001). The 90-day study mortality proportion (0%) was similar to the literature proportion (2.3%; P = 0.397). The study postoperative pancreatic fistula proportion was lower (3.2%), when compared to the literature proportion (18.4%; P < 0.001; risk ratio = 5.8). The study patients had a lower reoperation proportion (3.1%) than the literature proportion (8.7%; mid-P = 0.051; risk ratio = 2.8). The study patients had a lower surgical site infection proportion (3.1%) than those in the literature (21.1%; P < 0.001; risk ratio = 6.8). The study patients had equivalent delayed gastric emptying (15.6%) when compared to literature patients (10.6%; P = 0.216). The study patients had decreased Clavien–Dindo grades III–IV complications (10.9%) compared to the literature patients (21.8%; mid-P = 0.018). Lastly, the study patients had a similar readmission proportion (20.3%) compared to literature patients (18.4%; P = 0.732).ConclusionDespite pancreatic surgical patients having greater preoperative medical comorbidities, the current community study outcomes were comparable to or better than high-volume academic center results.

First Report With Medium-term Follow-up of Intestinal Transplantation for Advanced and Recurrent Nonresectable Pseudomyxoma Peritonei.

To report our experience with the combination of radical surgical excision and intestinal transplantation in patients with recurrent pseudomyxoma peritonei (PMP) not amenable to further cytoreductive surgery (CRS). CRS and heated intraoperative peritoneal chemotherapy are effective treatments for many patients with PMP. In patients with extensive small bowel involvement or nonresectable recurrence, disease progression results in small bowel obstruction, nutritional failure, and fistulation, with resulting abdominal wall failure. Between 2013 and 2022, patients with PMP who had a nutritional failure and were not suitable for further CRS underwent radical debulking and intestinal transplantation at our centre. Fifteen patients underwent radical exenteration of affected intra-abdominal organs and transplantation adapted according to the individual case. Eight patients had isolated small bowel transplantation and 7 patients underwent modified multivisceral transplantation. In addition, in 7 patients with significant abdominal wall tumor involvement, a full-thickness vascularized abdominal wall transplant was performed. Two of the 15 patients died within 90 days due to surgically related complications. Actuarial 1-year and 5-year patient survivals were 79% and 55%, respectively. The majority of the patients had significant improvement in quality of life after transplantation. Progression/recurrence of disease was detected in 91% of patients followed up for more than 6 months. Intestinal/multivisceral transplantation enables a more radical approach to the management of PMP than can be achieved with conventional surgical methods and is suitable for patients for whom there is no conventional surgical option. This complex surgical intervention requires the combined skills of both peritoneal malignancy and transplant teams.

Examining the transplant case composition of early-career transplant surgeons.

Fellowship training established by the American Society of Transplant Surgeons and certified by the Transplant Accreditation and Certification Council provides trainees with broad exposure and practice readiness for the core aspects of abdominal transplantation. However, the operative case mix of a new transplant surgeon early in practice is unknown. This study examined the volume and composition of the transplant case mix of early-career transplant surgeons to better inform residents interested in transplantation about potential career opportunities following fellowship. cas 209 early-career transplant surgeons were identified from the UNOS database containing encrypted surgeon-specific identifiers and were included in this study. At 5 years into practice, there were 85 (40.7%) kidney-predominant, 38 (18.2%) liver-predominant, and 86 (41.1%) multiorgan transplant surgeons. Comparing surgeon subgroups, multiorgan surgeons performed more transplants in year 5 of practice than both liver-predominant and kidney-predominant surgeons (both p<.05). This is the first study to describe the transplant case composition of the early-career transplant surgeons. This data can be used to inform aspiring transplant surgeons about potential career opportunities and to assist fellowship programs in guiding and mentoring fellows.

Biophysiological stress and sleep deprivation among abdominal transplant surgery fellows: A prospective multi-institutional study using a wearable device

BackgroundTransplant surgery fellowship is physically and emotionally demanding. The objective of this study was to characterize biophysiological stress and sleep patterns among transplant surgery fellows. MethodsParticipating fellows wore a biophysical monitor over a 28-day period and completed biweekly surveys. Sleep patterns were dichotomized as normal or sleep deprived, and heart rate variability (HRV) was used to assess stress. ResultsSeventeen fellows participated. Fellows were frequently sleep deprived (43.9% of nights) and stress was near universal (87.2% of days). Burnout was reported by 2 fellows (11.8%). Only 4 fellows (23.5%) reported compliance with the Transplant Accreditation and Certification Council managed time policy; these fellows experienced fewer days of stress than non-compliant fellows (79.8% vs 89.2% p = 0.02). ConclusionsThis is the first study to quantify sleep deprivation and stress among transplant fellows. Future work is needed to evaluate the effects of sleep deprivation, and stress on burnout and patient outcomes.

