Long-term Outcome Of Patients Research Articles

Long-Term Outcomes and Risk Factors for Lymph Node Metastasis in Siewert Type II/III Early Gastric Cancer

Objectives: The incidence of adenocarcinomas of the esophagogastric junction (EGJ) and cardia has been gradually increasing in the East. Cancers of the EGJ and gastric cardia have poor prognoses. This study aimed to investigate lymph node metastasis (LNM) rates, their predictive factors, and determine the long-term outcomes of patients with Siewert type II/III early gastric cancer (EGC).Methods: Between January 2014 and June 2022, a total of 573 patients with gastric cancer, including 130 with Siewert type II/III EGC, underwent total gastrectomies at the Kosin University Gospel Hospital. Factors associated with LNM were analyzed using a logistic regression model.Results: Of the 130 patients with Siewert type II/III EGC, 10 (7.7%) demonstrated LNM (LNM-positive group). Macroscopically elevated lesions (I+IIa) (60.0% vs. 16.7%; <i>p</i>=0.009) and lymphovascular invasion (70.0% vs. 5.8%; <i>p</i><0.001) were more common and the depth of invasion was deeper (<i>p</i>=0.003) in the LNM-positive patients than in the LNMnegative group. Multivariate analysis showed that macroscopically elevated lesions (odds ratio [OR], 19.48; 95% confidence interval [CI], 1.93–197.11; <i>p</i>=0.012) and lymphovascular invasion (OR, 52.63; 95% CI, 5.26–526.51; <i>p</i>=0.001) were associated with LNM. Kaplan–Meier analysis revealed that the 5-year overall and disease-specific survival rates of patients with Siewert type II/III EGC were 90.0% and 98.9%, respectively. During a median follow-up period of 49 months (range, 12–122 months), one patient (0.8%) died owing to gastric cancer recurrence.Conclusions: Patients with Siewert type II/III EGC showed favorable long-term outcomes. Macroscopically elevated lesions and lymphovascular invasion are associated with LNM.

Management of biliary complications after LDLT.

Biliary complications (BC) in the recipient continue to be an as yet, unresolved issue following living donor liver transplantation (LDLT). Bile leaks (BL) and biliary anastomotic strictures (BAS) are the most common BCs, with the latter contributing to close to 80%. With increasing expertise, endoscopic treatment with endoscopic retrograde cholangiography (ERC) [the first-line treatment] and percutaneous transhepatic cholangiography (PTC) with percutaneous transhepatic biliary drainage (PTBD) alone or in combination with ERC lead to successful management in a majority of these cases. However, prediction of difficulty of endoscopic success in biliary strictures, optimal duration of indwelling stents and their planned removal, management options in high-grade strictures (HGS) and the long-term outcome of patients requiring intervention for BC's are still unanswered questions in this setting. This review will try to summarise pertinent issues, novel insights and finally propose basic principles to be adhered to when dealing with the gamut of possible biliary complications after LDLT.

Framingham risk score is a useful indicator of posttransplant cardiovascular events and survival among Korean kidney transplant recipients: a nationwide, prospective cohort study.

Cardiovascular disease is an important risk factor for mortality among kidney transplant recipients. In this study, we aimed to investigate the association between cardiovascular risk score at kidney transplantation and long-term outcomes of patients. In this prospective, observational cohort study, we enrolled kidney transplant recipients who participated in the Korean Organ Transplantation Registry and underwent transplantation between April 2014 and December 2019. The cardiovascular risk status of kidney transplant recipients was assessed using the Framingham risk score. All-cause mortality, major adverse cardiovascular events, allograft failure, estimated glomerular filtration rates (eGFRs), and composite outcomes were evaluated after kidney transplantation. Of the 4,682 kidney transplant recipients, 96 died during 30.7 ± 19.1 months of follow-up. The Kaplan-Meier survival analysis results showed that high Framingham risk scores were associated with all-cause mortality, major adverse cardiovascular events, and composite outcomes. According to the multivariable Cox analysis, high Framingham risk scores were associated with an increased risk of mortality (hazard ratio [HR], 3.20; 95% confidence interval [CI], 1.30-7.91), major adverse cardiovascular events (HR, 8.43; 95% CI, 2.41-29.52), and composite outcomes (HR, 2.05; 95% CI, 1.19-3.46). The eGFRs after transplantation were significantly higher among patients in the low Framingham risk score group (p < 0.001). However, Framingham risk scores were not associated with graft loss or rapid decline in eGFRs. The Framingham risk score is a useful indicator of cardiovascular events, mortality, and kidney function after kidney transplantation.

