Liberal Use Research Articles

Improvement in Lymphoma CAR-T Outcomes over Time in the UK - CAR-T Learning Curve or Better Bridging?

Introduction / Aims CD19 CAR-T therapy for relapsed/refractory (r/r) large B-cell lymphoma (LBCL) has been implemented by the UK National Health Service since December 2018. First data from the UK real-world experience suggested inferior outcomes compared to the pivotal trials, but results have improved over time. We aimed to identify potential differences in patient selection and management between treatment eras, reflecting the CAR-T learning curve, as well as determinants of improved outcome. Methods We included 120 consecutive LBCL patients approved for treatment with axicabtagene ciloleucel (axi-cel) or tisagenlecleucel (tisa-cel) at King's College Hospital London (KCH cohort) and split them into 2 treatment eras - Era 1 (Dec 2018 - Dec 2019), and Era 2 (Jan 2020 - Mar 2022). Survival analyses were extended to the UK national cohort of 446 patients intended to be treated (ITT) with CAR-T across 10 UK CAR-T centers, with a median follow-up of 25.7 months. Results In the KCH cohort, baseline patient and disease characteristics did not significantly differ between Era 1 and 2, except for a lower incidence of patients with pre-lymphodepletion (LD) elevated LDH (eLDH) in Era 2 (see Table). CAR-T product choice and median vein-to-vein time were similar in both eras. Bridging strategies evolved with more use of polatuzumab vedotin-based bridging in Era 2 (48% vs 3%, p<0.001) as well as a trend to more radiotherapy bridging (40% vs 25%, p=0.12). There were fewer bridging failures (drop-out after leukapheresis due to clinical deterioration or death) in Era 2 vs 1: 3% vs 14%, p=0.05. In total, 88% (Era 2) vs 82% (Era 1) of the ITT population proceeded with CAR-T infusion (p=0.45). When assessing CAR-T toxicity in Era 2 vs Era 1, the incidence of high-grade toxicity was lower (Grade 3+ CRS/ICANS 8% vs 22%, p=0.046), with more liberal use of tocilizumab and corticosteroids in Era 2 (see Table). One-year non-relapse mortality (NRM) was similar between eras (5% vs 8%, p=0.40). Progression-free survival (PFS) showed a trend to improvement in Era 2 (median PFS 11.3mths vs 5.2mths, 1-yr-PFS 41% vs 31%, p=0.057) and overall survival was significantly longer (median OS NR vs 11.7mths, 1-yr-OS 71% vs 48%, p=0.006). We extended our survival analysis to the UK-wide CAR-T cohort of 446 patients. Similarly, for Era 2 vs 1, we observed a lower incidence of eLDH pre-LD (50% vs 66%, p 0.004), increased use of polatuzumab- based bridging (45% vs 3%, p<0.001), fewer bridging failures (10% vs 20%, p=0.003), and a higher use of tocilizumab/steroids (77%/49% vs 60%/34% (both p<0.001). In addition, patients in Era 2 were older (median 62y vs 58y, p<0.001), had better pre-LD ECOG PS (7.5% vs 12% ECOG 2+, p=0.002) and were more likely to receive axi-cel (78% vs 69%, p=0.004). Outcome analyses of the total cohort showed unequivocally that both PFS and OS were longer in the more recent era (median PFS 6.8mths vs 4.4mths, 1-yr-PFS 39% vs 25%, p<0.001; median OS NR vs 8.3mths, 1-yr-OS 59% vs 40%, p<0.001). In univariate analysis of both PFS and OS including all patients, baseline IPI, 3+ extranodal sites, baseline eLDH, bulky disease, refractoriness to all prior therapy, lack of response to bridging, pre-LD eLDH, pre-LD ECOG 2+, pre-LD CRP, tisa-cel use and Treatment Era 1 vs 2 were significantly associated with inferior survival. On MVA, 3+ extranodal sites (HR 2.0 [1.1 - 3.7]); pre-LD eLDH (HR 1.7 [1.1 - 2.8]) and lack of bridging response (HR 1.6 [1.0 - 2.6]) remained significant for PFS, and 3+ EN sites (HR 2.5 [1.3 - 4.8]); pre-LD eLDH (HR 2.8 [1.5 - 4.9]); ECOG 2+ (HR 2.0 [1.0 - 4.0]) and lack of bridging response (HR 2.1 [1.2 - 3.7]) for OS. Conclusions Our data show improvement over time in survival outcomes for LBCL patients treated with CD19 CAR-T at our center and nationally which appear to be mainly driven by improvements in bridging therapy. Incidence of high-grade CAR-T toxicities was low and seems to have further reduced with more proactive toxicity management in the recent era. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Perfect variations in Romance

