Back Table Research Articles

Thrombectomized autologous portal Y-graft inflow construction can be an option in living-donor liver transplantation: a case report

BackgroundIn living-donor liver transplantation (LDLT), portal Y-graft interposition using the recipient’s portal vein (PV) bifurcation has been used for right lobe grafts with double PV orifices. We herein report the use of thrombectomized autologous portal Y-graft interposition for a recipient with preoperative portal vein thrombosis (PVT) in a right lobe LDLT with double PV orifices.Case presentationThe recipient was a 54-year-old male with end-stage liver disease due to alcoholic liver cirrhosis. There was PV thrombus in the recipient’s PV. The living liver donor was his 53-year-old spouse, and a right lobe graft was planned for the transplantation. Since the donor's liver had a type III PV anomaly, autologous portal Y-graft interposition after thrombectomy was planned for PV reconstruction in the LDLT. The portal Y-graft was resected from the recipient and a thrombus extending from the main PV to the right PV branch was removed on the back table. The portal Y-graft was anastomosed to the anterior and posterior portal branches of the right lobe graft. Followed by venous reconstruction, the Y-graft was anastomosed to the recipient’s main PV. The operation time was 545 min and the intraoperative blood loss was 1355 ml. The recipient was discharged on postoperative day 13 without any complications. The recipient remains well with the patency of the portal Y-graft one year after the liver transplantation.ConclusionWe herein report the successful use of autologous portal Y-graft interposition after thrombectomy on the back table for a recipient with PVT in a right lobe LDLT.

Management of donor partial anomalous pulmonary veins during lung transplantation

Management of donor partial anomalous pulmonary veins during lung transplantation

Understanding the Basics of Commonly Used Catheters in Interventional Radiology.

The field of interventional radiology (IR) continues to grow necessitating the development of a rapidly expanding variety of tools and devices. Given the scope of the interventional armamentarium, it is essential that trainees be intimately familiar with the basic tools at their disposal and understand the appropriate situations in which to deploy them. In addition to operator's comfort, thorough knowledge of the “back table” is a known factor in mitigating poor outcomes.[1] [2] Despite this, there is a general paucity of resources detailing the variety of options and use cases available for various vascular catheters. Apart from special-use models, a majority of physician familiarity with catheters is obtained on the job. Herein, we aim to provide a “big-picture” view of vascular catheters used in day-to-day practice.

PD31-12 THE CANADIAN ANATOMIC KIDNEY SCORE (CAKS): ASSESSMENT OF REPRODUCIBILITY AMONG SURGEONS AND TRAINEES ACROSS CANADA