AGR – 2 The Multi-Dimensional Role of Neuropsychology in Diagnostically Complex Epilepsy Patients: Refining the Surgical Plan and Post-Operative Expectations

Abstract Objective We present a case highlighting the importance of neuropsychological involvement at all phases of a pre-surgical epilepsy work-up, including clinical interview, neuropsychological evaluation, Wada testing, extra-operative electrical stimulation mapping (ESM), and psychoeducation. Method A 24-year-old, right-handed, Caucasian female presented with non-lesional, intractable left-hemisphere localization-related epilepsy characterized by frequent experiences of déjà vu and autonomic sensations. Results Neuropsychological evaluation revealed weaknesses in processing speed and verbal memory implicating left hippocampal involvement. Wada testing suggested minimal contralateral memory support, indicating poor candidacy for resective surgery. The patient underwent prolonged sEEG monitoring to refine a plan for device implantation (i.e., responsive neurostimulation; RNS). No typical events were captured during extended study. Episodic somatosensory changes were captured, which had no electrographic correlate and were presumed to be non-epileptic. ESM evoked the patient’s classic semiology, elucidating nuanced information about her seizure onset zone and network. Barriers to extended monitoring and consistent, reliable engagement during ESM included depression, anxiety, and trauma; considerable neuropsychologist-led emotional support was required. Typical seizure semiology was elicited during stimulation of entorhinal cortices, posterior and anterior hippocampi, amygdala, cingulate and insula. RNS placement included a depth electrode targeting the medial structures (via a posterior approach) with a sub-temporal strip. Conclusions Involvement of neocortical and mesial temporal structures, coupled with a clear neuropsychiatric component, were believed to be poly-etiological factors to the patient’s presentation. Neuropsychological input at all phases of pre-surgical assessment was instrumental in systematically identifying and addressing her complex needs. Psychotherapeutic intervention was suggested to be equally as important to clinical, long-term patient outcome.

Prone Single Position Approach to Lateral Lumbar Interbody Fusion: Systematic Review and Meta-Analysis.

Lateral lumbar interbody fusion (LLIF) with posterior screw fusion is a safe and effective treatment for patients suffering from degenerative spine disorders. While LLIF has been shown to restore disc height, decompress neural components, correct sagittal imbalances, and improve pain scores, the approach requires repositioning patients for posterior pedicle fixation, which requires 2 separate surgeries. The evolution of surgical techniques, navigation, and robotics has allowed for a single position approach to LLIF with the patient in the prone position. The purpose of this study was to perform a systematic review and meta-analysis comparing the prone single position (PSP) LLIF approach to the dual position LLIF approach. We hypothesized that PSP LLIF will have a reduced operative time, complication rate, and blood loss compared with the dual position LLIF procedure. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. PubMed and Embase databases were searched with key terms: (lateral AND [interbody OR "inter body"] AND lumbar AND fusion) AND (prone OR single). Results were extracted and reviewed by 2 authors (MR and RB) per selection criteria. Patient demographics were extracted from the selected studies, along with surgical, patient-reported, and radiographic outcomes. A meta-analysis was performed using an unstandardized mean difference or log odds ratio with a confidence level of 95%. Fifteen studies were included in the systematic review and 5 studies compared PSP LLIF to dual position LLIF for meta-analysis. PSP LLIF had a reduced operative time and length of stay compared with the dual position approach, although there was no significant reduction in estimated blood loss. Additionally, PSP LLIF improved lumbar lordosis more effectively than dual position LLIF. There was no difference in segmental lordosis or pelvic tilt. There was no difference in intraoperative complications, postoperative complications, or reoperations. PSP LLIF reduces operative time and length of stay, with no relative increase in complications or reoperations compared with the dual position approach. Additionally, PSP LLIF improves lumbar lordosis relative to dual position LLIF, which may improve functional outcomes and reduce the risk of developing adjacent segment disease. The associated operative and postoperative benefits of PSP LLIF may improve long-term outcomes of patients undergoing spinal fusion.

Long-term Outcomes Following Colectomy and Liver Transplantation for Inflammatory Bowel Disease with Primary Sclerosing Cholangitis.

