Ischemia Time Research Articles

Influence of donor and harvesting protocol on 30 day mortality after heart transplantation

Abstract Purpose Heart transplantation continues to be the gold standard for the treatment of advanced HF, as it promotes increased survival, exercise capacity and quality of life. The choice of the potential donor, as well as the safety of the harvesting process, graft preservation and transportation are fundamental to the success of the procedure. With the territorial extension of Brazil and a large number of donations in other states and regions, evaluating donors remotely, as well as structuring an adequate fundraising plan are fundamental. Therefore, the study of these variables and their influence on the outcome at 30 days was the objective of this study. Methods A retrospective cohort was conducted involving patients aged 18 or over, who underwent heart transplantation from July 2012 to July 2022 at our center. Patients who underwent re-transplantation and those who not used the bicaval technique were excluded. Statistical analysis was performed using STATA Software version 18. The Kaplan-Meier method was used to obtain the overall survival curve and, to identify risk factors for death, Cox proportional hazards. The Log test -rank was used for comparisons between groups. Results 255 cases of heart transplantation were studied, with a 30-day survival rate of 86.6%. The average age of donors was 29 years old and the main cause of death was traumatic brain injury.Regarding the factors that increase the risk of mortality in 30 days, the longest CPB time (HR 1.01; 95% CI 1.002-1.014; p = 0.011) and the donor's age (HR 1.08; 95% CI 1.023-1.139; p = 0.005) were statistically significant. In the univariate analysis, the donor's nutritional status (overweight or obese) was also significant (p = 0.03).The donor's length of hospital stay, use of vasoactive drugs or antimicrobials, serum sodium level or history of previous PCR did not influence the recipient's 30-day survival. Distance organ retrival surgery did not influence the outcome as long as the ischemia time of less than 240 minutes was respected. Conclusion The distance harvesting protocol used in our institution proved to be safe and effective. Adequate evaluation of the donor through echocardiography as well as management of vasoactive drugs and electrolytes may have influenced the non-relevance of classic factors that affect the outcomes of patients after heart transplantation.

Clinical impact of helicopter transport with a physician in cardiogenic shock complicating acute coronary syndrome

Abstract Introduction Cardiogenic shock (CS) remains the leading cause of death in patients with acute coronary syndrome (ACS). Helicopter transport with a physician may improve the prognosis through reduction of the ischemic time and an early critical care. However, the impact of transfer of a physician-staffed helicopter and outcomes of CS complicating ACS is uncertain. Purpose The aim of the present study was to evaluate compare the clinical characteristics and long-term outcome between helicopter transport with a physician and ground transport in CS complicating ACS patients. Methods We retrospectively investigated 2324 consecutive patients with ACS who underwent primary percutaneous coronary intervention (pPCI) in our institution from January 2004 to December 2017. The primary outcome was cardiovascular (CV) death. Results Among the 2324 eligible patients, 273 ACS patients (11.7%) were complicated by CS. Of 273 CS complicating ACS, a total of 81 (29.7%) patients were transported by helicopter, 166 (60.8%) patients were transported by ambulance, and 26 (9.5%) patients did not use emergency medical service. The mean age was 71 years, 75% of patients were male, STEMI was seen in 87%, and mechanical circulatory support was used in 64%. Kaplan-Meier analysis showed that CV mortality up to 30 days was significantly lower with helicopter transport group compared those with ground transport (P = 0.0407). The rate of long-term CV death was comparable between groups (P = 0.19). Multivariate Cox regression analysis showed helicopter transport was significantly associated with lower 30-day CV mortality (adjusted HR 0.56, 95%CI 0.32-0.99, P = 0.0447). Conclusions Helicopter transport with a physician may improve cardiovascular outcomes of CS complicating ACS.Figure 1.Figure 2.

Prognosticating short-term outcomes in STE-ACS patients with intra-procedure slow flow/no-reflow: an analysis of predictive factors in primary percutaneous coronary revascularization