You have accessJournal of UrologyCME1 Apr 2023PD31-12 THE CANADIAN ANATOMIC KIDNEY SCORE (CAKS): ASSESSMENT OF REPRODUCIBILITY AMONG SURGEONS AND TRAINEES ACROSS CANADA William Luke, Juliano Chrystian Mello Offerni, Danny Matti, Haider Abed, Yanbo Guo, Pavel Roshanov, Carol Wang, Alp Sener, and Patrick Luke William LukeWilliam Luke More articles by this author , Juliano Chrystian Mello OfferniJuliano Chrystian Mello Offerni More articles by this author , Danny MattiDanny Matti More articles by this author , Haider AbedHaider Abed More articles by this author , Yanbo GuoYanbo Guo More articles by this author , Pavel RoshanovPavel Roshanov More articles by this author , Carol WangCarol Wang More articles by this author , Alp SenerAlp Sener More articles by this author , and Patrick LukePatrick Luke More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003324.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: As the Canadian population has aged the gap between renal graft availability and recipient need has continued to widen. Intra-operative organ assessment is known to be associated with organ discard. The Canadian Anatomic Kidney Score (CAKS) is a numeric, multifactorial system, we have shown to be correlated with delayed graft function as well as KDPI. We hypothesize that this system is highly reproducible across clinicians with variable levels of experience, enabling implementation across institutions. METHODS: An anonymous survey was distributed to surgical attendings, fellows and residents at teaching centres across Canada. These surveys contained images of 6 separate kidneys (2 images each) at the time of intra-operative back table dissection. Participant demographics were collected. Images were given scores for 3 factors: vascular (calcifications/location), anatomic (cysts/scars), and sticky fat (proportion of adherent fat); with scores between 0 points (ideal) and 2 points (unfavourable). Respondents were stratified by level of training and specialty. Participant scores were compared in subgroups of residents, fellows and staff using a one way ANOVA. Pair-wise exclusion a Cronbach’s alpha was calculated overall and for each scoring factor RESULTS: Of the 46 respondents, 31 had undergone or were undergoing Urology residency, 12 General Surgery, and 2 Vascular Surgery (Table 1). 61% of participants were attending physicians, 13% fellows and 26% residents. Of the 18 questions during the survey there was no significant difference between fellow, resident and attending scoring except for 2/6 sticky fat image sets (Table 2). Cronbach α=0.98, for overall CAKS. CONCLUSIONS: Overall the CAKS represents a reproducible scoring system across multiple levels of training, in centres across Canada. These scores were reliably generated, despite only 2 images shown of each kidney. Increasing training level correlated with consistency in rating suggesting that this score can capture some degree of surgical judgement. CAKS may offer a concrete system to incorporate clinical judgement into prognostication and graft selection in kidneys with an equivocal KDPI score. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e905 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information William Luke More articles by this author Juliano Chrystian Mello Offerni More articles by this author Danny Matti More articles by this author Haider Abed More articles by this author Yanbo Guo More articles by this author Pavel Roshanov More articles by this author Carol Wang More articles by this author Alp Sener More articles by this author Patrick Luke More articles by this author Expand All Advertisement PDF downloadLoading ...

Real-time Lung Weight Measurement During Cellular Ex Vivo Lung Perfusion: An Early Predictor of Transplant Suitability.

Increased extravascular lung water during ex vivo lung perfusion (EVLP) is associated with ischemia reperfusion injury and poor pulmonary function. A non-invasive technique for evaluating extravascular lung water during EVLP is desired to assess the transplant suitability of lungs. We investigated real-time lung weight measurements as a reliable method for assessing pulmonary functions in cellular EVLP using a porcine lung model. Fifteen pigs were randomly divided into 3 groups: control (no warm ischemia) or donation after circulatory death groups with 60 or 90 min of warm ischemia (n = 5, each). Real-time lung weight gain was measured by load cells positioned at the bottom of the organ chamber. Real-time lung weight gain at 2 h was significantly correlated with lung weight gain as measured on a back table ( R = 0.979, P < 0.01). Lung weight gain in non-suitable cases (n = 6) was significantly higher than in suitable cases (n = 9) at 40 min (51.6 ± 46.0 versus -8.8 ± 25.7 g; P < 0.01, cutoff = +12 g, area under the curve = 0.907). Lung weight gain at 40 min was significantly correlated with PaO 2 /FiO 2 , peak inspiratory pressure, shunt ratio, wet/dry ratio, and transplant suitability at 2 h ( P < 0.05, each). In non-suitable cases, lung weight gain at 66% and 100% of cardiac output was significantly higher than at 33% ( P < 0.05). Real-time lung weight measurement could potentially be an early predictor of pulmonary function in cellular EVLP.

Protection From Second Warm Ischemic Injury Using a Thermal Barrier Bag in Kidney Transplantation.

A living-donor nephrectomy was performed using a minimum skin incision procedure. After back table preparation, the kidney graft was placed inside the TBB and preserved during vascular anastomosis. The graft surface temperature was measured before and after vascular anastomosis using a noncontact infrared thermometer. After completion of the anastomosis, the TBB was removed from the transplanted kidney before graft reperfusion. Clinical data, including patient characteristics and perioperative variables, were collected. The primary endpoint was safety, which was assessed by evaluating adverse events. The secondary endpoints were the feasibility, tolerability, and efficacy of the TBB in kidney transplant recipients. Ten living-donor kidney transplant recipients with a median age of 56 y (range, 39-69 y) were enrolled in this study. No serious adverse events related to the TBB were observed. The median second warm ischemic time was 31 (27-39) min, and the median graft surface temperature at the end of anastomosis was 16.1 °C (12.8-18.7 °C). TBB can maintain transplanted kidneys at a low temperature during vascular anastomosis, which contributes to the functional preservation of transplanted kidneys and stable transplant outcomes.