To investigate the long-term outcomes of patients with combined primary sclerosing cholangitis/inflammatory bowel disease (PSC-IBD) undergoing both liver transplantation (LT) and total abdominal colectomy (TAC). The fraction of patients with PSC-IBD that require both LT and TAC is small, thereby limiting significant conclusions regarding long-term outcomes. Adult and pediatric patients from nine centers from the US IBD Surgery Collaborative who underwent staged LT and TAC for PSC-IBD were included. Long-term outcomes, including survival, were assessed. Among 127 patients, 66 underwent TAC-before-LT, with a median time from TAC to LT of 7.9 yrs, while 61 underwent LT-before-TAC, with a median time from LT to TAC of 4.4 years. Median patient survival post TAC was significantly worse in those undergoing LT-before-TAC (16.0 yrs vs. 42.6 yrs, P=0.007), while post LT survival was not impacted by the order of TAC and LT (21.6 yrs vs. 22.0 yrs, P=0.81). Patients undergoing TAC for medically refractory disease had a higher incidence of recurrent PSC (rPSC) (P=0.02) and biliary complications (0.09) compared to those undergoing TAC for oncologic indications. Definitive TAC reconstruction with either end ileostomy or ileal-pouch anal anastomosis (IPAA) did not impact post-LT or post-TAC outcomes. Long term survival in PSC-IBD was contingent upon progression to LT and was not impacted by the need for TAC. PSC-IBD patients undergoing TAC for medically refractory disease had a higher incidence of rPSC and biliary complications. The use of IPAA in PSC-IBD was a viable alternative to end ileostomy.

The risk factor for adverse pregnancy outcomes and its impact on clinical effect in IgA nephropathy: A retrospective observational study.

IgA nephropathy (IgAN) is the most common primary glomerular disease worldwide. Pregnant IgAN patients are more susceptible to adverse pregnancy outcomes (APO). However, the risk factor for APO and its effects on the long-term renal outcome of pregnant IgAN patients remained unclear. We performed a retrospective observational study covering 2003-2019 that included 44 female IgAN patients with pregnancy history to investigate the risk factor for APO and its impact on clinical outcome in IgAN. Renal function outcome and proteinuria remission were evaluated in pregnant IgAN women with and without APO. In this retrospective and observational study, we found that patients with APO exhibited higher levels of serum creatinine and IgM, and lower haemoglobin levels while other clinical characteristics, pathological characteristics and therapy protocol had no significant difference. We found that anaemia and a higher level of serum IgM were independent risk factors for APO. IgAN pregnant women without APO experienced a higher proportion of proteinuria remission than those with APO, but there is no difference in the renal function outcome. Pregnant IgAN patients with higher risks, including lower haemoglobin levels and higher IgM levels deserve intensive monitoring, and aggressive therapy to reduce proteinuria should be carried out in pregnant IgAN patients with APO.

CAR expression in invasive breast carcinoma and its effect on adenovirus transduction efficiency

BackgroundBreast cancer is the second leading cause of death in women, with invasive ductal carcinoma (IDC) and invasive lobular carcinoma (ILC) as the two most common forms of invasive breast cancer. While estrogen receptor positive (ER+) IDC and ILC are treated similarly, the multifocality of ILC presents challenges in detection and treatment, worsening long-term clinical outcomes in patients. With increasing documentation of chemoresistance in ILC, additional treatment options are needed. Oncolytic adenoviral therapy may be a promising option, but cancer cells must express the coxsackievirus & adenovirus receptor (CAR) for adenoviral therapy to be effective. The present study aims to evaluate the extent to which CAR expression is observed in ILC in comparison to IDC, and how the levels of CAR expression correlate with adenovirus transduction efficiency. The effect of liposome encapsulation on transduction efficiency is also assessed.MethodsTo characterize CAR expression in invasive breast carcinoma, 36 formalin-fixed paraffin-embedded (FFPE) human breast tumor samples were assayed by CAR immunohistochemistry (IHC). Localization of CAR in comparison to other junctional proteins was performed using a multiplex immunofluorescence panel consisting of CAR, p120-catenin, and E-cadherin. ILC and IDC primary tumors and cell lines were transduced with E1- and E3-deleted adenovirus type 5 inserted with a GFP transgene (Ad-GFP) and DOTAP liposome encapsulated Ad-GFP (DfAd-GFP) at various multiplicities of infection (MOIs). Transduction efficiency was measured using a fluorescence plate reader. CAR expression in the human primary breast carcinomas and cell lines was also evaluated by IHC.ResultsWe observed membranous CAR, p120-catenin and E-cadherin expression in IDC. In ILC, we observed cytoplasmic expression of CAR and p120-catenin, with absent E-cadherin. Adenovirus effectively transduced high-CAR IDC cell lines, at MOIs as low as 12.5. Ad-GFP showed similar transduction as DfAd-GFP in high-CAR IDC cell lines. Conversely, Ad-GFP transduction of ILC cell lines was observed only at MOIs of 50 and 100. Furthermore, Ad-GFP did not transduce CAR-negative IDC cell lines even at MOIs greater than 100. Liposome encapsulation (DfAd-GFP) improved transduction efficiency 4-fold in ILC and 17-fold in CAR-negative IDC cell lines.ConclusionThe present study demonstrates that oncolytic adenoviral therapy is less effective in ILC than IDC due to differences in spatial CAR expression. Liposome-enhanced delivery may be beneficial for patients with ILC and tumors with low or negative CAR expression to improve adenoviral therapeutic effectiveness.