The morpho-syntactic configuration auxiliary (have or be) + past participle known as the have-perfect functions as a tense-aspect category in many Western European languages. Synchronic variation within Romance nicely illustrates the developmental pattern described as the aoristic drift, whereby the perfect develops over time into a perfective past with full-fledged past meanings. A parallel corpus study of L’Étranger by Albert Camus (1942) and its translations using the Translation Mining methodology provides empirical data supporting the view that modern French, Romanian and Italian make a more liberal use of the perfect, whereas the perfect distribution in Spanish is closer to (but not identical to) English. Catalan occupies an intermediate position and Portuguese has the most restricted perfect among the Romance languages. We argue that this variation is best captured by a perfect scale, without a clear cut-off point between perfect and perfective past meaning. The meaning ingredients that govern the distribution of the have-perfect across Romance languages emerge from the parallel corpus. They include lexical, compositional and discourse semantics, and range from sensitivity to aspectual class, pluractionality, hodiernal and pre-hodiernal past time reference to narration.

Liberal use of local anaesthetic and the risk of toxicity in elective arthroplasties at a tertiary teaching hospital

Background Local anaesthetic systemic toxicity (LAST) is a life-threatening potential complication that may follow the administration of local anaesthetic (LA) drugs, and is cumulative across the drug class. Local anaesthetics are commonly administered via different routes for elective orthopaedic procedures – both by anaesthetists and surgeons. We hypothesized that total doses of LA may be routinely encroaching upon toxicity. Methods All total hip or knee arthroplasties (THAs and TKAs) performed within a 3 month period at the John Hunter Hospital (tertiary referral centre and teaching hospital) were audited to assess total administration of LA. Demographics, surgical characteristics, use of general anaesthesia or sedation, and use of local anaesthetic via any route of administration was recorded. For each patient, a weight-based theoretical maximum safe dose was calculated and compared against the dose they received. Data is presented as mean ± SD, percentages. Statistical significance was determined at p &lt; 0.05. Results 130 THAs and TKAs were identified within the audit period. 52 patients exceeded their drug-class theoretical maximum safe dose. 49 patients exceeded their weight-based maximum dose for a single LA agent, in all cases ropivacaine. Non-obese individuals receive significantly higher mean dose than obese individuals (119.4% [98.6–140.3] vs 78.82% [65.95–91.69], p = 0.001). No LAST events were identified. Conclusions Patients who received elective total hip or knee arthroplasties were exposed to concerningly high total doses of local anaesthetic, suggesting that greater awareness of the additive toxicity of drugs within this class is required.

Cholecystectomy for asymptomatic gallstones: Markov decision tree analysis.

Gallstones are a common public health problem, especially in developed countries. There are an increasing number of patients who are diagnosed with gallstones due to increasing awareness and liberal use of imaging, with 22.6%-80% of gallstone patients being asymptomatic at the time of diagnosis. Despite being asymptomatic, this group of patients are still at life-long risk of developing symptoms and complications such as acute cholangitis and acute biliary pancreatitis. Hence, while early prophylactic cholecystectomy may have some benefits in selected groups of patients, the current standard practice is to recommend cholecystectomy only after symptoms or complications occur. After reviewing the current evidence about the natural course of asymptomatic gallstones, complications of cholecystectomy, quality of life outcomes, and economic outcomes, we recommend that the option of cholecystectomy should be discussed with all asymptomatic gallstone patients. Disclosure of material information is essential for patients to make an informed choice for prophylactic cholecystectomy. It is for the patient to decide on watchful waiting or prophylactic cholecystectomy, and not for the medical community to make a blanket policy of watchful waiting for asymptomatic gallstone patients. For patients with high-risk profiles, it is clinically justifiable to advocate cholecystectomy to minimize the likelihood of morbidity due to complications.