Antagonist of sphingosine 1-phosphate receptor 3 reduces cold injury of rat donor hearts for transplantation

Cold storage is widely used to preserve an organ for transplantation; however, a long duration of cold storage negatively impacts graft function. Unfortunately, the mechanisms underlying cold exposure remain unclear. Based on the sphingosine-1-phosphate (S1P) signal involved in cold tolerance in hibernating mammals, we hypothesized that S1P signal blockage reduces damage from cold storage. We used an in vitro cold storage and rewarming model to evaluate cold injury and investigated the relationship between cold injury and S1P signal. Compounds affecting S1P receptors (S1PR) were screened for their protective effect in this model and its inhibitory effect on S1PRs was measured using the NanoLuc Binary Technology (NanoBiT)-β-arrestin recruitment assays. The effects of a potent antagonist were examined via heterotopic abdominal rat heart transplantation. The heart grafts were transplanted after 24-hour preservation and evaluated on day 7 after transplantation. Cold injury increased depending on the cold storage time and was induced by S1P. The most potent antagonist strongly suppressed cold injury consistent with the effect of S1P deprivation in vitro. In vivo, this antagonist enabled 24-hour preservation, and drastically improved the beating score, cardiac size, and serological markers. Pathological analysis revealed that it suppressed the interstitial edema, inflammatory cell infiltration, myocyte lesion, TUNEL-positive cell death, and fibrosis. In conclusion, S1PR3 antagonist reduced cold injury, extended the cold preservation time, and improved graft viability. Cold preservation strategies via S1P signaling may have clinical applications in organ preservation for transplantation and contribute to an increase in the donor pool.

Modifications in Abdominal Wall Graft Retrieval: When the Donor Closure Is Not Guaranteed

Twenty percent of intestinal transplant recipients will require a surgical alternative to conventional primary abdominal wall closure. Abdominal wall transplant is adevelopingtechnique that is increasingly performed for this purpose in isolated intestinal or multivisceral recipients; however, adequate closure of the donor is paramount while simultaneously obtaining a large enough graft. The aim of this study is to describe alternative surgical techniques for closure of the donor in cases in which abdominal wall graft extraction hinders subsequent donor abdominal closure. We describe the cases of 2 young donors in whom intestinal extraction was not carried out and in whom wall closure was not feasible, following standard techniques after abdominal wall graft extraction. We performed 2 different procedures to obtain adequate closure. 1. Hemifascia and hemiabdominal wall graft extraction: It is an option when the recipients require an extension of the abdominal aponeurosis yet have enough skin to guarantee skin closure. The perfusion of both epigastric arteries is needed. The remaining cutaneous half is used for closing the donor's abdomen.2. Hemiabdominal wall graft extraction: Full-thickness abdominal wall is harvested from the donor, selecting the most vascularized half. It is an alternative for recipients who need a skin implant in addition to an aponeurosis extension. This option should be used for recipients who do not require a large fascial graft but do require a significant cutaneous graft. The nontransplanted half of full-thickness abdominal wall is used for donor closure. Abdominal wall transplant allows forexpansion of the abdominal cavity in organ recipients and reduces the risk of compartmental syndrome and subsequent ischemia. However, the donor wall defect must be considered. The choice of donation technique was based on the magnitude of the defect in the donor as well as the size of defect to be covered in the recipient while ensuring a tight and complete closure of the donor's abdomen. Abdominal wall graft extraction can be performed using nonconventional techniques that account for the extension and type of coverage needed by the recipient while guaranteeing proper closure of the donor.

A novel assessment model for teaching robot-assisted living donor nephrectomy in abdominal transplant surgery fellowship

BackgroundAn increasing number of transplant centers have adopted robot-assisted living donor nephrectomy. Thus, a transplant fellow assessment tool is needed for promoting operative independence in an objective and safe manner. MethodsIn this pilot study, data was prospectively collected on both fellow performance with focus on technique, efficiency, and communication (“overall RO-SCORE”), and operative steps (“operative steps RO-SCORE”). Robotic user performance metrics were analyzed from the da Vinci Xi system, including fellow percent active control time (ACT) and handoff counts. ResultsFrom July 2020 to February 2021, twenty-one robot-assisted donor nephrectomies were performed. In regression analysis, fellow performance (based on both RO-SCOREs and robot % ACT) was significantly associated with both time and case number, with time-to-independence modelled at 8.4–14.2 months, and case number-to-independence estimated at 15–22 cases. Robot user metrics provided valid objective measures alongside RO-SCOREs. ConclusionsThis pilot study provides an effective assessment tool for promoting operative competency in robot-assisted donor nephrectomy among transplant fellows.