Renal transplant nephrolithiasis: Presentation, management and follow-up with control comparisons.

To analyse the presentation, management and long-term outcomes of renal transplant patients who formed kidney stones in their allograft. The secondary aim was to identify risk factors for stone formation in this cohort. Patient information from an institutional renal transplant database was used to identify individuals who both did and did not form kidney stones following renal transplantation. Computerized tomography (CT) imaging was used to make the diagnosis of kidney stones and measure stone size. Age- and gender-matched controls never forming a stone in their allograft were used for comparative analysis to identify risk factors for stone formation in transplant patients. A total of 8835 transplant patients were included in the study, of which 128 (1.4%) formed a kidney stone in their allograft after surgery. The mean time to kidney stone identification was 6.2years, and the mean number of stones formed was 1.7, with a mean maximum size dimension on a CT scan of 5.7mm per stone. A total of 26 patients were subjected to stone-removing procedures, the most common being ureteroscopy (42.3%). The primary intervention failed in eight patients requiring a secondary intervention, and percutaneous nephrolithotomy (PCNL) had the lowest success rate (60%). A total of 164 controls were identified. In comparison to controls, stone formers had lower serum calcium (p= 0.008), lower estimated glomerular filtration rates (p= 0.019), higher lymphocyte counts (p= 0.021) and greater rate of urinary tract infection (p= 0.003). Graft failure rates were the same (p= 0.524), but time to graft failure was significantly longer in stone patients compared with controls (p= 0.008). The rate of stone formation is low in transplant patients. Success rates for stone treatment vary based on the surgery selected, with PCNL being the worst. Graft survival rates were equivocal, but survival time was better in stone patients. Our analysis calls for further investigation of this important topic.

Renin angiotensin system inhibitors and outcome in patients with takotsubo syndrome: A propensity score analysis of the GEIST registry

BackgroundFew data are available on long-term drug therapy and its potential prognostic impact after Takotsubo syndrome (TTS). Aim of the study is to evaluate clinical characteristics and long-term outcome of TTS patients on Renin Angiotensin system inhibitors (RASi). MethodsTTS patients were enrolled in the international multicenter GEIST (GErman Italian Spanish Takotsubo) registry. Median follow-up was 31 (Interquartile range 12-56) months. Comparison of RASi treated vs. untreated patients was performed within the overall population and after 1:1 propensity score matching for age, sex, comorbidities, type of trigger and in-hospital complications. Registrationclinicaltrials.gov, NCT04361994, https://clinicaltrials.gov/study/NCT04361994 ResultsOf the 2453 TTS patients discharged alive, 1683 (68%) received RASi therapy. Patients with RASi were older (age 71±11 vs 69±13 years, p=0.01), with higher prevalence of hypertension (74%vs53%, p<0.01) and diabetes (19%vs15%, p=0.01), higher admission left ventricular ejection fraction (LVEF) (41±11% vs 39±12%, p<0.01) and lower rates of in-hospital complications (18.9% vs 29.6%, p<0.01). At multivariable analysis, RASi therapy at discharge was independently associated with lower mortality (HR 0.63, 95%CI 0.45-0.87, p<0.01). Survival analysis showed that at long term, patients treated with RASi had lower mortality rates in the overall cohort (log-rank p=0.001). However, this benefit was not found among patients treated with RASi in the matched cohort (log-rank p=0.168). Potential survival benefit of RASi were present, both in the overall and matched cohort, in two subgroups: patients with admission LVEF ≤40% (HR 0.54 95%CI 0.38-0.78, p=0.001; HR 0.59, 95%CI 0.37-0.95, p=0.030) and diabetes (HR 0.41, 95%CI 0.23-0.73, p= 0.002; HR 0.41, 95%CI 0.21-0.82, p=0.011). ConclusionsLong-term therapy with RASi after a TTS episode was not associated with lower mortality rates at propensity score analysis. However, potential survival benefit can be found among patients with admission LVEF ≤40% or diabetes.