First experience of 3D-laparoscopy in donor nephrectomy

To assess the first experience of 3D imaging for laparoscopic donor nephrectomy. The study included 28 laparoscopic donor nephrectomies and 28 subsequent transplantations to related recipients. Of these, 14 laparoscopic donor nephrectomies were performed using 3D camera. The main intraoperative parameters and information about postoperative period in donors and recipients were compared with similar data on previous laparoscopic donor nephrectomies and kidney transplantations with traditional 2D imaging. There were 15 left-sided and 13 right-sided nephrectomies. Twenty and eight laparoscopic nephrectomies were performed via retroperitoneal and transperitoneal access, respectively. There were no significant between-group differences in age, sex ratio, BMI, side of surgery and number of renal arteries. Surgery time (119.28±9.18 and 124.85±7.49 min, respectively) and blood loss (106.78±16.12 and 119.28±19.79 ml, respectively) were similar. Laparoscopic nephrectomy with 3D imaging was followed by significantly shorter primary warm ischemia (2.41±0.79 and 3.23±0.57 min, respectively, p=0.004) and time of extracorporeal preparation of the transplant (back table) under cold preservation (27.21±5.42 and 32.36±5.33 min, respectively, p=0.02). Initial experience of video systems with 3D imaging in laparoscopic donor nephrectomy has not yet led to significant reduction of surgery time and improvement of transplant function compared to traditional 2D imaging. At the same time, there was a shorter period of primary warm ischemia and back table time. Further analysis is needed to assess possible benefits of 3D imaging in laparoscopic donor nephrectomy.

Medial Patellofemoral Ligament Reconstruction With a Single-Limb Allograft: A Reproducible and Effective Technique

Background: Medial patellofemoral ligament (MPFL) injury occurs in up 96% of lateral patellar dislocations, commonly affecting those less than 20 years old. The MPFL can be reconstructed using either a double-limb or single-limb technique. While both techniques achieve similar patient outcomes, a single-limb technique may require less operative time. Indications: The MPFL reconstruction is indicated in patients with recurrent patellar subluxations, dislocations, or unresolved apprehension. Care should be exercised in identifying whether patients require additional procedures in addition to MPFL reconstruction such as tibial tubercle osteotomy or trochleoplasty. These considerations include TT-TG &gt;17 to 20 mm and Dejour B/D trochlear dysplasia. Technique Description: Following diagnostic arthroscopy, a medial peripatellar incision is made. Layers 1 and 2 are sharply dissected over the patellar periosteum, and tissue planes are subsequently developed using Metzenbaum scissors. A plane between layers 2 and 3 extending from the medial patella to the medial femoral epicondyle is developed. Using fluoroscopy, Schöttle point is identified, and a femoral tunnel is drilled. Two PEEK anchors are placed at the junction of the proximal one-third and distal two-thirds of the patella. In parallel, a tibialis anterior graft is sized, whipstitched, and tensioned on the back table. One end of the prepared graft is secured in the femoral tunnel with a PEEK tenodesis screw. The graft is then shuttled between layers 2 and 3, followed by fixation on the patellar side using the previously placed suture anchors. Isometry of the graft is confirmed under direct and arthroscopic visualization. Results: In multiple systematic reviews of single-limb versus double-limb MPFL reconstruction, no differences were observed in terms of patient-reported outcome scores, repeat dislocation, and reoperation. Furthermore, a recent meta-analysis suggests a trend toward less postoperative stiffness (1.2% vs 3.5%, P = .09) for single-bundle techniques. Discussion/Conclusion: Single-limb MPFL reconstruction is reproducible and effective, with clinically satisfactory outcomes and low failure rates. Single-limb MPFL reconstruction demonstrates similar outcomes as double-limb reconstruction, with a potential decrease in surgical time and postoperative stiffness. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopic-Assisted Anterior Glenoid Reconstruction Using Nonrigid Fixation With Distal Tibia Osteochondral Allograft