Prenatal Developmental Toxicity and Histopathological Changes of the Placenta Induced by Syzygium guineense Leaf Extract in Rats.

Many of the traditional herbal products are served to the consumer without proper efficacy and safety investigations. A laboratory-based experimental study was employed to investigate the toxic effects of Syzygium guineense leaf extract on the fetal development and histopathology of the placenta in rats. Fifty pregnant Wistar albino rats were randomly allocated into five groups, each consisting of 10 rats. S. guineense leaf extract, at doses of 250, 500, and 1000 mg/kg of body weight, was respectively administered to groups I-III rats. Groups four and five were control and ad libitum control, respectively. The number of resorptions, implantation sites, and live or dead fetuses was counted. The weight and crown-rump length of the fetuses were measured. The histopathological investigation of the placenta was conducted. Administration of 70% ethanol extract of S. guineense leaves reduced weight gain and food intake of pregnant rats at p value <0.05. The crown-rump length of the near-term rat fetus was significantly reduced in rats treated with 1000 mg/kg body weight of S. guineense extract (p value <0.05). The plant extract did not affect the number of implantations, fetal resorptions, live births, and stillbirths. The weight of the fetuses and the placentae also decreased dose-dependently. Decidual cystic degeneration was the most prevalent histopathological change observed in a rat's placenta treated with 1000 mg/kg body weight of S. guineense extract. Consumption of S. guineense leaves, especially at a high dose, may affect fetal development. Therefore, liberal use of S. guineense leaves during pregnancy should be avoided.

Single-centre review of the management of intra-thoracic oesophageal perforation in a tertiary oesophageal unit: paradigm shift, short- and long-term outcomes over 15 years

BackgroundOesophageal perforation is an uncommon surgical emergency associated with high morbidity and mortality. The timing and type of intervention is crucial and there has been a major paradigm shift towards minimal invasive management over the last 15 years. Herein, we review our management of spontaneous and iatrogenic oesophageal perforations and assess the short- and long-term outcomes.MethodsWe performed a retrospective review of consecutive patients presenting with intra-thoracic oesophageal perforation between January 2004 and Dec 2020 in a single tertiary hospital.ResultsSeventy-four patients were identified with oesophageal perforations: 58.1% were male; mean age of 68.28 ± 13.67 years. Aetiology was spontaneous in 42 (56.76%), iatrogenic in 29 (39.2%) and foreign body ingestion/related to trauma in 3 (4.1%). The diagnosis was delayed in 29 (39.2%) cases for longer than 24 h. There was change in the primary diagnostic modality over the period of this study with CT being used for diagnosis for 19 of 20 patients (95%). Initial management of the oesophageal perforation included a surgical intervention in 34 [45.9%; primary closure in 28 (37.8%), resection in 6 (8.1%)], endoscopic stenting in 18 (24.3%) and conservative management in 22 (29.7%) patients. On multivariate analysis, there was an effect of pathology (malignant vs. benign; p = 0.003) and surgical treatment as first line (p = 0.048) on 90-day mortality. However, at 1-year and overall follow-up, time to presentation (≤ 24 h vs. > 24 h) remained the only significant variable (p = 0.017 & p = 0.02, respectively).ConclusionOesophageal perforation remains a condition with high mortality. The paradigm shift in our tertiary unit suggests the more liberal use of CT to establish an earlier diagnosis and a higher rate of oesophageal stenting as a primary management option for iatrogenic perforations. Time to diagnosis and management continues to be the most critical variable in the overall outcome.

T065: Reproduction patterns among Classical Hodgkin Lymphoma Survivors Treated with BEACOPP and ABVD in Sweden, Denmark, and Norway