Abstract Background "ST-segment elevation myocardial infarction (STEMI)" is the most lethal form of "ischemic heart disease (IHD).primary "percutaneous coronary intervention (PCI)" as the first-line treatment for STEMI patients, as it offers better outcomes compared to other medical or surgical options [1,2]. One major concern in interventional cardiology is the occurrence of "slow flow/no-reflow (SF/NR)", which refers to the poor myocardial perfusion to the infarct-related artery as a result of microvascular obstruction. Objectives In this study, we compared the incidence of short-term outcomes between two groups of patients based on the occurrence of intra-procedure "slow flow/no-reflow (SF/NR)" and identified predictors of short-term outcomes. Method This study enrolled a series of consecutive patients who underwent primary "percutaneous coronary intervention (PCI)" for "ST-elevation myocardial infarction (STEMI)". The patients who developed SF/NR during the procedure were compared with their counterparts for the incidence of short-term "major adverse cardiovascular events (MACE)". Furthermore, the study aimed to identify predictors of short-term mortality in these patients. Result In this study, a total of 2,582 patients were included. Among them, 79.1% (2,042) were male. The average age of the patients was 55.7 ± 11.2 years. Intra-procedure SF/NR was observed in 21.7% (560) of the patients. During median short-term follow-up of 180 [144-205] days, patients with SF/NR exhibited higher incidence of all-cause mortality (23.6% vs. 12.3%; p<0.001), and MACE (30.4% vs. 16.9%; p<0.001) with hazard ratio of 1.82 [1.46-2.27; p<0.001] and 1.69 [1.39-2.05; p<0.001], respectively. Among patients with SF/NR, adjusted odds ratio for total ischemic time: 1.04 [1.00-1.07; p=0.041], random blood sugar levels: 1.01 [1.00-1.01; p<0.001], intubation status: 2.79 [1.26-6.18; p=0.011], post-procedure sub-optimal flow: 1.76 [1.04-2.98; p=0.034], and intra-procedural arrhythmias: 5.48 [2.03-14.79; p<0.001] were found to be independent predictors of short-term mortality. Conclusion In conclusion, the presence of intra-procedure SF/NR carries significant prognostic implications. Patients with intra-procedure SF/NR face a significantly higher risk of short-term adverse outcomes.

Use of fibrin sealant in vein anastomosis in renal transplantation and its effect in preventing blood loss and postoperative peri-graft collection.

This study is to assess efficacy of fibrin sealant in vein anastomosis in renal transplantation in preventing blood loss and postoperative peri-graft collection. This is a retrospective analytical case-control study of renal transplantations done in a tertiary care center in India in a 1-year period. Fibrin sealant was randomly used in vein anastomosis during the period. All the data were extracted and retrospectively analyzed. Those with fibrin sealant use were the study group and without sealant use were the control group. Primary objective was to assess effectiveness of fibrin sealant in preventing blood loss and postoperative peri-graft collection. Secondary objectives were to evaluate patients' demographic profile, hospital stay and other intraoperative and postoperative characteristics. During the study, 163 patients were enrolled, 82 study group and 81 control group. Warm ischemia, cold ischemia and operative times of study group were 2.57 ± 2.03, 44.23 ± 8.89 and 189.6 ± 51.6min, respectively, and that of control group were 2.67 ± 2.07, 42.37 ± 8.5 and 178.8 ± 54.6min, respectively. The mean intraoperative blood loss in study and control groups was 124.83 ± 110.89 and 155 ± 50.27ml, respectively, and the difference was statistically significant (p .027). The mean peri-graft collection in study group and control group were 72.33 ± 29.18ml and 134.67 ± 102.84ml, respectively, but the difference was not statistically significant (p .086). The study also demonstrated that the duration of hospital stays significantly differed between two groups (p < .043). In this study, fibrin sealant has demonstrated both safety and efficacy in effectively managing bleeding, sealing vascular anastomoses, and mitigating peri-graft collection.

Accuracy of warm ischemia time measurement using a surgical intelligence software in partial nephrectomies: A validation study

AbstractObjectivesThe objectives of this study are to compare the accuracy of warm ischemia times (WITs) derived by a surgical artificial intelligence (AI) software to those documented in surgeon operative reports during partial nephrectomy procedures and to assess the potential of this technology in evaluating postoperative renal function.Patients and methodsA surgical AI software (Theator Inc., Palo Alto, CA) was used to capture and analyse videos of partial nephrectomies performed between October 2023 and April 2024. The platform utilized computer vision algorithms to detect clamp placement and removal, enabling precise WIT measurement. Expert‐reviewed surgical videos served as the ground truth. Platform‐derived WITs were compared to those in surgeon operative reports using paired‐sample t‐tests. Additionally, we analysed the correlation between platform‐derived WITs and postoperative creatinine levels extracted from electronic health records (EHRs) integrated via health level seven (HL7) messaging protocols.ResultsOf 64 eligible cases, 61 were included in the final analysis. Platform‐derived WITs were within 1 min of the ground truth in all procedures, within 30 s in 97%, and within 10 s in over 80%. The mean difference between platform‐derived WITs and ground truth was 8.3 s, significantly lower than the 2.45 min difference for operative reports (p &lt; 0.001). No significant correlation was found between platform‐derived WIT and postoperative creatinine changes, aligning with the view that WIT may not independently determine postoperative renal function. Although not the primary goal of this study, significant correlations were observed between WIT, tumour size and RENAL score.ConclusionThis study demonstrates the high accuracy of a surgical intelligence platform in measuring WIT during partial nephrectomies. The findings support the use of AI‐based surgical time measurement for precise intraoperative documentation and highlight the potential of integrating these data with EHRs to advance research on surgical outcomes.