Baseline platelet count and long-term clinical outcomes in patients with acute venous thromboembolism: a prospective cohort study.

An abnormal platelet count (PC) is common in acute venous thromboembolism (VTE) but its relationship with clinical outcomes remains ill-defined. We aimed to explore the association between baseline PC and the long-term risk of clinically relevant outcomes in a prospective cohort of 991 patients with acute VTE. We classified patients into four PC groups: very low (< 100 G/l), low (≥ 100 to < 150 G/l), normal (≥ 150 G/l to ≤ 450 G/l), and high (> 450 G/l). The primary outcome was major bleeding (MB), secondary outcomes were recurrent VTE and overall mortality. We examined the association between PC and clinical outcomes, adjusting for confounders, competing risk for mortality, and periods of anticoagulation. After a median follow-up of 30 months, 132 (13%) of patients experienced MB, 122 (12%) had recurrent VTE, and 206 (21%) died. Compared to patients with a normal PC, patients with a very low PC had a sub-distribution hazard ratio (SHR) for MB of 1.23 (95% confidence interval [CI] 0.52-2.91) and those with a high PC a SHR of 1.87 (95%CI 0.82-4.29). Patients with a low PC had a twofold increased VTE recurrence risk (SHR 2.05, 95%CI 1.28-3.28). Patients with low and very low PC had a hazard ratio for mortality of 1.43 (95%CI 0.99-2.08) and of 1.55 (95%CI 0.80-2.99), respectively. Our findings do not suggest a consistent relationship between baseline PC and long-term clinical outcomes in patients with VTE.

Compartment Syndrome in Association with Tibial Plateau Fracture: Standardized Protocols Ensure Optimal Outcomes.

The purpose of this study was to report on the treatment, results, and longer-term outcomes of patients who sustained a tibial plateau fracture with an associated leg compartment syndrome (CS). A total of 766 patients who sustained 766 tibial plateau fractures met inclusion criteria. Fourteen patients (1.8%) were diagnosed with CS in association with a tibial plateau fracture during their initial hospitalization, 13 at the time of presentation and 1 delayed. The treatment protocol consisted of initial external fixation and fasciotomy, followed by irrigation and debridement, and eventual closure. Fasciotomy cases included 2/14 (14.3%) single incision approaches and 12/14 (85.7%) dual incision approaches. Operative treatment of the tibial plateau fracture was performed at the time of final closure or once soft tissues were permitted. One case of CS that developed following definitive fixation was treated with fasciotomy and delayed primary closure after initial stabilization. Ten (71.4%) were available at 1-year follow-up. We compared these 10 cases to the patients with operative tibial plateau fractures without CS to assess for surgical, radiographic, clinical, and functional outcomes. We used a propensity match based on age, body mass index, sex, Charleson comorbidity index, and fracture type to reduce the presence of confounding biases. Standard statistical methods were employed. Those in the CS cohort were younger males (p < 0.05). At latest follow-up, function did not differ between those in the CS group compared with the non-CS cohort (p > 0.05). Clinically, knee flexion (130.7 vs. 126; p = 0.548), residual depression (0.5 vs. 0.2; p = 0.365), knee alignment (87.7 vs. 88.3; p = 0.470), and visual analog scale pain scores (3.0 vs. 2.4; p = 0.763) did not differ between the cohorts. Although infection was higher in the CS cohort, the overall complication rates did not differ between the CS patients and non-CS cohort (p > 0.05). Early identification and standardized treatment protocols for the management of CS that develops in association with a tibial plateau fracture lead to outcome scores that were not significantly different from patients who did not develop CS.