Introduction: Traumatic anterior glenohumeral instability events result in a capsulolabral (Bankart lesion) and/or osseous injury with subsequent attritional bone loss, particularly with recurrence. Up to 88% of patients with recurrent instability experience glenoid bone loss, which predisposes to future dislocations and subluxations, even with arthroscopic capsulolabral repair. The surgical management of glenoid bone loss includes a number of different techniques such as the Latarjet or coracoid transfer as well as other osseous and osteoarticular autografts and allografts. However, operative management of shoulder instability has increasingly shifted toward arthroscopic approaches with preservation of anatomy when possible. Indications: Arthroscopic-assisted allograft distal tibia bone block augmentation to the anterior glenoid is indicated for revision anterior glenohumeral instability procedures with anterior bone loss and in primary cases of anterior instability with critical bone loss. Technique: Our technique for nonrigid arthroscopic anterior glenoid reconstruction with allograft distal tibia and anterior labral repair is performed preferentially in the lateral position without necessitating patient repositioning. The preplanned tibial bone block is prepared on a back table prior to the arthroscopic procedure. After creation of portals and elevation of labral tissue, a guide and drill are used to introduce a retrograde reamer which is deployed to create a perpendicular edge for apposition of the allograft tibia. The bone block is then introduced through a rotator interval portal by pulling sutures retrograde through glenoid bone tunnels and is secured to the prepared surface medial to the liberated labrum. The articular surface of the graft and glenoid are aligned and suture-based fixation is used to compress the bone block against the native glenoid. The anterior labral tissue is then mobilized over the graft and repaired to the native glenoid when possible. Description/Conclusion: The benefits of allograft tibia augmentation for anterior instability with glenoid bone loss include an anatomic joint surface restoration including articular cartilage, lack of donor site morbidity, and a minimally invasive arthroscopic approach. When performed arthroscopically and with nonrigid fixation, this technique permits concurrent anterior labral repair and anatomic reconstruction, safe graft passage without necessity of a far medial portal, and expeditious return to function.

Long-term Transplant Function After Thrombolytic Treatment Ex Vivo of Donated Kidneys Retrieved 4 to 5 H After Circulatory Death.

Using a novel thrombolytic technique, we present long-term transplant function, measured by creatinine and iohexol clearance, after utilizing kidneys from porcine donors with uncontrolled donation after circulatory deaths, with 4.5-5 h of warm ischemia. Pigs in the study group were subjected to simulated circulatory death. After 2 h, ice slush was inserted into the abdomen and 4.5 h after death, the kidneys were retrieved. Lys-plasminogen, antithrombin-III, and alteplase were injected through the renal arteries on the back table. Subsequent ex vivo perfusion was continued for 3 h at 15°C, followed by 3 h with red blood cells at 32°C, and then transplanted into pigs as an autologous graft as only renal support. Living-donor recipient pigs that did not receive ex vivo perfusion, and unilateral nephrectomized pigs served as the controls. Pigs in the study group (n = 13), surviving 10 d or more were included, of which 7 survived for 3 mo. Four animals in the living-donor group (n = 6) and all 5 nephrectomized animals survived for 3 mo. Creatinine levels in the plasma and urine, neutrophil gelatinase-associated lipocalin levels, Kidney Injury Marker-1 expression, and iohexol clearance at 3 mo did not differ significantly between the study and living-donor groups. Histology and transmission electron microscopy after 3 mo showed negligible fibrosis and no other damage. The present method salvages kidneys from extended unontrolled donation after circulatory death using thrombolytic treatment while preserving histology and enabling transplantation after ex vivo reconditioning, with clinically acceptable late function after 3 mo, as measured by creatinine and iohexol clearance.