Impacts of completely endophytic renal masses on perioperative, oncologic, and functional outcomes in robot-assisted partial nephrectomy: a systematic review and meta-analysis.

The objective of this study was to perform a comprehensive pooled analysis aimed at comparing the efficacy and safety of robot-assisted partial nephrectomy (RAPN) between completely endophytic tumors (CERT) and non-completely endophytic tumors (non-CERT). This study adhered rigorously to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to conduct a systematic review and meta-analysis. We performed a systematic search in the PubMed, Embase, Web of Science, and Cochrane Library databases, focusing on studies published in English up to May 2024. Our analysis primarily evaluated key outcomes, specifically perioperative, functional, and oncological outcomes. A total of 2126 patients across six studies were included in the analysis. Compared to non-CERT, CERT was associated with significantly higher rates of major complications (Odds Ratio [OR]: 2.47; 95% CI: 1.14 to 5.34; p = 0.02), longer warm ischemia times (Weighted Mean Difference [WMD]: 3.27min; 95% CI: 0.61 to 5.39; p = 0.02), a greater decline in estimated glomerular filtration rate (eGFR) (WMD: 2.93 ml/min/1.73 m2; 95% CI: 0.75 to 5.11; p = 0.008), and relatively lower trifecta achievement rates (OR: 0.63; 95% CI: 0.41 to 0.96; p = 0.03). However, no statistically significant differences were observed between the two groups in terms of operative time, length of stay, blood loss, transfusion rates, intraoperative complications, overall complications, positive surgical margins, and local recurrence. Although CERT was associated with greater declines in eGFR and lower rates of trifecta achievement, it yielded perioperative, functional, and oncologic outcomes comparable to those of non-CERT in RAPN. Our findings suggest that RAPN for completely endophytic renal masses can achieve acceptable outcomes when performed in centers with substantial expertise in robotic surgery. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=555067, identifier CRD42024555067.

A Systematic Review of Renal Perfusion in Complex Abdominal Aortic Aneurysm Open Repair

Introduction: This systematic review aims to analyze the current literature regarding 30-day mortality and postoperative acute kidney disease (AKI) in complex abdominal aortic aneurysms (cAAAs), which included juxtarenal aortic aneurysm (JAA), suprarenal aortic aneurysm (SRAA), and type IV thoracoabdominal aortic aneurysm (TAAA) open surgery (OS), to evaluate the impact of renal perfusion on AKI and to try to define which is the best way to perform it. Methods: A literature search in PubMed and Cochrane Library was performed, and articles published from January 1986 to January 2024 reporting on JAA, SRAA, and TAAA type IV open surgery management were identified. Multicenter studies, single-center series, and case series with ≥10 patients were considered eligible. Comparisons of outcomes of patients who underwent OS for complex abdominal aortic aneurysms (cAAAs) with or without perfusion of the renal arteries were analyzed when available. The titles, abstracts, and full texts were evaluated by two authors independently. The primary outcomes included AKI and 30-day mortality rates. The new-onset dialysis rate was considered a secondary outcome. Results: A total of 295 articles were evaluated, and 21 were included, totaling 5708 patients treated for cAAAs with OS. The male patients totaled 4094 (71.7%), with a mean age of 70.35 ± 8.01 and a mean renal ischemia time of 32.14 ± 12.89 min. Data were collected and analyzed, at first in the entire cohort and then divided into two groups (no perfusion of the renal arteries—group A vs. selective perfusion—group B), with 2516 patients (44.08%) who underwent cAAAs OS without perfusion of the renal arteries and 3192 patients (55.92%) with perfusion. In group B, four types of renal perfusion were reported. Among the 21 studies included, 10 reported on selective renal perfusion in cAAA OS, with several types of fluids described: (1) “enriched” Ringer’s solution, (2) “Custodiol” (Istidine-tryptophan-ketoglutarate or Custodiol HTKsolution), (3) other cold (4 °C) solutions (i.e., several combinations of 4 °C isotonic heparinized balanced salt solution containing mannitol, sodium bicarbonate, and methylprednisolone), and (4) warm blood. Thirty-day mortality for patients in group A was 4.25% (107/2516) vs. 4.29% (137/3192) in group B. The reported incidence of AKI and new onset of dialysis was, respectively, 22.14% (557/2516) and 5.45% (137/2516) for group A and 22.49% (718/3192) and 4.32% (138/3192) for group B. A total of 579 patients presented with chronic kidney disease (CKD) at admission across all studies, which included 350 (13.91%) in group A vs. 229 (7.17%) in group B. Acute kidney injury, 30-day mortality, and new-onset dialysis rate were reported in four subgroups: (1) In the “Ringer” group, 30-day mortality was 2.52% (3/113), AKI affected 27.73% (33/119) of patients, and the new-onset dialysis rate was 2.52% (3/113). (2) In the “Custodiol” group, 30-day mortality was 3.70% (3/81), AKI affected 20.17% (24/81) of patients, and the new-onset dialysis rate was 2.46% (2/81). (3) In the “cold solutions” group (i.e., NaCl and mannitol), 30-day mortality was 4.38% (130/2966), AKI affected 21.81% (647/2966) of patients, and the new-onset dialysis rate was 4.48% (133/2966). (4) In the “Warm blood” group, 30-day mortality was 3.85% (1/26), AKI affected 53.84% (14/26) of patients, and the new-onset dialysis rate was 0% (0/26). Conclusions: This systematic review highlights the lack of standard definitions for AKI, CKD, and the type of renal perfusion. Despite similar results in terms of AKI and 30-day mortality, renal perfusion seems to be protective of the new-onset hemodialysis rate. Moreover, Custodiol appears to have lower rates of AKI and hemodialysis than the other perfusion types. A prospective randomized controlled trial to perform further subgroup analysis and research the various types of renal perfusion may be necessary to identify possible benefits.