FP1.9 - Evaluating outcomes of multi-visceral resections for locally advanced colorectal cancer

Abstract Introduction Multi-visceral resection for colorectal cancer invading into adjacent organs is often difficult and involves serious complications. The aim of this study is to evaluate the short- and long-term outcomes of patients undergoing multi visceral and beyond TME (total mesorectal excision) resections for locally advanced CRC. Methods Patients undergoing elective surgery for advanced or recurrent CRC between October 2018 and October 2023 were identified. Demographic and clinical data were recorded, and outcomes analysed. Primary outcome was R0 resection rate and post-operative complication rate. Results Thirty-three patients (51.5% male, 48.5% female) were included, with a median age of 66.8 years (IQR 38-82) and median BMI was 26.7 kg/m2 (13.8-50). Majority of patients (n = 29, 87.8%) had surgery for primary, locally advanced CRC and most were referred from external Trusts (n=25, 75.7%). Thirteen patients (39.3 %) had robotic resections, one case was completed laparoscopically, and the remaining were open procedures (n= 19, 57.5%). Seventeen individuals had previous abdominal surgeries with no differences between open (8/20 = 40%) and robotic approach (9/13 = 69.2%) (p=0.207). Median LOS in open and robotic groups were 16 and 10 days respectively (p=0.047). There was no post-operative mortality. Proportion of CD I-II complications was 9/33 (27.3%) and CD III-IV 18/33 (54.5%). R0 resections rate was 63.6 % and eight patients (24.2%) developed recurrence during the follow up period (median = 47.6 months). Conclusions An aggressive surgical approach as part of a multimodal strategy affords the best prospect for long-term survival in selected patients. Robotic multi-visceral resection for locally advanced CRC is a safe and feasible, minimally invasive approach in selected cases.

Real-world outcomes of stage II and III colorectal cancers treated by postoperative adjuvant chemotherapy based on the mismatch repair status.

In Japan, immunohistochemistry for mismatch repair (MMR) proteins targeted at stage II and III colorectal cancers (CRCs) has been covered by national insurance since October, 2022. This study aimed to clarify the long-term outcomes of patients with stage II and III CRCs receiving postoperative adjuvant chemotherapy based on their MMR status. The outcomes of 640 patients who underwent radical surgery for stage II and III CRCs were analyzed retrospectively. Deficient MMR (dMMR) was diagnosed in 41 (13.3%) patients with stage II and 28 (9.1%) patients with stage III CRC. The overall survival and recurrence rates were not significantly different between the patients with stage II and those with stage III CRC. The risk factors for recurrence among those with stage II CRC were tumors on the left side, T4 disease, and the presence of BRAF wild type. The recurrence rates were lower in the stage II CRC patients with sporadic dMMR than in those with suspected Lynch syndrome (LS). The first site of recurrence was more frequently the peritoneum or distant lymph node in patients with dMMR. Stage IICRC patients with sporadic dMMR were found to have a very good prognosis. On the other hand, peritoneal dissemination or distant lymph node metastasis tended to develop in patients with dMMR.

Transplant Immunology in Liver Transplant, Rejection, and Tolerance

Liver transplantation is the most effective treatment for end-stage liver disease. Despite improvements in surgical techniques, transplant rejection remains a significant concern. The liver is considered an immune-privileged organ due to its unique microenvironment and complex interactions among various cell types. Alloimmune responses mediated by T cells and antigen-presenting cells (APCs) play crucial roles in transplant rejection. The liver’s dual blood supply and unique composition of its sinusoidal endothelial cells (LSECs), Kupffer cells (KCs), hepatocytes, and hepatic stellate cells (HSCs) contribute to its immune privilege. Alloantigen recognition by T cells occurs through direct, indirect, and semidirect pathways, leading to acute cellular rejection (ACR) and chronic rejection. ACR is a T cell-mediated process that typically occurs within the first few weeks to months after transplantation. Chronic rejection, on the other hand, is a gradual process characterized by progressive fibrosis and graft dysfunction, often leading to graft loss. Acute antibody-mediated rejection (AMR) is less common following surgery compared to other solid organ transplants due to the liver’s unique anatomy and immune privilege. However, when it does occur, AMR can be aggressive and lead to rapid graft dysfunction. Despite improvements in immunosuppression, rejection remains a challenge, particularly chronic rejection. Understanding the mechanisms of rejection and immune tolerance, including the roles of regulatory T cells (Tregs) and hepatic dendritic cells (DCs), is crucial for improving transplant outcomes. Strategies to induce immune tolerance, such as modulating DC function or promoting Treg activity, hold promise for reducing rejection and improving long-term graft survival. This review focuses on the liver’s unique predisposition to rejection and tolerance, highlighting the roles of individual cell types in these processes. Continued research into the mechanisms of alloimmune responses and immune tolerance in liver transplantation is essential for developing more effective therapies and improving long-term outcomes for patients with end-stage liver disease.