Observational study of sterile field bioburden levels during orthopedic arthroplasty surgery in operating rooms complying with current United States ventilation specifications

Airborne contamination from microbe carrying particles (MCPs) is a risk factor for devastating early onset periprosthetic joint infection(PJIs). There are no published guidelines to quantify this risk factor for PJI events. This observational cohort project addresses this gap and utilizes a simple passive system to produce quantitative data from 80 total joint replacement cases performed in operating rooms built to current USA standards. A petri dish-based system inspired by industrial cleanroom technology was deployed. Surgical helmet systems (SHSs) and strict protocols were used in all cases. 450 MCPs/m2 was used as a cutoff for bioburden. This benchmark corresponds to the ultraclean air standard of 10 MCPs/m3. 75/80 cases (94%) achieved desired benchmark levels of bioburden at the wound zone compared to only 52/80 (65%) of back table zones. No surgical site infections (SSI) or PJI events (0/80; 95% CI, 0.00-3.68%) at minimum 18-month (average 25.8 months) follow-up were detected. The current USA ventilation design uses low velocity airflow and appears to achieve ultraclean air conditions at the surgical site but requires SHSs and strict protocols. Higher contamination levels seen in back tables are consistent with this design. This settle plate system may be useful for early onset PJI event investigations and thus lower the incidence of these complications.

Controlling Torque Ripple Vibration in a Single-Phase PFC Using the Neutral Point of an IPMSM

This paper proposes a method to reduce the torque ripple vibration of an integrated power factor correction (PFC) converter by using the zero-phase inductance of an interior permanent magnet synchronous motor (IPMSM) when the motor is not running. When an integrated PFC converter is applied to electric vehicle (EV) chargers, it is necessary to reduce the torque oscillation of the motor caused by the charging current. In an integrated PFC converter using an IPMSM, the zero-phase current and magnetomotive force harmonics of the permanent magnet cause torque vibration. In the proposed control method, the generated torque is estimated using the back EMF table, and the phase current is controlled to cancel it. The proposed method can be used to suppress torque vibration irrespective of the mechanical angle of the rotor. The effectiveness of the proposed method is experimentally verified. Using the proposed method, the torque vibration can be suppressed by up to 91.3% as compared to that in the case of the conventional control method. Furthermore, a power factor of 99.9% is achieved under a load condition of 1kW.

Safe heart flush technique during recovery from donors after circulatory death.

Donation after circulatory death is the donation after cardiac arrest. This technique has been employed and adopted by clinicians to overcome the shortage of available hearts for transplant. Warm ischemia time plays a pivotal role in the survival outcome of the heart recipients. To assess the efficacy of using the Foley catheter to flush the heart during procurement from donation after circulatory death donors. We utilized a 2-WAY Foley catheter to flush the heart during procurement. The catheter was prepared and modified on the back table. We were successfully able to flush the heart within 3 minutes from skin incision with a good recipient outcome. Using the Foley catheter to flush the heart during recovery from donation after circulatory death donors was both efficient and fast.

Is a Preservation Solution for Living Donor Liver Transplantation Needed? Adding a New Chapter in LDLT!

Background.Preservation solutions are required for organ viability in deceased donor liver transplantation (LT). However, their role in live donor LT (LDLT) has not been standardized.Methods.Eighty adult recipients who underwent right lobe LDLT at the Department of Liver Transplantation Surgery, Gambat, Pakistan, were studied. Based on shorter cold ischemia time and no back table reconstruction work, recipients were assigned to receive “no preservation solution” (cases/non–histidine-tryptophan-ketoglutarate group; n = 40) or “HTK group” (controls; n = 40). Early allograft dysfunction (bilirubin, transaminases, and international normalized ratio), postoperative complications (biliary and vascular), hospital stay, and 1-y survival were reported. The direct cost was also reported.Results.Demographics and clinical characteristics were comparable in the 2 groups. Comparing cases versus controls, mean bilirubin, alanine aminotransferase, aspartate aminotransferase, and international normalized ratio on postoperative day 7 were similar in the 2 groups. Five (12.5%) cases and 4 (10%) controls developed early allograft dysfunction (P = 0.72). Post-LT complications (biliary leak 2.5% in cases versus 0 in control), strictures (15% in cases versus 17.5% in controls), hepatic artery thrombosis (2.5% versus 00%)‚ and portal vein thrombosis (0 versus 2.5%) were comparable. Mean hospital stay (10.80 + 2.36 and 11.78 + 2.91 d) and 30 d mortality (2.5% versus 5%) were also comparable. Finally, 1-y survival based on Kaplan-Meier analysis was comparable in both groups (ie, 92.5%; non-HTK group versus 90%; HTK group) (P = 0.71). The direct cost of using a non-HTK–based approach was less than the HTK solution.Conclusion.In a selected cohort of right lobe LDLT recipients, preservation solutions can be avoided safely with comparable outcomes.