Grasping time - longevity of vascularized composite allografts.

Despite significant advancements in the field of vascularized composite allotransplantation, challenges, particularly regarding the long-term viability and functionality of vascularized composite allotransplantation (VCA) grafts, persist. This paper provides a review of the current literature on the longevity of VCA grafts, focusing on factors influencing graft survival, immunological considerations and clinical outcomes. Longevity of VCA grafts is influenced by a variety of peri- and postoperative factors including cold ischemia time, human leukocyte antigen matching, environmental exposure, psychosocial factors, adherence, immunosuppression, and complications. Due to the limited number of VCA transplants performed and heterogenous reporting, direct correlation of single factors with VCA outcomes remains inconclusive. Indirect evidence, however, supports their importance. High immunosuppressive burden, frequent occurrence of acute and accumulating cases of chronic rejection remain a significant challenge of the field. Insights gained from this review aim to inform clinical practice and guide future research endeavors with the goal of ameliorating outcomes after VCA transplantation and facilitate wider use of VCA grafts for restoration of tissue defects.

Single-Port Versus Multi-Port Robotic Retroperitoneal Partial Nephrectomy: A Propensity Score-Matched Comparison.

Objective: To compare the surgical results of retroperitoneal (RP) robot partial nephrectomy (PNx) using either a single-port robot (SP) or a multi-port robot (MP). Materials and Methods: We retrospectively reviewed all RP robotic PNx performed at a single institution from September 2021-when the SP robot was introduced to the institution-through April 2023. In total, 125 patients underwent the surgery; 81 patients were treated with surgery using a MP robot whereas 44 patients were treated with surgery using a SP. All MP surgeries were performed with da Vinci Xi (Intuitive, Sunnyvale, California, USA), while all SP surgeries were performed with da Vinci SP (Intuitive, Sunnyvale, California, USA). We performed a propensity score-matching (PSM) analysis of these 125 patients. Results: There was no significant difference between the two groups after PSM. In terms of operation time, that for MP was 103.68 ± 21.89 minutes whereas that for SP was 95.43 ± 32.22 minutes (p-value = 0.164). Meanwhile, in terms of console time, that for MP was 70.95 ± 21.92 minutes whereas that for SP was 64.14 ± 32.06 minutes (p-value = 0.248). In terms of estimated blood loss was 90.91 ± 91.06 mL in MP and 92.27 ± 104.30 mL in SP (p-value = 0.948). Lastly, there was a statistically significant difference in warm ischemic time, as it was 17.18 ± 6.56 minutes in MP and 13.82 ± 4.59 in SP (p-value = 0.007). There were no statistically significant differences between MP and SP in any other surgical outcomes. Conclusions: SP robot RP PNx demonstrated comparable outcomes to those achieve using MP procedures. This means SP robot RP PNx can be considered a preferable and more convenient surgical approach than conventional methods, particularly when dealing with small renal masses located in the posterior side of the kidney.

Normothermic Ex Vivo Perfusion Before Transplantation of the Kidney (NEXT-Kidney): A Single-center, Nonrandomized Feasibility Study.