Incidence of attrition among early-career abdominal transplant surgeons

BackgroundThe prevalence of burnout and depression among abdominal transplant surgeons has been well described. However, the incidence of early-career transplant surgeons leaving the field is unknown. The objective of this study was to quantify the incidence of attrition among early-career abdominal transplant surgeons. MethodsA custom database from the Organ Procurement and Transplantation Network with encrypted surgeon-specific identifiers was queried for transplant surgeons who entered the field between 2008 and 2019. Surgeons who experienced attrition, defined as not completing a subsequent transplant after a minimum of 5, were identified. Surgeon-specific case volumes, case mix, and recipient outcomes were modeled to describe their association with attrition. ResultsBetween 2008 and 2018, 496 abdominal transplant surgeons entered the field and performed 76,465 transplant procedures. A total of 24.4% (n = 121) experienced attrition, with a median time to attrition of 2.75 years. Attrition surgeons completed fewer kidney (7 vs 21, P < .01), pancreas (0.52 vs 1.43, P < .01), and liver transplants (1 vs 4, P < .01) in their first year of practice. Attrition surgeons completed a smaller proportion of their transplant center’s volume (9% vs 18%, P < .01) and were less likely to participate in pediatric transplants (26.5% vs 52.5%, P < .01) and living donor kidney transplants (64.5% vs 84.5%, P < .01). On multivariable analysis, performing fewer kidney (odds ratio: 0.98, 95% confidence interval: 0.98–0.99) and liver transplants (odds ratio: 0.98, 95% confidence interval: 0.97–0.98) by year 5 and completing a smaller proportion of their centers’ volume (odds ratio: 0.96, 95% confidence interval: 0.94–0.98) were associated with attrition. Furthermore, attrition surgeons had worse allograft and patient survival for liver transplant recipients (both log-rank P < .01). ConclusionThis investigation was the first to quantify the high incidence of attrition experienced by early-career abdominal transplant surgeons and its association with surgeon-specific case volumes, case mix, and worse recipient outcomes. These findings suggested the abdominal transplant workforce is struggling to retain their fellowship-trained surgeons.

337.2: Comparison of Hypothermic Static and Normothermic Ex-situ Donor Heart Preservation in Heterotopic Heart Transplantation With the Murine Model

Introduction and Background: Hypothermic static and Normothermic ex-situ preservation methods are the most widely used preservation technique worldwide. While cold static storage is associated with subsequent ischemic injury, Normothermic perfusion preservation has the potential to elongate preservation time with less ischemia. The current study compares the hypothermic and normothermic preservation methods in terms of graft performance, morphologic changes, and acute immune response in an experimental model. Materials and Method: Twenty-five rats underwent heterotopic abdominal heart transplantation after two hours of donor heart hypothermic storage (HT group; n=10) or normothermic ex-situ preservation (NT group; n=15). Blood samples were obtained just before and after 4-hours of implantation to analyze surface markers of immune cells (CD4, CD8, CD161, CD45R). ECG and Echocardiography were performed before harvesting and after implantation. Hearts were extracted after four hours of implantation for Hematoxylin-Eosin (HE) and TUNEL-staining, and recipient rats were euthanized. Results: 19 (76%) rats successfully survived after implantation (HT group: 100%, NT group: 60%). The mean ischemic time of the donor heart was 162.7±8.34 minutes in the HT group and 45±3.7 minutes in the NT group. The NT group showed no significant change in the heart rate before and after implantation but significantly decreased in the first hour of implantation in the HT group (259.5±24.3rpm) and normalized at 3 hours (338.3±34.1rpm). Ejection fraction and fractional shortening significantly decreased after implantation in both groups but were less significant in the NT group (P=0.001). Granulocyte was less significantly increased in the NT group compared to the HT group after the experiment (p=0.037). Although the gross structure was well preserved in both groups in HE-staining, the number of TUNEL positive cells was significantly higher in the HT group. Conclusions: Our findings suggest that normothermic ex-situ preservation is associated with well-preserved donor hearts but similar recipient immune response in comparison with hypothermic static preservation.

