Procurement Techniques Research Articles

Organ Procurement in the Brain Dead Donors Without In Vivo Cold Perfusion: A Novel Technique

We describe our technique of exvivo organ perfusion and procurement in donation after deceased brain death (DBD) donors. This technique comprises warm dissection of liver, kidneys, and heart, in hemodynamically stable DBD donors and perfusing them exvivo. The cardiac and abdominal dissection can take place simultaneously. As a precaution, the iliac arteries and the abdominal aorta are dissected and kept ready for rapid cannulation and perfusion, should the donor become unstable at any stage.The liver dissection is in principle similar to living donor hepatectomy, where portal dissection is combined with supra and infrahepatic caval dissection to completely mobilize liver to allow it to be removed and perfused exvivo. The renal dissection is done after hepatic dissection is complete. The sequence of recovery of organ was modified where kidneys were procured first followed by hepatic and cardiac procurement simultaneously. Twelve multivisceral (liver and kidneys in all and heart in four) procurements have been performed. The average perfusion fluid volume for liver was 3.4L. All recipients had uneventful postoperative course. Ourtechnique has not affected recipient outcomes and with benefits of less use of preservation solution, shortening bench surgery time, and decreasing the propensity of procurement injuries by avoiding cold-phase dissection.

Is Reconstruction of Large Mandibular Defects Using Bioengineering Materials Effective?

Clinical tissue engineering has revolutionized surgery by improving surgical efficiency and decreasing the risks associated with traditional bone graft procurement techniques. Compared with autogenous bone grafts, composite tissue-engineered grafts fulfill the principles of osteoconduction, osteoinduction, and osteogenesis and provide adequate bone volume for maxillofacial reconstruction with less morbidity. The present study aimed to demonstrate the effectiveness, as defined by our success criteria, of a composite tissue-engineered bone graft in the reconstruction of mandibular defects. We implemented a retrospective case series and enrolled a sample of patients with mandibular defects that had been reconstructed using allogeneic bone combined with recombinant human bone morphogenic protein-2 and bone marrow aspirate concentrate at our institution during a 5-year period. The success criteria were as follows: 1) bone union, defined as a homogenous radiopaque pattern continuous with native bone without mandibular mobility; and 2) volume of grafted bone adequate for implant placement, defined as at least 1.0cm (height) by 0.8cm (width). Clinical examinations and computed tomography scans were performed at 6months postoperatively. Descriptive statistics were computed for each variable. From 2014 to 2019, tissue engineering reconstruction was used in 31 patients with and 3 patients without mandibular continuity defects, for a total of 34 patients. The median follow-up was 6months. The mean length of the continuity defects was 5.5cm (range, 1.0 to 12.5). Of the 30 patients with mandibular continuity defects, 27 achieved success according to our criteria, with an average gained height of 2.12±0.64cm and width of 1.53±0.46cm. Of the 34 patients, 1 was lost to follow-up, and treatment failed in 3 patients. Although the use of autogenous graft remains the reference standard, the evolving science behind clinical tissue engineering has resulted in an effective treatment modality for complex head and neck defects with less morbidity and graft material equal to that of autogenous bone.

Procurement Methodologies to Optimize the Inventory Levels of Spare Parts

Inventory is essential for the smooth running of any organization. It acts as a link between procurement and sales. Inventory constitutes of current assets/ working capital of the organization. Thus, it is very essential to have suitable control over inventories. The purpose of inventory management is to ensure availability of parts in sufficient numbers as and when required and also to minimize the accumulation. The main objective of this paper is to devise an inventory management method for spare parts management system in order to utilize the space effectively and to stabilize FIFO system which would help the company personnel to keep record of spares precisely. A three dimensional approach is performed using sales order line frequency, seasonal frequency and sales value through ABC analysis. In addition to this, four different procurement techniques are adopted viz., one bin, two bins, multi bins and zero bin. Demand variation is measured for a period of last one year and this parameter is included during the calculation of the inventory maintenance. It is evident that a large amount of money is saved without compromising the customer order fulfilment.

Teaching and learning FNA biopsy: An update for the modern audience

Teaching and learning FNA biopsy: An update for the modern audience

Technique for Rapid Hand Transplant Donor Procurement Through the Elbow.

Background: Hand and distal forearm allotransplantation has advanced over the last 20 years from experimental to a viable treatment option for bilateral upper extremity amputation. Despite widespread growth of this field, there are few technical reports that elaborate the details of donor arm procurement. This article details a technique for rapid donor procurement through the elbow for mid to distal forearm-level hand allograft procurement. Methods: Nine arm procurements were performed on deceased tissue-only donors provided by the local organ procurement organization, including two bilateral and five unilateral cases. Technique highlights include using a fishmouth incision through the lateral and medical epicondyles, identification of the neurovascular structures, and disarticulating the elbow joint. Results: Procuring through the elbow provides straightforward anatomy, bypasses the need to cut through bone, and allows tissue allotransplantation teams to achieve procurement, flushing, and packaging within 20 minutes. Conclusions: Procurement through the elbow is a simple procedure that streamlines the process for multi-organ donors by minimizing the time needed for hand allograft procurement. Team coordination and surgical rehearsals are essential for successful hand and upper extremity procurement and allotransplantation.