There is conflicting evidence regarding the efficacy of normothermic machine perfusion (NMP) in suboptimal deceased donor kidneys. We aimed to assess the feasibility and short-term efficacy of brief preimplantation NMP in circulatory death (DCD) kidneys. In this nonrandomized, single-center, prospective clinical trial, DCD kidneys underwent 1 to 3 h of NMP before implantation, aiming to achieve short ischemic times off NMP. The primary outcomes included feasibility and safety. Secondary outcomes included efficacy outcomes (delayed graft function and estimated glomerular filtration rate (eGFR) at 1, 6, and 12 mo), which were compared with the contralateral kidney that did not receive NMP. Eighteen DCD kidneys underwent NMP between 2020 and 2022, with at least 1 h completed in 16 (88.9%) of these kidneys (median 1 h); one kidney was removed after 5 min because of cannula failure and another at 54 min because of a sudden drop in blood flows. There was no episode of graft loss on the machine or postoperative vascular thromboses. All 18 kidneys were transplanted, with no cases of PNF or graft loss at 12 mo. Seventeen of the contralateral CS kidneys were transplanted. Compared with the contralateral kidneys, a lower incidence of delayed graft function (23.5% versus 64.7%; P = 0.046) was observed. There were no differences in the eGFR slopes between the two groups over time (P = 0.254). NMP is safe, feasible and efficacious in the Australian setting, with this relatively small cohort demonstrating good early outcomes compared to CS alone in our study of DCD kidneys.

Outcomes of Del Nido and hyperkalemic blood cardioplegia in adult cardiac surgery with prolonged aortic cross clamp times.

Background The utility and uptake of Del Nido cardioplegia in adult cardiac surgery is rapidly increasing. Cases with prolonged aortic cross clamp times necessitate multi dosing however an understanding of safe ischaemic times and definitive guidelines in this domain are lacking. Therefore, the aim of this study was to assess the safety and efficacy of our DNC strategy by comparing post-operative troponin profiles and clinical outcomes between del Nido and hyperkalaemic cardioplegia for cases with aortic cross clamp times of greater than 90 minutes. Methods A single centre, retrospective cohort study at Flinders Medical Centre and Flinders Private Hospital of patients undergoing composite cardiac surgery with a cross clamp time longer than 90 minutes. Data was prospectively collected from the Flinders Cardiac Surgery Registry from June 2014 to December 2022. A propensity matched (1:1) analysis was performed comparing patients receiving del Nido cardioplegia (n=194) to those receiving hyperkalemic blood cardioplegia (n=194). Primary outcome was the post-operative troponin release profile with clinical events reported as secondary outcomes . Results There was no difference in the peak or median troponin at 6, 12 and 72 hours nor number of patients with positive troponin profile post operatively between cohorts. There was no difference in clinical outcomes between groups with aortic cross clamp times of 90min which remained true in Sensitivity analysis extending out to 120min. The Del Nido cohort received less cardioplegia volume (p &lt;0.001) and were more likely to return to spontaneous rhythm (p &lt;0.002). Conclusion Del Nido cardioplegia for anticipated aortic cross clamp times of greater than 90min provided equivocal post operative troponin profiles and clinical outcomes compared to multidose hyperkalemic blood cardioplegia.

Impact of Tumor Volume and Other Factors on Renal Function After Partial Nephrectomy.

Background and Objectives: One of the main objectives of partial nephrectomy is to preserve as much renal function as possible. However, the removal of functioning nephrons and ischemic damage secondary to the clamping of the renal pedicle can be associated with a certain degree of renal function loss. We aim to evaluate the relationship between tumor volume and other factors on renal function in the short term (1-3 months) and long term (6-12 months) in our series of partial nephrectomies. Methods: A retrospective study was conducted on 147 patients who underwent open or laparoscopic partial nephrectomy between 2018 and 2022. Tumor volume was estimated through reconstructions from the computed tomography images. Univariate and multivariate analyses of the data were performed. Results: The mean age was 58.2 years, with an average glomerular filtration rate (GFR) of 79 mL/min/m2. Of all partial nephrectomies, 76.2% were laparoscopic, 57.1% were T1a tumors, and the mean volume was 17 cc. The average ischemia time during surgery was 14.3 min, with a mean hemoglobin loss of 2.8 g/dL in the immediate postoperative period. No significant differences were found either in the short or long term regarding ischemia time (p = 0.57, p = 0.32) or tumor volume (p = 0.57, p = 0.33). However, in the multivariate analysis, it was observed that the variable with the greatest influence on short-term renal function was perioperative glomerular filtration, while in the long term, ischemia time, age, and tumor volume also had an influence. Conclusions: Tumor volume is not an independent factor for renal function deterioration in the short or long term. Short-term renal function is primarily determined by perioperative glomerular filtration. Perioperative glomerular filtration, ischemia time, age, and tumor volume can jointly predict long-term renal function.