Abstract P3069: The Impact Of Lymphatic Vasculature Post-Cardiac Transplantation On Allograft Function, Fibrotic Remodeling, And Lymphatic Drainage

Lymphatic drainage inherently modulates cardiac function by maintaining the immune response and tissue-fluid homeostasis. During cardiac transplantation, the lymphatic collecting vessels are severed at the time of donor heart excision and not surgically reconstructed in the recipient. We hypothesize severed cardiac lymphatics contribute to transplant rejection and reduced cardiac function by influencing myocardial edema and immune cell transit. Methods: A heterotopic abdominal heart transplant (HAHT) rodent model permitted the immunologic evaluation of transplant rejection as supported in past literature. Echocardiography confirmed allograft survival via active contraction, while histologic quantification of lymphatic vessels and fibrosis were obtained for native and transplanted rodent hearts (n=3). Lymphatic drainage was assessed via intramyocardial injection of fluorescein isothiocyanate (FITC)-dextran. Results: Electrocardiographic impulses detected during the echocardiograms revealed additional QRS complexes attributed to contractions of the transplanted hearts. Histologic analysis of fibrosis in rodent allografts at an early timepoint exhibited increases in total tissue accumulation (1.48 – 5.15 fold) and significant increases in various focal regions (left ventricle, ***p &lt; 0.001; interventricular septum, ****p &lt; 0.0001) compared to the native hearts. Furthermore, large amounts of cellular infiltrate and marginal increases in cardiac diameter (1.10 – 1.42 fold) were observed in the transplants. While the scarcity of immunofluorescence signal for lymphatic markers has caused cardiac lymphatic quantification to be inconclusive, evaluation of lymphatic transport revealed fluctuating time-dependent circulating FITC levels (0.002 - 0.010 mg/mL; *p &lt; 0.05) suggesting multi-teared compartmental release properties between the microcirculatory system, lymphatic system, and cardiac tissue. Conclusion: The HAHT rodent model provides a promising modality to assess both lymphatic transport and transplant rejection. Moreover, these studies will progress understanding of transplant rejection’s pathological intricacies and provide the groundwork for lymphangiogenic-based therapeutic intervention.

Application of expanded anterolateral thigh myocutaneous flap in the repair of huge chest wall defect

To investigate the application of expanded anterolateral thigh myocutaneous flap in the repair of huge chest wall defect. Between August 2018 and December 2020, 12 patients, including 4 males and 8 females, were treated with expanded anterolateral thigh myocutaneous flap to repair huge complex defects after thoracic wall tumor surgery. The age ranged from 28 to 72 years, with an average of 54.9 years. There were 4 cases of phyllodes cell sarcoma, 2 cases of soft tissue sarcoma, 1 case of metastatic chest wall tumor of lung cancer, and 5 cases of breast cancer recurrence. All cases underwent 2-7 tumor resection operations, of which 3 cases had previously received lower abdominal flap transplantation and total flap failure occurred, the other 9 cases were thin and were not suitable to use the abdomen as the flap donor site. After thorough debridement, the area of secondary chest wall defect was 300-600 cm 2; the length of the flap was (24.7±0.7) cm, the width of the skin island was (10.6±0.7) cm, the length of the lateral femoral muscular flap was (26.8±0.5) cm, the width was (15.3±0.6) cm, and the length of the vascular pedicle was (7.9±0.6) cm. The myocutaneous flaps and the skin grafts on the muscular flaps were all survived in 11 patients, and the wounds in the donor and recipient sites healed by first intention. One male patient had a dehiscence of the chest wall incision, which was further repaired by omentum combined with skin graft. The appearance of the reconstructed chest wall in 12 patients was good, the texture was satisfactory, and there was no skin flap contracture and deformation. Only linear scar was left in the donor site of the flap, and slight hyperplastic scar was left in the skin harvesting site, which had no significant effect on the function of the thigh. All patients were followed up 9-15 months, with an average of 12.6 months. No tumor recurrence was found. The expanded anterolateral thigh myocutaneous flap surgery is easy to operate, the effective repair area is significantly increased, and multiple flap transplantation is avoided. It can be used as a rescue means for the repair of huge chest wall defects.