Figure 1: Aalen-Johansen estimates of the cause-specific cumulative incidence (CIF) of childbirth estimated in the presence of competing risks of death. Background: Reproduction in classical Hodgkin lymphoma (cHL) survivors has been shown to be reduced compared to the general population, likely due to multi-agent chemotherapy. Understanding if contemporary treatment protocols are associated with reduced reproduction is important as treatment guidelines shift towards more liberal use of more intensive chemotherapy. Methods: We identified 2,937 individuals aged 18–40 years with cHL in Swedish and Danish lymphoma registers, and in the clinical database at Oslo University Hospital (OUH) between 1995 and 2019, who were linked to national medical birth registers in each country. Cox regression adjusted for stage, performance status, year and age at diagnosis was used to estimate hazard ratios (HRs) contrasting time to first childbirth by treatment groups (ABVD, 2–4 BEACOPP, 6–8 BEACOPP) up to ten years after diagnosis. Cause-specific cumulative incidence (CIF) of childbirths was further estimated using flexible parametric survival models. All analyses included an interaction between cHL treatment and sex. Results: Overall, 71.4% of patients were treated with ABVD, 3.6% with 2–4 BEACOPP, and 10.3% with 6–8 BEACOPP. The reproduction rates (per 1,000 person-years) were 45.5 (males) and 48.2 (females) in the ABVD group, and 23.8 (males) and 39.9 (females) in the 6–8 BEACOPP group. The adjusted HR comparing reproduction rates in individuals treated with 6–8 BEACOPP to ABVD was 0.51 (95% CI 0.35–0.73) for males and 0.82 (95% CI 0.57–1.19) for females. The CIF after 10 years was 20.0% (CI: 14.7%–27.2%) for males and 33.0% (CI: 24.6%–44.3%) for females treated with 6–8 BEACOPP. Conclusion: We found that BEACOPP treatment is associated with decreased reproduction rates compared to ABVD in male cHL patients. Infertility counselling should be prioritized for this group. This abstract has been accepted and presented at the EHA 2022 congress.

A RARE CASE OF ACUTE PULMONARY HISTOPLASMOSIS FOLLOWING COVID-19 INFECTION

SESSION TITLE: COVID-19 Case Report Posters 3SESSION TYPE: Case Report PostersPRESENTED ON: 10/19/2022 12:45 pm - 01:45 pmINTRODUCTION: The most reported fungal infections in patients with COVID-19 include aspergillosis, invasive candidiasis, and mucormycosis. We hereby present a case of a male who developed acute pulmonary histoplasmosis (APH) after COVID-19 infection.CASE PRESENTATION: 51-year-old male with PMHx of COVID-19 infection 3 weeks ago presenting with worsening shortness of breath. Patient had a complicated hospital course with COVID-19 treated with high doses of methylprednisolone. Patient was local to Arizona and lived on a ranch with livestock. CT chest suggestive of multilobar pneumonia and bilateral pleural effusions (Image 1). Coccidiomycosis serology came back negative. Urinary Histoplasma galactomannan antigen came back positive. The diagnosis of APH after COVID-19 infection was established. Patient was started on voriconazole. His symptoms significantly improved. Patient was discharged to skilled nursing facility with outpatient infectious disease follow-up.DISCUSSION: The current literature on APH in the setting of COVID-19 infection is limited. The few proposed mechanisms are: 1. Liberal use of high dose steroids in COVID-19 leading to reactivation of latent H. Capsulatum. 2. Systemic inflammation in COVID-19 causes interstitial lung damage permitting conidia to proliferate leading to acute infection. The Histoplasma urine antigen test is highly sensitive in the diagnosis of APH, especially in immunocompromised patients like our patient. With this case we would like to increase awareness of the possibility of rare fungal infections like APH in patients with COVID-19, as timely diagnosis and appropriate management can lead to improved outcomes.CONCLUSIONS: Rare fungal infections following COVID-19 have been documented and timely diagnosis and management are imperative to improve patient outcomes.Reference #1: Macedo, Priscila M, et al. APH following COVID-19. Case Report J.Fungi 2021DISCLOSURES: No relevant relationships by Ali Rajano disclosure on file for Yamin Saddouk;No relevant relationships by Parita SoniNo relevant relationships by Lyndie Wilkins Parker SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: The most reported fungal infections in patients with COVID-19 include aspergillosis, invasive candidiasis, and mucormycosis. We hereby present a case of a male who developed acute pulmonary histoplasmosis (APH) after COVID-19 infection. CASE PRESENTATION: 51-year-old male with PMHx of COVID-19 infection 3 weeks ago presenting with worsening shortness of breath. Patient had a complicated hospital course with COVID-19 treated with high doses of methylprednisolone. Patient was local to Arizona and lived on a ranch with livestock. CT chest suggestive of multilobar pneumonia and bilateral pleural effusions (Image 1). Coccidiomycosis serology came back negative. Urinary Histoplasma galactomannan antigen came back positive. The diagnosis of APH after COVID-19 infection was established. Patient was started on voriconazole. His symptoms significantly improved. Patient was discharged to skilled nursing facility with outpatient infectious disease follow-up. DISCUSSION: The current literature on APH in the setting of COVID-19 infection is limited. The few proposed mechanisms are: 1. Liberal use of high dose steroids in COVID-19 leading to reactivation of latent H. Capsulatum. 2. Systemic inflammation in COVID-19 causes interstitial lung damage permitting conidia to proliferate leading to acute infection. The Histoplasma urine antigen test is highly sensitive in the diagnosis of APH, especially in immunocompromised patients like our patient. With this case we would like to increase awareness of the possibility of rare fungal infections like APH in patients with COVID-19, as timely diagnosis and appropriate management can lead to improved outcomes. CONCLUSIONS: Rare fungal infections following COVID-19 have been documented and timely diagnosis and management are imperative to improve patient outcomes. Reference #1: Macedo, Priscila M, et al. APH following COVID-19. Case Report J.Fungi 2021 DISCLOSURES: No relevant relationships by Ali Raja no disclosure on file for Yamin Saddouk; No relevant relationships by Parita Soni No relevant relationships by Lyndie Wilkins Parker