Cold ischemia time alters cell-type specific senescence leading to loss of cellular integrity in mouse lungs

Purpose: Ischemia-reperfusion injury (IRI) is a major challenge in lung transplantation often causing graft dysfunction and chronic airway illnesses in recipients. To prevent potential transplant related complications, strict guidelines were put in place to choose viable donor lungs with minimal risk of IRI. These regulations deem most of the donor organs unfit for transplant which then are donated for research to understand the mechanisms of health and diseases in human. However, resected organs that are being transported undergo cold ischemia that can negatively affect the tissue architecture and other cellular functions under study. Thus, it is important to assess how cold ischemia time (CIT) affects the physiological mechanism. In this respect, we are interested in studying how CIT affects cellular senescence in normal aging and various pulmonary pathologies. We thus hypothesized that prolonged CIT exhibits cell-type specific changes in lung cellular senescence in mice. Methods: Lung lobes from C57BL/6J (n = 5–8) mice were harvested and stored in UW Belzer cold storage solution for 0, 4-, 9-, 12-, 24-, and 48-h CIT. Lung cellular senescence was determined using fluorescence (C12FdG) assay and co-immunolabelling was performed to identify changes in individual cell types. Results: We found a rapid decline in the overall lung cellular senescence after 4-h of CIT in our study. Co-immunolabelling revealed the endothelial cells to be most affected by cold ischemia, demonstrating significant decrease in the endothelial cell senescence immediately after harvest. Annexin V-PI staining further revealed a prominent increase in the number of necrotic cells at 4-h CIT, thus suggesting that most of the cells undergo cell death within a few hours of cold ischemic injury. Conclusions: We thus concluded that CIT significantly lowers the cellular senescence in lung tissues and must be considered as a confounding factor for mechanistic studies in the future.

Oncologic Outcomes and Safety Assessment of Retroperitoneal Laparoscopic Partial Nephrectomy versus Open Partial Nephrectomy in Treating Patients with Localized Renal Cell Carcinoma: A Propensity Score Matching Study.

Surgical intervention is crucial in radical resection of renal cell carcinoma (RCC). Different surgical procedures have different oncologic outcomes and safety in patients with RCC. Therefore, we aimed to investigate the oncologic outcomes and safety of retroperitoneal laparoscopic partial nephrectomy (RLPN) versus open partial nephrectomy (OPN) in treating patients with localized RCC. This retrospective cohort study included 160 patients with localized RCC who underwent either OPN or RLPN from January 2016 to June 2020. Out of these patients, 75 patients were treated with OPN and 85 patients were treated with RLPN. After propensity score matching, 130 patients (65 cases in each group) were finally included in the analysis. Additionally, surgical outcomes, three-year survival rates, and renal function parameters were assessed between the two groups, and the data were statistically analyzed using SPSS. Compared to the OPN group, RLPN demonstrated significantly shorter surgical time, lower estimated blood loss (p < 0.05), and lower incidence of complications (p = 0.024). In contrast, the RLPN group had significantly longer warm ischemia time (p = 0.011) than the OPN group. Furthermore, there were no significant differences in three-year overall survival, disease-free survival, cancer specific survival rates, positive surgical margins, hospitalization time between the RLPN and OPN groups (p > 0.05). The incidence of complications in the RLPN group was significantly lower than that in the OPN group (p = 0.024). Postoperatively, creatinine level was significantly lower following RLPN at one year compared to OPN (p = 0.029). RLPN offers advantages in surgical time, estimated blood loss, and postoperative complications, and it positively affects postoperative renal function, while OPN shows a shorter warm ischemia time. These two approaches result in comparable three-year survival rates. This study provides valuable insights into the oncologic outcomes and safety of RLPN compared to OPN in treating localized RCC.

Revisiting the Prognostic Influences of Donor-Recipient Size Mismatch in Deceased Donor Liver Transplantation.

Liver transplantation (LT) outcomes are influenced by donor-recipient size mismatch. This study re-evaluated the impact on graft size discrepancies on survival outcomes. Data from 53 389 adult LT recipients from the United Network for Organ Sharing database (2013-2022) were reviewed. The study population was divided by the body surface area index (BSAi), defined as the ratio of donor body surface area (BSA) to recipient BSA, into small-for-size (BSAi < 0.78), normal-for-size (BSAi 0.78-1.24), and large-for-size (BSAi > 1.24) grafts in deceased donor LT (SFSD, NFSD, and LFSD). Multivariate Cox regression and Kaplan-Meier survival analyses were conducted. The frequency of size mismatch in deceased donor LT increased over the past 10 y. SFSD had significantly worse 90-d graft survival (P < 0.01), and LFSD had inferior 1-y graft survival among 90-d survivors (P = 0.01). SFSD was hazardous within 90 d post-LT because of vascular complications. Beyond 1 y, graft size did not affect graft survival. LFSD risk within the first year was mitigated with lower model for end-stage liver disease (MELD) 3.0 scores (<35) or shorter cold ischemia time (<8 h). The negative impacts on donor-recipient size mismatch on survival outcomes are confined to the first year post-LT. SFSD is associated with a slight decrease in 90-d survival rates. LFSD should be utilized more frequently by minimizing cold ischemia time to <8 h, particularly in patients with MELD 3.0 scores below 35. These findings could improve donor-recipient matching and enhance LT outcomes.