Combined MPFL Reconstruction with Tibial Tubercle Osteotomy and Repair of Patellar Cartilage Defect with Particulated Juvenile Articular Cartilage.

Combined MPFL Reconstruction with Tibial Tubercle Osteotomy and Repair of Patellar Cartilage Defect with Particulated Juvenile Articular Cartilage.

S1229 The Feasibility and Safety of Selected Liver Grafts Flushed With Cold Normal Saline (NS) and Comparison With Liver Grafts Flushed With Histidine-Tryptophan-Ketoglutarate Solution in Living Donor Liver Transplantation

Introduction: Preservation solutions are required for organ viability in deceased donor liver transplantation (LT). However, their role in live donor LT (LDLT) has not been standardized. The aim of this study is to compare the outcomes of selected liver grafts flushed with cold normal saline (NS) with Histidine-Tryptophan-Ketoglutarate (HTK) solution. Methods: One hundred consecutive adult recipients who underwent right lobe LDLT from February 2020 to December 2020 at Gambat, Pakistan were studied. Recipients were assigned to receive “no preservation solution” (cases/non-HTK group; n=50) based on shorter CIT & no back Table reconstruction work or “HTK group” (controls; n=50) requiring standard back Table reconstruction. Various outcomes, including early graft dysfunction (bilirubin, transaminases, and INR), postoperative complications (biliary & vascular), hospital stay, and one-year survival, were compared between the two groups. The direct cost was also reported. Results: Demographics and clinical characters were comparable in the two groups. Comparing cases vs. controls, mean bilirubin, ALT, AST, and INR on the 7thpostoperative day were similar in the two groups. 5(10%) cases and 4(8%) controls developed EAD(p=0.72). Post-LT complications (biliary leak 2% in cases vs. 0 in control), strictures (12% in cases vs. 16% in controls), hepatic artery thrombosis (4% vs. 2%) and portal vein thrombosis (0 vs. 2%) were equally distributed. Mean hospital stay (11.02 + 2.63 and 12.06 + 3.68 days) and 30-day mortality (8% vs 8%) were also comparable in two groups. Finally, 1-year survival (92% vs 90%) based on Kaplan-Meier analysis was also comparable (p-value:0.71). The cost of using a non-HTK-based approach was much lesser than the HTK solution. (Figure) Conclusion: To our knowledge, this is the first innovative report on avoiding preservative solutions in LDLT recipients. We found that EAD including liver function tests; post-operative complications (biliary and vascular), 30 days’ mortality, and 1-year survival were comparable in the two groups. We also found that avoiding the preservative solution has an impact on saving direct costs. (Table). In our study, the postoperative complications and the overall one-year survival rate in the non-preservation group (92%) and the HTK group (90%) were equal and matched with other studies from the region. From an economic perspective, we also found that avoiding the use of preservation solutions is very attractive.Figure 1.: Kaplan-Meier showing a comparable survival rate in non-HTK and HTK groups at 1-year post-liver transplantation Table 1. - Recipient demographics, clinical characteristics, laboratory values, and complications in study groups Recipient demographics, clinical characteristics, laboratory values, and complications in