Perioperative Ethics: The Search for Truth, a Semblance of Certainty, and the ‘Right’ Things to Do

Ask the Expert| July 2022 Perioperative Ethics: The Search for Truth, a Semblance of Certainty, and the ‘Right’ Things to Do Zachary Deutch, MD, FASA; Zachary Deutch, MD, FASA Search for other works by this author on: This Site PubMed Google Scholar Alyssa M. Burgart, MD, MA, FAAP Alyssa M. Burgart, MD, MA, FAAP Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor July 2022, Vol. 86, 18–19. https://doi.org/10.1097/01.ASM.0000842044.92704.36 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share MailTo Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation Zachary Deutch, Alyssa M. Burgart; Perioperative Ethics: The Search for Truth, a Semblance of Certainty, and the ‘Right’ Things to Do. ASA Monitor 2022; 86:18–19 doi: https://doi.org/10.1097/01.ASM.0000842044.92704.36 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsASA Monitor Search Advanced Search Topics: ethics, perioperative care Hello everyone – I hope you are all enjoying summertime! Our last column touched peripherally on the concept of ethics in medicine, when we explored the question of what obligation the developed world has to assist the emerging world. In this installment, we dive headlong into the topic of perioperative ethics with our expert Alyssa M. Burgart, MD, MA, FAAP. Dr. Burgart is an eloquent, thoughtful medical ethicist who regularly engages people across medical disciplines and across the world, in no small part via her highly effective social media presence. I am delighted to have her join us and enlighten this universally applicable topic. Welcome, Dr. Burgart! Please describe your current position and responsibilities. Thank you for this invitation! I am a pediatric anesthesiologist at Lucile Packard Children's Hospital at Stanford University (LPCH). I subspecialize in abdominal transplant anesthesiology, and I am part of a five-member team... You do not currently have access to this content.

Impact of a pharmacist-led tacrolimus management protocol in the outpatient setting

BackgroundClinical pharmacists are often used to make recommendations regarding tacrolimus therapy in the post transplant setting.Therapeutic drug monitoring (TDM) of tacrolimus after transplant is based on trough levels in the setting of predetermined institutional immunosuppression goals. To evaluate time within therapeutic range (TTR) of tacrolimus the Rosendaal method can be utilized. ObjectiveOur study aimed to compare objective therapeutic drug monitoring outcomes after the implementation of a pharmacist driven tacrolimus management protocol (postprotocol initiation) with previous management by providers (preprotocol initiation). Practice descriptionThe Ohio State University Wexner Medical Center (OSUWMC) is a 700-bed academic medical center in Columbus, OH. On average, OSUWMC completes more than 300 kidney transplants each year. There are 6 abdominal transplant pharmacists (including one postgraduate year 2 transplant pharmacy resident) that rotate through the inpatient and outpatient setting. Practice innovationA pharmacist-led tacrolimus management protocol in kidney transplant recipients was initiated in October 2018 at our institution, which enabled pharmacists to dose and adjust tacrolimus in the outpatient setting in accordance with prespecified goals. Evaluation methodsThis single-center retrospective analysis included adult kidney transplant recipients on de novo tacrolimus. Patient’s tacrolimus levels were evaluated for 6 months after transplant. The mean tacrolimus percent TTR and the median coefficient of variation (CV) were calculated and compared in postprotocol initiation group (n = 85) with preprotocol initiation group (n = 39). TTR was calculated using the Rosendaal method. ResultsThere was no statistically significant difference between the preprotocol initiation and postprotocol initiation group mean TTR (59.6% vs. 60.5%, P = 0.723), mean CV from 0-3 months after transplant (36.3 vs. 36.0, P = 0.900), and mean CV from at least 3-6 months after transplant (24.5 vs. 22.7, P = 0.351). Rejection rates, development of donor-specific antibodies, and renal function were similar between groups. ConclusionBased on our findings, transplant pharmacists were equally as effective at maintaining tacrolimus percent TTR and CV in the designated kidney transplant recipients included in the management protocol compared with primary management by other transplant providers. The delegation of tacrolimus management to clinical pharmacists is a viable alternative to primary management by outpatient practitioners.

Demographic Factors Associated With Research and Career Interests in Aspiring Academic Surgeons: What are the Implications for Tomorrow's Workforce?