Novel artificial intelligence for diabetic retinopathy and diabetic macular edema: what is new in 2024?

Given the increasing global burden of diabetic retinopathy and the rapid advancements in artificial intelligence, this review aims to summarize the current state of artificial intelligence technology in diabetic retinopathy detection and management, assessing its potential to improve care and visual outcomes in real-world settings. Most recent studies focused on the integration of artificial intelligence in the field of diabetic retinopathy screening, focusing on real-world efficacy and clinical implementation of such artificial intelligence models. Additionally, artificial intelligence holds the potential to predict diabetic retinopathy progression, enhance personalized treatment strategies, and identify systemic disease biomarkers from ocular images through 'oculomics', moving towards a more precise, efficient, and accessible care. The emergence of foundation model architectures and generative artificial intelligence, which more clearly reflect the clinical care process, may enable rapid advances in diabetic retinopathy care, research and medical education. This review explores the emerging technology of artificial intelligence to assess the potential to improve patient outcomes and optimize personalized management in healthcare delivery and medical research. While artificial intelligence is expected to play an increasingly important role in diabetic retinopathy care, ongoing research and clinical trials are essential to address implementation issues and focus on long-term patient outcomes for successful real-world adoption of artificial intelligence in diabetic retinopathy.

Nephronsparing surgery for retroperitoneal sarcomas

Objective: to clarify the indications for the use of nephron-sparing technologies in surgical treatment of patients with retroperitoneal sarcomas. Material and Methods. The study included 64 patients with primary retroperitoneal sarcomas with kidney and renal pedicle invasion, who underwent surgical treatment in the Thoracic-abdominal Department of the P.A. Herzen Moscow Oncology Research Institute from 2010 to 2021. Twenty-one patients underwent nephrectomies, and 43 patients underwent nephron-sparing surgery. The morphological profile of sarcomas, age and gender of the patients, feasibility of using nephron-sparing technologies, postoperative complications, and long-term outcomes in patients of both groups were analyzed. Results. Forty-three patients with primary retroperitoneal sarcomas with invasion of the renal parenchyma, ureter, and renal pedicle underwent nephron-sparing surgery (precision mobilization of the kidney, ureter and vascular structures of the kidney from tumor tissue, kidney resection, ureteral stenting, resection of the renal vein orifices, resection of the ureters, and kidney autotransplantation). Postoperative complications were observed in 19.0 % of nephrectomy group patients (4 pts: II, IIIB, IV and V types according to Clavien–Dindo) and in 30.2 % of nephron-sparing group patients (15 pts: types II – 8, IIIA – 1, IIIB – 3, IV – 1). No statistical differences in the relapse-free period and survival time between two groups were observed. The 1-, 3- and 5-year survival rates were 84.1 %, 65.9 %, and 51.4 %, respectively. Multifactorial analysis showed that mortality increased significantly in patients over 64 years of age and was associated with both disease recurrence and concomitant pathology (p=0.009). There was also a trend toward decreased survival in patients with leiomyosarcoma (p=0.066). Conclusion. In retroperitoneal sarcomas, tumor resection with preservation of organs and structures not directly invaded by the tumor is the optimal surgical strategy. Nephron-sparing technologies do not worsen both immediate and long-term treatment outcomes. For leiomyosarcoma, tumor resection with nephrectomy is the most suitable approach.

Prognosis of myocarditis stratified by initial clinical presentation: Does “intermediate” risk still play a role?