study groups. Variables non-HTK group (n=50) HTK group (n=50) p-value Recipients Age(years) 39.18+11.69 36.84+6.77 0.224 Gender 44(88%) 46 (92%) 0.741 Male 6(12%) 4 (08%) Female BMI(kg/m2) 22.46±4.29 22.84±4.24 0.657 Etiology Viral 47 (94%) 45 (90%) NASH 2 (04%) 1 (02%) Alcoholic 00 (00%) 00 (00%) Budd Chiari 00 (00%) 1 (02%) PBC 00 (00%) 1 (02%) Wilson 1 (02%) 1 (02%) PSC 00 (00%) 1 (02%) HCC 11 (22%) 02 (04%) 0.015 Co-Morbidities DM 4 (08%) 2 (04%) 0.67 HTN 00 (00%) 3 (06%) 0.24 CVD 00 (00%) 00 (00%) 0.00 CTP score 0.59 A 3 (06%) 1 (02%) B 9 (18%) 9 (18%) C 38 (76%) 40 (80%) MELD-Na 19.53±5.51 20.88±4.75 0.19 Operation time (min) 537±70.66 534.60±60.72 0.85 Blood loss(ml) 1622±317.70 1512±300.775 0.07 Hospital stays(days) 11.02±2.63 12.06±3.68 0.10 Mean Post-operative labs (at day 07) Total bilirubin (mg/dL)INR (IU/L)ALT (IU/L)AST (IU/L) 2.96 ± 2.97 3.06 ± 3.24 0.91 1.44 ± 0.24 1.39 ± 0.18 0.82 186.79 ± 144.95 137.69 ± 97.28 0.05 119.69 ± 133.45 93.78 ± 85.65 0.26 Complication EAD 4 (8%) 5(10%) 0.727 PNF 00 1 (2%) 0.315 ACR 3(6%) 4 (8%) 0.695 HAT 2 (4%) 1(2%) 0.558 Sepsis 5 (10%) 4 (8%) 0.727 PVT 00 1 (2%) 0.315 Biliary complicationsStrictureLeak 6 (12%)1 (2%) 8 (16%)00 0.5640.315 Clavin-dindo Grade>III 11 (22%) 13 (26%) 0.64 30-day Mortality 4 (8%) 4 (8%) 1.00 1-year mortality (excluding 1st month) 00 1 (2%) 0.315 BMI: body mass index; HCC: hepatocellular carcinoma; HTN: hypertension; CVD: cardiovascular disease; CTP: Child Turcotte Pugh; INR: international normalized ratio; ALT: alanine aminotransferase; AST: aspartate aminotransferase; EAD: early graft dysfunction; PNF: primary non-function; ACR: acute cellular rejection; HAT: hepatic artery thrombosis; PVT: portal vein thrombosis.

Sterile Setup Table in the Operating Room Is Not So Sterile

BackgroundOne of the important factors for surgical site infection prevention is the implementation of an ultraclean operating room. This study was designed to evaluate back-table sterility during total joint arthroplasty. MethodsThis prospective study includes 52 patients undergoing primary total joint arthroplasty between November 2021 and January 2022. A total of 4 swabs (2 air swabs and 2 table swabs) were obtained for each case, at the conclusion of surgery and prior to the takedown of drapes. One swab from each set was sent for culture, and the other was sent for next-generation sequencing (NGS) analysis. ResultsAmong 104 back-table swabs, a total of 13 (12.5%) organisms were isolated. Of these, 7 organisms were isolated by culture and 6 by NGS. No microorganisms were isolated by both culture and NGS from back-table swabs. Among 104 air swabs, a total of 11 (10.6%) organisms were isolated. Of these, 6 microorganisms were isolated by culture and 5 by NGS. In 4 of the 104 swabs, both culture- and NGS-isolated organisms were from air swabs. Of the 104 (12.5%) back-table and air swabs, 13 were culture positive. While more than 1 pathogen was identified in 2 air swabs, all back-table swabs were monomicrobial by culture. Pathogens were identified from 11 of 104 (10.6%) swabs by NGS, while more than 1 pathogen was identified in 4 swabs (2 air and 2 back table). ConclusionThe findings of this study raise an important issue that the surgical field including the sterile table setup for instruments is not “sterile” and can harbor pathogens.