Impact of tumor dissecting technique on trifecta achievement in patients requiring extended warm ischemia during robot-assisted partial nephrectomy.

To clarify specific factors associated with surgical outcomes in robot-assisted partial nephrectomy (RAPN) that require extended warm ischemia time (WIT), which may have a negative impact, but cannot always be avoided. We included 1,182 patients who had RAPN performed between January 2016 and December 2022 from a prospectively generated multi-institutional RAPN database, divided into normal WIT (nWIT) (≤ 20min; 843 patients) and extended WIT (eWIT) (> 20min; 339 patients) groups. Primary outcome measures were WIT and the Surface-Intermediate-Base (SIB) margin score, which contribute to postoperative trifecta achievement. Results were compared between the two groups using logistic regression. Patients in the eWIT group had larger tumors, higher RENAL nephrometry scores, and lower SIB scores than those of the nWIT group. The trifecta achievement rate was significantly different between the two groups (nWIT: 70.1 vs. 49.0%, p < 0.001). In the nWIT group, WIT (coefficient: -0.105 [standard error 0.020], p < 0.001) and SIB score (coefficient: -0.107 [0.053], p = 0.045) were significant predictors of trifecta achievement. In the eWIT group, the SIB score (coefficient - 0.216 [0.082], p = 0.008) was significantly associated with trifecta attainment, whereas WIT only showed a trend toward significance. Limitations included a lack of long-term survival, renal function, and chronic complications data. For patients with eWIT during RAPN, the tumor dissection technique may be more important than WIT in predicting postoperative outcomes. Further prospective studies are required to confirm our results.

Impact of Heart Transplant Allocation Change on Waitlist Mortality and Posttransplant Mortality in Patients With Left Ventricular Assist Devices.

In October 2018, the US heart transplant (HT) allocation system was revised giving patients with left ventricular assist device (LVAD) intermediate priority status. Few studies have examined the impact of this policy change on outcomes among patients with LVAD. We sought to determine how the allocation change impacted waitlist and posttransplant mortality in patients with LVAD. We retrospectively assessed the United Network for Organ Sharing registry for patients with LVAD who were listed for or underwent HT between October 2016 and October 2021. We evaluated waitlist mortality using competing risks analysis and a multivariable Fine-Gray model, and posttransplant mortality using Kaplan-Meier survival analysis and a multivariate proportional hazards model. We analyzed data from 3835 patients with LVAD listed for HT and 3486 patients with LVAD who underwent HT during the study period. Listing for HT preallocation change was significantly associated with an increased risk of waitlist mortality (Gray P=0.0058) compared with postallocation change. After adjustment for covariates, mortality differences by listing era were attenuated, but LVAD brand was significantly associated with waitlist mortality (HM3 versus HMII; hazard ratio, 0.38 [95% CI, 0.21-0.69]; P=0.002; HVAD versus HMII; hazard ratio, 0.79 [95% CI, 0.48-1.30]; P=0.36; overall P=0.004). In contrast, HT postallocation change was associated with increased posttransplant mortality (log-rank P=0.0172) compared with preallocation change. In a multivariable analysis, the association with posttransplant mortality between transplant eras was attenuated, but ischemic time (hazard ratio, 1.16 [95% CI, 1.07-1.26]; P<0.001) and status at time of HT (Status 1-3 versus 4; hazard ratio, 1.29 [95% CI, 1.04-1.61]; P=0.02) were significantly associated with posttransplant mortality. Among patients with LVAD, lower waitlist mortality postallocation change was likely driven by improved LVAD technology. Higher posttransplant mortality following the allocation change was largely attributable to longer ischemic times and patient acuity.