SPIKED THROUGH THE HEART: A RARE COMPLICATION OF INFERIOR VENA CAVA (IVC) FILTER PLACEMENT

SPIKED THROUGH THE HEART: A RARE COMPLICATION OF INFERIOR VENA CAVA (IVC) FILTER PLACEMENT

Diversity bias in colorectal surgery: a global perspective

There is a specific lack of data on equity and injustices among colorectal surgeons regarding diversity. This study aimed to explore colorectal surgeon’s lived experience of diversity bias with a specific focus on gender, sexual orientation or gender identity and race or religion. A bespoke questionnaire was designed and disseminated to colorectal surgeons and trainees through specialty association mailing lists and social media channels. Quantitative and qualitative data points were analysed. 306 colorectal surgeons responded globally. 58.8% (n = 180) identified as male and 40.5% (n = 124) as female. 19% were residents/registrars. 39.2% stated that they had personally experienced or witnessed gender inequality in their current workplace, 4.9% because of sexual orientation, and 7.5% due to their race or religion. Sexist jokes, pregnancy-related comments, homophobic comments, liberal use of offensive terms and disparaging comments and stereotypical jokes were commonly experienced. 44.4% (n = 135) did not believe their institution of employer guaranteed an environment of respect for diversity and only 20% were aware of society guidelines on equality and diversity. Diversity bias is prevalent in colorectal surgery. It is necessary to work towards real equality and inclusivity and embrace diversity, both to promote equity among colleagues and provide better surgical care to patients.

Traumatic injuries to the trachea and bronchi: a narrative review.

ObjectiveIn this narrative review, we aim to provide a definition of traumatic tracheo-bronchial injuries as well as an approach to their diagnosis and management, including operative and non-operative strategies.BackgroundTraumatic tracheo-bronchial injuries are relatively uncommon, but are associated with a high mortality, both at the scene and among patients who survive to hospital. Management often requires an emergency airway, usually intubation over a flexible bronchoscope, followed by definitive repair.MethodsThe published literature on the diagnosis and management of traumatic airway injuries was searched through PubMed. Additional references were identified from the bibliography of relevant publications identified. The evidence was then summarized in a narrative fashion, incorporating the authors’ knowledge, experience, and perspective on the topic.ConclusionsDefinitive diagnosis of traumatic tracheo-bronchial injuries usually involves direct visualization through liberal use of bronchoscopy in addition to cross-sectional imaging to evaluate for associated injuries, notably to the great vessels and esophagus. Important considerations for management include concerns for airway obstruction, uncontrolled air leak, and mediastinitis. Early repair of injuries recognized acutely is favored in attempts to prevent the development of airway stenosis. Key operative principles include exposure, conservative debridement to preserve length when possible, creation of a tension-free anastomosis, preservation of the blood supply, and creation of a tracheostomy, particularly in polytrauma patients. An interposition muscle flap is also required, specifically in the setting of combined esophageal and airway injuries. Patients with penetrating injuries tend to have more favorable outcomes, possibly on account of fewer concomitant injuries. Selective non-operative management is also an option in the subset of patients with iatrogenic injuries to the posterior membranous wall of the trachea, and includes broad-spectrum antibiotics and surveillance bronchoscopy.