Coaxial Stent Graft inside a Constraining Stent for Transjugular Intrahepatic Portosystemic Shunt Reduction

A technique to create a coaxial, self-expanding stent graft inside a constraining, bare-metal, balloon-expandable stent for transjugular intrahepatic portosystemic shunt (TIPS) reduction is described. The key steps are performed on a back table rather than inside the patient, and the resulting construct is deployed using standard unsheathing maneuvers. The construct was used in 4 patients to make 6 TIPS diameter reductions (mean postreduction diameter, 6 mm; range, 0–8 mm), all resulting in increases in the portosystemic pressure gradient (mean increase, 6 mm Hg; range, 1–19 mm Hg). On average, hepatic encephalopathy improved 1 point on the West Haven scale (range, 0–2).

Back Table Preparation of the Right Lobe Live Donor Liver Allograft: A Crucial Part of the Adult Live Donor Liver Transplant Procedure

IntroductionWe aimed to describe our procedure for vascular reconstruction and back table bench preparation for the right lobe live donor allograft. Live donor liver transplantation (LDLT) remains an important option for the expansion of the donor pool. The procedure has been widely used, and its success is dependent on a technically perfect operation with appropriate inflow and outflow of the allograft. Adequate preparation of the right lobe (RL) allograft prior to implantation remains a vital part of the procedure. MethodsOur technique of back table vascular reconstruction of the RL allograft has been performed using a hepatic vein patch venoplasty, inferior hepatic vein inclusion, portal vein reconstruction, and segment V and VIII reconstruction for all of our LDLTs. ResultsBetween March 2009 and January 2020, 321 consecutive adult LDLTs were performed and underwent back table reconstruction with the techniques described. During that time period, no patients had hepatic insufficiency. There was a single thrombosis of a superior mesenteric vein (SMV) to PV jump conduit. ConclusionsOur technique of back table reconstruction of the LDLT right lobe graft remains a crucial part of the operative procedure. Our experience with RL grafts without middle hepatic vein (MHV) and our systematic approach for inflow and outflow reconstruction has yielded excellent results with no technical outflow issues and minimal inflow complications.

Effectiveness of Manual Terminal Cleaning Varies on High-Touch Surfaces Near the Operative Field

BackgroundPeriprosthetic joint infection may result from pathogen to patient transmission within the environment. The purpose of this study is to evaluate the contamination level of selected high-touch surfaces in the operating room (OR) using a blacklight fluorescent marking system after a manual terminal clean. MethodsPrior to the manual terminal clean, 16 high-touch surfaces were marked using a blacklight fluorescent gel. The marked areas were assessed the next morning for thoroughness of cleaning. Surfaces were categorized based on the average percent of the marks removed as “clean” (>75%), “partially clean” (26%-74%), or poorly cleaned (<25%). This process was repeated randomly 12 times. Terminal cleaning was done in the standard fashion, and the perioperative team was unaware of the initiation of this study. ResultsA total of 936 marks were analyzed. There was a significant difference in the number of marks completely clean (29.1%, 272/936) vs marks that were not touched (40.8%, 382/936), P < .001. Only the OR back table (75%) had a rating of clean. Partially clean areas included Mayfield table (72%), overhead lights (70.1%), infusion pump (61.1%), clock reset button (58.3%), table remote control (50%), tourniquet machine (50%), and the OR table (33.3%). Poorly cleaned surfaces included anesthesia medication cart (21.8%), door handles (20.8%), phone (16.7%), electrocautery unit (16.7%), foot pedal (16.7%), anesthesia cart (16.2%), nurses’ station (14.1%), and supply cabinet doors (6%). ConclusionsEffectiveness of manual terminal cleaning varied greatly across surfaces. In general, surfaces further from the operative field were less likely to have markings removed.