To evaluate the research and career interests of aspiring academic surgeons and determine the influence of demographic factors. Cross-sectional survey SETTING: Single institution, academic general surgery residency program PARTICIPANTS: Medical students invited to interview during 2019-2020 and 2020-2021 residency cycle RESULTS: One hundred fifty-four of 160 (96%) potential respondents representing 63 medical schools completed the survey, American Association for Public Opinion Research Response Rate 6. Fifty-three percent of the study population was female. Seventeen percent identified as Black, 14% Asian, 13% Latinx, 50% white, and 6% other. Respondents were most interested in education, professional development, and surgical culture (32%) followed by basic and translational science (23%), global and community health (20%), and health services (18%). On multiple logistic regression, interest in global/community health was associated with identifying as Black (OR 5.9 [2.0, 17.8] p = 0.001) and female (OR 2.7 [1.0, 7.0] p = 0.044). A plurality of participants were undecided on future specialty (n = 63, 41%). The most common specialty interests were surgical oncology (n = 28, 18%); trauma, acute care, or surgical critical care (n = 21, 14%); pediatric and cardiothoracic surgery (n = 20 for each, 13%); and abdominal transplant (n = 15, 10%). In this cross-sectional survey of highly competitive academic general surgery applicants, respondents who were underrepresented in medicine (URiM) and women were more interested in research fields with a history of lower relative NIH funding. In light of these findings, academic programs seeking a more diverse residency workforce should consider strategies beyond recruitment to promote the scholarly achievement of women and URiM residents.

Targeting PCSK9 Ameliorates Graft Vascular Disease in Mice by Inhibiting NLRP3 Inflammasome Activation in Vascular Smooth Muscle Cells.

BackgroundGraft vascular disease (GVD), which limits the long-term survival of patients after solid-organ transplantation, is associated with both immune responses and nonimmune factors, including dyslipidemia. Recent studies have shown that inhibition of proprotein convertase subtilisin/kexin type 9 (PCSK9), a U.S. Federal Drug Administration-approved treatment for hyperlipidemia, reduces cardiovascular events, regulates inflammatory responses, and enhances the efficacy of immune checkpoint therapy in cancer treatment through a cholesterol-independent mechanism. However, whether targeting PCSK9 is a potential therapeutic strategy for GVD remains unknown.MethodsSerum samples and grafts were harvested from male mice undergoing abdominal aortic transplantation. The pathological alterations in the aortic grafts were detected by hematoxylin and eosin staining, Verhoeff’s Van Gieson staining, and Masson staining. Inflammatory cell infiltration and proinflammatory cytokine expression in the aortic grafts were detected by immunohistochemistry and quantitative real-time polymerase chain reaction (qRT-PCR), respectively. The regulatory effects of PCSK9 on vascular smooth muscle cell (VSMC) migration and proliferation were examined by transwell, EdU, and western blot assays. The effect of Evolocumab, a PCSK9 inhibitor, on GVD in humanized PCSK9 mice was also evaluated.ResultsPCSK9 was upregulated in the serum, grafts, and liver of mice in the allograft group subjected to abdominal aortic transplantation. Pcsk9 knockout significantly reduced vascular stenosis, the intimal hyperplasia area and collagen deposition. Pcsk9 depletion also inhibited macrophage recruitment and the mRNA expression of proinflammatory cytokines in aortic grafts. Furthermore, Pcsk9 knockout suppressed the migration and proliferation of VSMCs, which was related to the inhibition of NLRP3 inflammasome activation. Meanwhile, Evolocumab significantly ameliorated GVD in humanized PCSK9 mice.ConclusionPCSK9 is upregulated in a mouse model of GVD, and Pcsk9 knockout reduces vascular occlusion, suggesting that PCSK9 may be a promising target for the treatment of GVD.

Interventional endoscopy for abdominal transplant patients

Interventional endoscopy can play a significant role in the care and management of children pre-and post- abdominal solid organ transplantation. Such procedures primarily include endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and balloon-assisted enteroscopy (BAE), though additional interventions are available using standard endoscopes (gastroscopes, colonoscopes) for therapeutics purposes such as endoscopic hemostasis.The availability of pediatric practitioners with the advanced training to effectively and safely perform these procedures are most often limited to large tertiary care pediatric centers. These centers possess the necessary resources and ancillary staff to provide the comprehensive multi-disciplinary care needed for these complex patients.In this review, we discuss the importance of interventional endoscopy in caring for transplant patients, during their clinical course preceding the potential need for solid organ transplantation and inclusion of a discussion related to endoscopic post-surgical complication management. Given the highly important role of interventional endoscopy in patients with recurrent and chronic pancreatitis, we also include a discussion related to this complex disease process leading up to those patients that may need pancreas surgery including total pancreatectomy with islet autotransplantation (TPIAT).