Stability characteristic of cryopreserved human umbilical cord wharton's jelly–derived mesenchymal stromal cells

Background & Aim Mesenchymal stromal cells (MSCs) are multipotent mesodermal linage derived stem cells that can self–replicate and differentiate into all mesodermal, some of neuroectodermal and hepatic endodermal progenies. Umbilical cord derived Wharton's jelly MSCs (WJ–MSCs) are an attractive source for cell–based therapy regenerative medicine due to the stability in large scale expansion, non–tumor formation and low immunological rejection. Therefore, WJ–MSCs are a superior banking MSCs source for further clinical application. Methods, Results & Conclusion WJ–MSCs were isolated at a 100% successful rate and characterized by flow cytometry for CD34, CD45, CD73, CD90, CD105, CD106 and STRO–1. Growth kinetics characteristics were investigated by population doublings (PD), clinical large–scale expansion and high viability maintenance. MSCs were assessed for differentiation potential to cartilage, adipose and bone. Flow cytometry analysis showed no differences in expression of CD34, CD45, CD73, CD90, CD105, CD106 and STRO–1 among all cryopreserved WJ–MSCs for six years (2013–2018: n=30). All years of cryopreserved WJ–MSCs maintained high proliferative potential with no difference in all passages. Moreover, they were capable to differentiate into cartilage, adipose and bone structures as determined with histochemistry. WJ–MSCs have a high potential for stem cell banking from umbilical cord due to its noninvasive techniques of procurement, high successful isolation rate and low risk microorganism contamination. Furthermore, WJ–MSCs are suitable sources of stem cells for potential use in regenerative medicine in further clinical applications. Mesenchymal stromal cells (MSCs) are multipotent mesodermal linage derived stem cells that can self–replicate and differentiate into all mesodermal, some of neuroectodermal and hepatic endodermal progenies. Umbilical cord derived Wharton's jelly MSCs (WJ–MSCs) are an attractive source for cell–based therapy regenerative medicine due to the stability in large scale expansion, non–tumor formation and low immunological rejection. Therefore, WJ–MSCs are a superior banking MSCs source for further clinical application. WJ–MSCs were isolated at a 100% successful rate and characterized by flow cytometry for CD34, CD45, CD73, CD90, CD105, CD106 and STRO–1. Growth kinetics characteristics were investigated by population doublings (PD), clinical large–scale expansion and high viability maintenance. MSCs were assessed for differentiation potential to cartilage, adipose and bone. Flow cytometry analysis showed no differences in expression of CD34, CD45, CD73, CD90, CD105, CD106 and STRO–1 among all cryopreserved WJ–MSCs for six years (2013–2018: n=30). All years of cryopreserved WJ–MSCs maintained high proliferative potential with no difference in all passages. Moreover, they were capable to differentiate into cartilage, adipose and bone structures as determined with histochemistry. WJ–MSCs have a high potential for stem cell banking from umbilical cord due to its noninvasive techniques of procurement, high successful isolation rate and low risk microorganism contamination. Furthermore, WJ–MSCs are suitable sources of stem cells for potential use in regenerative medicine in further clinical applications.

Public Procurement in Broadband Infrastructure Projects in the Republic of Croatia

This paper investigates public procurement in Broadband Infrastructure Projects in the Republic of Croatia, the funding of which is provided by the European Regional Development Fund for the period 2014-2020. Since successfully implemented procurement procedure for the infrastructure solution is one of the key factors for grant approval and the start of project implementation, the question arises as to which public procurement techniques contribute best to achieving the goals and meeting the objectives of these specific projects. It is estimated that the available literature and legal cases are not sufficient to make a decision on the selection of the procedure. Therefore, a conclusion of possible procedures was reached on the efficient and effective process through a comparison, as well as multicriteria analysis, leading to the successful completion of the procurement process.