COVID-19 Vaccine Intention and Social Cognitive Theory: The Role of Individual Responsibility and Partisan Media Use in a Moderated Moderated Mediation Model

ABSTRACT Despite the sheer devastation caused by the COVID-19 pandemic in the United States, vaccine hesitancy is a major barrier to a successful implementation of the vaccine. We apply two moderators to examine the associations of efficacy and expectancies with COVID-19 vaccine intention. Specifically, we use national survey data collected online in 2020 (N = 1264) and a moderated moderated mediation PROCESS model to examine 1) the associations between self-efficacy about COVID-19 and vaccine intention mediated by positive outcome expectancies and 2) moderating roles of individual responsibility and partisan media use. The findings show that the path from efficacy to expectancies is moderated by individual responsibility, while the path from expectancies to vaccine intention is moderated by liberal media use. Our findings support the strategic application of SCT to emphasize the role of personal responsibility in campaigns to encourage vaccination for the COVID-19 virus.

Repair by Primary Closure of Traumatic Blunt Duodenal Injuries: Simple is Not Always Safe

IntroductionRecent literature on managing traumatic duodenal injuries suggests the superiority of primary repair. We hypothesized that duodenal trauma repair by primary closure might not be a safe strategy in an environment dealing predominantly blunt injuries with limited resources. MethodsData analysis was done from the prospectively maintained trauma registry. The study period chosen was from January 1, 2014 to December 31, 2018. Data of 63 patients were analyzed for demographics, injuries, management, and outcome. Logistic regression was used to identify mortality predictors. ResultsThe most common mechanism of injury was blunt (56/63, 88.9%). Forty (63.5%) patients had associated intraabdominal injuries. The most common American Association for the Surgery of Trauma grade of injury to the duodenum was three in 21 patients. Univariate analysis showed that mortality was associated with hypotension on presentation, higher duodenal grade, associated abdominal vascular injuries, primary closure, and duodenal leak. Logistic regression showed associated associated abdominal vascular injuries, primary closure, and leak remained significant predictors of mortality. ConclusionsPrimary repair was found to be an independent predictor of mortality. A patient's physiology is a critical determinant of the outcome. Liberal use of tube duodenostomy over primary repair seems reasonable for blunt duodenal injury management.

SP3.2.1 Management and outcomes of patients with small bowel obstruction in Denmark – a multicentre prospective cohort study

Abstract Aims The optimal management of small bowel obstruction (SBO) remains a matter of debate and treatment varies internationally. In Denmark, the traditional approach to patients with SBO is less conservative than that of the UK, but to what extent patient outcomes differ is unknown. This study aimed to describe the current management and outcomes of patients admitted with SBO in Denmark. Methods This was a prospective cohort study conducted at 6 acute hospitals in Denmark over a 4-month period. Patients aged &amp;gt; 18 years with a clinical or radiological diagnosis of SBO were eligible. Primary outcomes were 30-day mortality and major complication rates. Results 316 patients were included during the study period. The median age was 72 years and 56.0% were female. Diagnosis was made by computed tomography (CT) in 314 patients (99.1%), with the remaining 2 diagnosed clinically. Non-operative management was the initial strategy in 152 patients (48.1%) and successful in 120 (78.9%). Immediate surgery was performed in the remaining 164 (51.9%), with a laparoscopic approach used in 84 patients (51.2%). The 30-day mortality rate was 7.3% with major complications occurring in 61 patients (19.3%). Conclusions The management of SBO in Denmark differs significantly to that of the UK, with more liberal use of CT, a higher proportion of patients undergoing immediate surgery and a higher success rate of non-operative management. Despite these differences, patient outcomes are broadly similar. Adoption of the best components of both strategies may improve patient outcomes in both nations.

Battle of the buttress: 5-year propensity-matched analysis of staple-line reinforcement techniques from the MBSAQIP database.