Clinical application and efficacy analysis of robot-assisted laparoscopic tumor enucleation combined with tumor aspiration in the treatment of renal hilar angiomyolipoma

BackgroundFor renal hilar angiomyolipoma, general surgical resection is often quite challenging. The aim of this study is to evaluate the safety and efficacy of an innovative robot-assisted laparoscopic strategy that combines tumor enucleation with tumor aspiration in the treatment of renal hilar angiomyolipoma.MethodsThe clinical data of 38 patients with renal hilar angiomyolipoma who went through robotic tumor enucleation combined with tumor aspiration in the Department of Urology, the Affiliated Hospital of Nanjing University Medical School, from December 2019 to December 2022 were retrospectively analyzed. The basic characteristics, the perioperative variables, intraoperative procedures, and postoperative complications were all recorded. Patients were followed up to evaluate the angiomyolipoma recurrence and the renal function by urologic CT or ultrasound and renal function tests.ResultsAll surgeries were successfully completed without conversion to radical nephrectomy or open surgery. One patient developed urinary extravasation 10 days after surgery, and was readmitted to the hospital for transurethral ureteral stenting considering the injury of the renal collecting system. The median operative time was 181.5 (123.8-206.3) min, the warm ischemia time was 20.0 (17.3–24.0) min, the blood loss was 125 (100.0-262.5) ml, and no patients received blood transfusion during and after surgery. The median hospitalization time was 7.0 (6.0–9.0) days, and the duration of indwelling drainage tube was 2.0 (2.0–3.0) days. The serum creatinine (Scr) on the first day, 3 months, and 6 months after surgery were 55.5 (50.8–62.8) µmol/L, 55.5 (48.0–62.0) µmol/L and 54.0 (51.8–63.5) µmol/L, respectively, and there was no significant difference compared with the preoperative level 56.0 (47.8–60.3) µmol/L. All patients were followed up after surgery, and the urinary CT scan or renal color doppler ultrasound, and renal function were reexamined. The median follow-up time of all patients was 19.0 (14.75-33.0) months, and no local recurrence of angiomyolipoma was seen in all patients.ConclusionsThe surgical strategy of robot-assisted laparoscopic tumor enucleation combined with tumor aspiration is safe and effective in the treatment of renal hilar angiomyolipoma.

Outcomes of Donation After Circulatory Death Heart Transplantation Using Normothermic Regional Perfusion

BackgroundDonation after circulatory death (DCD) with cardiopulmonary bypass for thoracoabdominal normothermic regional perfusion (TA-NRP) has led to increased use of donor hearts. Rejection rates and long-term survival outcomes are not known. MethodsA single-center retrospective cohort review of patients who underwent DCD heart transplantation from January 2020 to December 2023 was performed. Donor and recipient characteristics, operative characteristics, and posttransplantation outcomes were analyzed. Subgroup analysis comparing co-localized vs distant donors and recipients was performed. The primary end point was 1-year survival. Secondary end points included incidences of primary graft dysfunction (PGD), cardiac allograft vasculopathy (CAV), rejection rate, and overall mortality. Our TA-NRP protocol has remained the same, consisting of sternotomy, ligation of aortic arch vessels, establishment of cardiopulmonary bypass, reintubation, resuscitation of the heart, and cold static storage during transport. ResultsIn total, 32 recipients underwent DCD heart transplantation, including 26 isolated hearts, 3 heart-lungs, and 3 heart-kidneys. The median age was 56 years for recipients and 39 years for donors; 21 donors and recipients were co-localized, whereas 11 were distant. One-year survival was 100%. Two patients required mechanical circulatory support for PGD. Four patients experienced grade 2R acute cellular rejection. Five patients had grade 1 CAV at 1 year. On subgroup analysis, distant donors and recipients had longer warm (47 vs 30 minutes; P < .005) and cold (213 vs 76 minutes; P < .005) ischemia times, without any other differences. ConclusionsOutcomes after DCD heart transplantation using TA-NRP remain encouraging with acceptable rates of rejection, PGD, CAV, and survival at 1 year.

Outcomes of Multiorgan Heart Transplant Between Donation After Circulatory Death and Brain Death.

There is insufficient data on the outcomes of donation after circulatory death (DCD) multiorgan transplant that includes heart. The primary objective of this study is to compare the overall survival outcomes of DCD and donation after brain death (DBD) multiorgan transplants. We identified all heart transplant patients from 2019 to June of 2023 using the United Network for Organ Sharing (UNOS) Database who also received an additional organ (kidney, liver, and lungs). A total of 1,844 DBD and 91 DCD multiorgan transplants occurred within the study period, the majority being combined heart-kidney transplantation. More patients were listed at a higher status in the DBD group (p < 0.05) and were in the intensive care unit (ICU) before transplant (p < 0.05). Despite the higher ischemia time in the DCD group (p < 0.05), the overall unmatched survival did not differ between the two groups (p < 0.05). Within the heart-kidney transplants, the overall survival between DBD and DCD heart-kidney transplants did not differ in either unmatched or matched groups (unmatched p = 0.5, matched p = 0.5). In conclusion, the data on the outcomes of DCD multiorgan transplants are limited. Still, our analysis of the currently available data suggests that the overall survival is comparable in the DCD multiorgan transplants.