Background/aimsMyocarditis is an inflammatory disease with diverse clinical presentations. It is known that low-risk patients have a good prognosis compared to high-risk patients. There are few data regarding the prognosis of intermediate-risk patients. This study aimed to analyze the long-term outcomes of patients with acute myocarditis with different risk profiles at presentation, focusing on the intermediate risk one. MethodsA retrospective multicenter study was conducted, enrolling patients who met the diagnostic criteria for clinically suspected myocarditis with acute presentation. Patients were stratified into high, intermediate and low risk, according to the classification proposed by Sinagra and his team. Cardiovascular adverse events (AEs) were assessed after a median follow-up of 19 months. Echocardiographic and cardiac magnetic resonance (CMR) parameters predictive of adverse events have been reported. ResultsWe enrolled 127 patients (mean age 30 ± 13 years; 103 men, 24 women). High-risk patients had a higher frequency of adverse events (80 %) compared to other groups (16 %–16 %, p < 0.0001). An association was observed between the number of segments with late gadolinium enhancement (LGE) at baseline CMR and the occurrence of adverse events (p < 0.0037). The sum of segments with LGE was statistically correlated with lower left ventricular GLS (p < 0.009). The number of segments with LGE that most accurately identified the occurrence of adverse events was 2.5 [AUC 0.5; p = 0.24]. ConclusionsOur study confirms the higher incidence of AE in the high group; the prognosis of patients at intermediate risk is not very different from those at low risk. It can be hypothesized that the extent of LGE at baseline is the main predictor of adverse events in patients at intermediate risk.

Metroticket approach in a retrospective cohort study to predict overall survival after surgical resection for intermediate stage hepatocellular carcinoma.

Surgical resection is a curative therapy for early-stage hepatocellular carcinoma (HCC) patients meeting the Milan criteria as well as a widely used therapy in intermediate-stage HCC. However, intermediate-stage HCC encompasses a wide spectrum of disease and there is a lack of good predictive models for the long-term clinical outcome of HCC patients currently. Here, we adopt Mazzaferro's Metroticket 2.0 to create a robust survival prediction model for intermediate-stage HCC patients undergoing surgical resection. Our algorithm considers age, AFP levels, ALBI score, and nodule size/number to generate survival estimates in an accessible graph format. Importantly, our model surpasses the American Joint Committee on Cancer staging model and was validated with independent US patient data. We conducted a retrospective analysis of OS and RFS in early- and intermediate-stage HCC patients treated with liver resection, including a training cohort in Singapore and a validation cohort in North Carolina, USA. We recorded 278 deaths (35.0%) and 428 patients (53.9%) in the first 5-years after surgical resection; higher ALBI score, higher lnAFP, more advanced age and higher tumour burden index were identified as significant parameters. The overall predictive capability of our model, with the inclusion of AFP, is reflected with a UNO's C-statistic of 0.655, which is 1.11 times better than the 0.5895 C-statistic of the 8th AJCC TNM Staging model. Our modified Metroticket model allows for more granular and better-informed prognostication. This will help surgeons and patients make accurate comparisons between the clinical outcomes of surgical resection and other non-surgical treatments.

Outcomes of 576 patients with extracorporeal life support for the treatment of perioperative cardiogenic shock.

This study aims to analyse the short- and long-term outcomes in patients who received extracorporeal life support for the treatment of perioperative low-output syndrome and identify risk factors for mortality. All consecutive patients who received extracorporeal life-support system during or after cardiac surgery at a high-volume German cardiac centre between 2008 and 2017 were identified retrospectively and followed up to December 2023. This cohort was characterized, and long-term survival (>10 years) was analysed. Univariate and multivariable regression analyses were performed to identify risk factors for mortality. Five-hundred and seventy-six patients were included; 21.7% underwent isolated coronary bypass, 16.5% single valve surgery, 34.3% combined cardiac surgery and 13.2% heart transplantation. The system was implanted peripherally in 60.8% of patients. In-hospital and 1-year mortality for all patients was 66.0% and 77.7%, respectively. In the multivariable Cox adjustment, severe aortic valve stenosis, previous cardiac surgery and intra-aortic balloon pump were independent risk factors for in-hospital mortality (P < 0.05). Older age, severe mitral regurgitation and patients on insulin were predictors for long-term mortality (P < 0.05). However, peripheral cannulation significantly reduced mortality. There was no time-dependent interaction of perioperative stroke with mortality. For patients who were discharged alive, the estimated 10-year survival was 32.4%. Treatment of perioperative low-output syndrome with extracorporeal life-support systems is associated with poor outcome and only 34% of patients could be discharged successfully. Peripheral cannulation is prognostically favourable. Special attention should be paid to these patients because age, insulin therapy and severe mitral regurgitation are strong predictors for mortality after 10 years.