Vertical sleeve gastrectomy (VSG) has demonstrated to be safe; however, controversy remains on how to decrease major complications, particularly bleeding and leaks. There are variations in staple-line reinforcement techniques, including no reinforcement, oversewing, and buttressing. We sought to evaluate the effect of those methods on post-operative complications using the Metabolic and Bariatric Surgery Accreditation Quality Initiative Program (MBSAQIP) database. The MBSAQIP was queried for patients who underwent VSG during 2015-2019. A propensity-matched analysis was performed between different staple-line reinforcement (SLR) methods, specifically No reinforcement (NR), Oversewing (OS), and Buttressing (BR). The primary outcome of interest was complications within 30days. A total of 513,354 VSG cases were analyzed. The cohort was majority female (79.0%), with mean (SD) age of 44.2 ± 11.9years and mean BMI of 45 ± 7.8kg/m2. Frequency of SLR methods used was 54%BR, 25.6%NR, 10.8% BR + OS, and 9.8%OS. There were no differences in rate of leaks among SLR methods. Compared to NR, BR was associated with decreased rate of reoperations, overall bleeding, and major bleeding (p < 0.05) but prolonged operative time and length of stay (LOS) (p < 0.05). OS was associated with decreased overall bleeding (p < 0.05) but prolonged operative times and length of stay (p < 0.05) compared to NR. Compared to BR, OS was associated with increased operative times, LOS, and rates of post-operative ventilator use, pneumonia, and venous thrombosis (p < 0.05). Patients with bleeding were associated with lower rate of BR (56% vs 61%) and higher rate of NR (34% vs 28%) compared to patients with no bleeding. Bleeding was associated with a greater frequency of leaks (4.4% vs 0.3%), along with higher morbidity and mortality (p < 0.05). Of the reinforcement methods evaluated, BR and OS were both associated with decreased bleeding despite longer operative times. No method was found to significantly reduce incidence of leaks; however, bleeding was associated with increased incidence of leaks, morbidity, and mortality. The liberal use of SLR techniques is recommended for further optimization of patient outcomes after VSG.

Clinical study on ureteritis observed in contrast-enhanced computed tomography in the emergency department.

ObjectiveWe aimed to investigate the causes and clinical and laboratory features of patients with ureteritis observed on intravenous contrast-enhanced abdominopelvic computed tomography (APCT) conducted in the emergency department (ED).MethodsAll APCTs conducted in the ED from November 2017 to November 2020 were investigated for the presence of ureteritis. The incidence of ureteritis, presumed cause of ureteritis, and clinical as well as laboratory features of patients with ureteritis were retrospectively analyzed.ResultsUreteritis was observed in 422 out of 7,386 patients (5.7%) who underwent APCTs. The two main reasons for undergoing APCT in the ED were abdominal pain (49%) and infection focus workup (33%). The first major cause of ureteritis was urinary tract infection (UTI) (351 of 422, 83%). Most patients (85%) were febrile, but 208 (59%) exhibited no urinary symptoms such as dysuria, increased frequency, or residual urine sense. The second major cause of ureteritis was ureteral stones (42 of 422, 10%). Thirty-two of 42 patients (76%) had simple obstructive uropathy, while 24% of patients had a combined infection along with an obstruction. Other rare causes were malignancy and the spread of adjacent inflammation.ConclusionUreteritis was a common finding observed in 5.7% of patients who underwent APCTs at the ED, and most of them were secondary to UTIs and ureteral stones. UTIs can cause ureteritis even without typical symptoms or signs suggestive of UTI, and diagnosis without an APCT can be difficult. More liberal use of APCTs should be considered when the cause of fever is difficult to diagnose.

Ex Vivo Liver Resection and Autotransplantation: Should It be Used More Frequently?

We herein advocate for more extensive utilization of ex vivo resection techniques for otherwise unresectable liver tumors by presenting the largest collective American experience. Advanced in situ resection and vascular reconstruction techniques have made R0 resection possible for otherwise unresectable liver tumors. Ex vivo liver resection may further expand the limits of resectability but remains underutilized due to concerns about technical complexity and vascular thrombosis. However, we believe that the skillset required for ex vivo liver resection is more widespread and the complications less severe than widely assumed, making ex vivo resection a more attractive option in selected case. We retrospectively analyzed 35 cases performed by surgical teams experienced with ex vivo liver resections (at least 4 cases) between 1997 and 2021. We categorized malignancies as highly aggressive (n=18), moderately aggressive (n=14), and low grade (n=3). All patients underwent total hepatectomy, vascular reconstruction and resection in hypothermia on the backtable, and partial liver autotransplantation. Overall survival was 67%/39%/28%, at 1/3/5 years, respectively, with a median survival of 710 days (range: 22-4824). Patient survival for highly aggressive, moderately aggressive, and low-grade tumors was 61%/33%/23%, 67%/40%/22%, and 100%/100%/100% at 1/3/5 years, respectively, with median survival 577 days (range: 22-3873), 444 days (range: 22-4824), and 1825 days (range: 868-3549). Ex vivo resection utilizes techniques commonly practiced in partial liver transplantation, and we demonstrate relatively favorable outcomes in our large collective experience. Therefore, we propose that more liberal use of this technique may benefit selected patients in centers experienced with partial liver transplantation.

Song in the Sumatran Highlands

Song in the Sumatran Highlands

Management of difficult hepatic artery reconstructions to reduce complications through continual technical refinements in living donor liver transplantations

BackgroundHepatic artery reconstruction (HAR) for liver transplantation is crucial for successful outcomes. We evaluated transplantation outcome improvement through continual technical refinements. Materials and methodsHAR was performed in 1448 living donor liver transplants by a single plastic surgeon from 2008 to 2020. Difficult HARs were defined as graft or recipient hepatic artery ≤2 mm, size discrepancy (≥2 to 1), multiple hepatic arteries, suboptimal quality, intimal dissection of graft or recipient hepatic artery (HA), and immediate redo during transplantation. Technique refinements include early vessel injury recognition, precise HA dissection, the use of clips to ligate branches, an oblique cut for all HARs, a modified funneling method for size discrepancy, liberal use of an alternative artery to replace a pathologic HA, and reconstruction of a second HA for grafts with dual hepatic arteries in the graft. ResultsDifficult HARs were small HA (21.35%), size discrepancy (12.57%), multiple hepatic arteries (11.28%), suboptimal quality (31.1%), intimal dissection (20.5%), and immediate redo (5.18%). The overall hepatic artery thrombosis (HAT) rate was 3.04% in this series. The average HAT rate during the last 4 years (2017–2020) was 1.46% (6/408), which was significantly lower than the average HAT rate from 2008 to 2016 (39/1040, 3.8%) with a statistical significance (p = 0.025). Treatment for posttransplant HAT included anastomosis after trim back (9), reconstruction using alternatives (19), and nonsurgical treatment with urokinase (9). ConclusionCareful examination of the HA under surgical microscope and selection of the appropriate recipient HA are key to successful reconstruction. Through continual technical refinements, we can reduce HA complications to the lowest degree.

Fluids, vasopressors, and acute kidney injury after major abdominal surgery between 2015 and 2019: a multicentre retrospective analysis

BackgroundPractice patterns related to intraoperative fluid administration and vasopressor use have potentially evolved over recent years. However, the extent of such changes and their association with perioperative outcomes, such as the development of acute kidney injury (AKI), have not been studied. MethodsWe performed a retrospective analysis of major abdominal surgeries in adults across 26 US hospitals between 2015 and 2019. The primary outcome was AKI as defined by the Kidney Disease Improving Global Outcomes definition (KDIGO) using only serum creatinine criteria. Univariable linear predictive additive models were used to describe the dose-dependent risk of AKI given fluid administration or vasopressor use. ResultsOver the study period, we observed a decrease in the volume of crystalloid administered, a decrease in the proportion of patients receiving more than 10 ml kg−1 h−1 of crystalloid, an increase in the amount of norepinephrine equivalents administered, and a decreased duration of hypotension. The incidence of AKI increased between 2016 and 2019. An increase of crystalloid administration from 1 to 10 ml kg−1 h−1 was associated with a 58% decreased risk of AKI. ConclusionsDespite decreased duration of hypotension during the study period, decreased fluid administration and increased vasopressor use were associated with increased incidence of AKI. Crystalloid administration below 10 ml kg−1 h−1 was associated with an increased risk of AKI. Although no causality can be concluded, these data suggest that prevention and treatment of hypotension during abdominal surgery with liberal use of vasopressors at the expense of fluid administration is associated with an increased risk of postoperative AKI.