Guest Editorial: Counteracting the Supply Chain Bullwhip Effect

Guest editorial Oil and gas companies operate in dynamic and complex environments, and face constant challenges, especially in terms of supply and demand. After the recent oil price downturn, the time has come to evaluate supply chain and procurement techniques and costs. Between the 1940s and 1970s, the average annual price of oil fluctuated within a 6.5% band, but from the 1980s until the last few years, the variation has widened to almost 11 times that. A range of factors has contributed to this volatility, including political crises, financial speculation, and sharp increases/decreases in demand. Regardless of the reasons behind the initial shocks, the turn from steady-state historical demand induced the “bull-whip effect,” in which small changes in demand cause oscillating and increasing reverberations in production, capacity, and inventory throughout the supply chain in markets for oil and gas field machinery and equipment such as generator sets, motors, turbines and electrical equipment, as well as other equipment and supplies. Small variations in demand at the retail end tend to dramatically amplify as they travel upstream across supply chains with the effect that order amounts are very unbalanced and can be exaggerated. This amplification of demand fluctuations from downstream to upstream in a supply chain is called the bullwhip effect. Consequences of the Bullwhip This bullwhip effect has caused the following types of economic inefficiency at oil company equipment suppliers: Equipment manufacturers held excess inventory during the boom and took a long time to draw it down when the recession hit. Equipment manufacturers made excessive capacity investments near the peak and suffered a low or negative return on investment. Component and parts suppliers lost orders that they were not able to fulfill at the peak due to inadequate capacity and long lead times caused by large backlogs. It is estimated that the bullwhip effect costs the oil industry about $2.8 billion per year. Over the long term, this volatility is the equivalent of 9% of the cost of producing a barrel of oil. Equipment and component suppliers bear even more of this cost than oil companies. The initial increase in demand for oil raises the production levels of crude oil and refinery products, which translates into increased demand for oilfield equipment such as pumps, compressors, and turbines. Excess output is higher at the refiner level than at the producer level, higher at the original equipment manufacturer than at the refiner, and higher at the component supplier than at the equipment manufacturer. Refiners and producers pay higher prices that are set when markets are overheated and are not readily de-escalated when recession hits. Moreover, equipment and service prices keep rising even as the price of oil falls, equipment orders drop, capacity utilization drops, and lead times to manufacturing decline. Capacity adjusts, with a lag, as orders and production fluctuate, which causes capacity utilization to behave erratically. Smoothing this volatility in demand and prices would result in steadier and more profitable capital expansion and a higher return on assets. Steadier prices would translate to higher operating profits and lower operating costs as companies would go through fewer waves of layoffs and subsequent rehiring. Perhaps most important, more stable R&D investments would result in greater oilfield productivity.

Policies towards donation after circulatory death liver transplantation: the need for a guideline?

Liver transplantation (LT) using grafts from donation after circulatory death (DCD) is evolving to standard of care in many countries. Various transplant centers have developed a protocol for DCD-LT. The existence of numerous protocols may cause inconsistencies. Knowledge of these differences may help improve the outcome of DCD-LT. An internet-based survey was sent to 119 transplant surgeons among four countries: Belgium (BE), the Netherlands (NL), Spain (ES) and the United Kingdom (UK). Thirty-three percent of all respondents indicated having no specific age limit for DCD-LT donors, and if there was a limit, half of them ignored it. Calculation of donor warm ischemia time (dWIT) varied substantially between countries. In ES and the UK, the starting point of dWIT was defined as deterioration of saturation/blood pressure, while in NL, cardiac arrest was used as starting point. Seventy-eight percent of the respondents used a super-rapid sterno-laparotomy as procurement technique. Surgeons from NL and BE mainly used aortic perfusion (95% and 72%), while dual perfusion was more common in the UK (90%) and ES (91%). This study demonstrates major differences in approach to DCD-LT. To assure both donors and recipients a consistent standard of care, a consensus meeting on DCD-LT is highly recommended.

The early use of fire among Neanderthals from a zooarchaeological perspective

Fire represented a real revolution in human lifestyles, transforming the way food was processed and leading to a new way of organising settlements and interacting socially. Yet, it is one of the most debated and controversial issues in the field of Palaeolithic archaeology. The scientific community generally proposes that the regular and controlled use of fire occurred from 400 to 300 ka onward, and that the archaeological signal became well established in sites younger than 100 ka. Thus, the chronological range between 400 and 300 ka is crucial to exploring how this phenomenon and the associated behavioural changes occurred. Here, we examine the zooarchaeological signature this process left on the faunal record, including procurement techniques and animal processing (e.g., roasting). The data are compared to information from sites without fire that are framed within the same chronological period. Our objective is to collect zooarchaeological data on the process of dependence on fire as a central element in the new human mode of adaptation.

Teaching FNA techniques and ultrasound guided FNA

Teaching FNA techniques and ultrasound guided FNA

Dual aortic and portal perfusion at procurement prevents ischaemic-type biliary lesions in liver transplantation when using octogenarian donors: a retrospective cohort study.

Several risk factors for ischaemic-type biliary lesions (ITBL) after liver transplantation (LT) have been identified, but the role of portal vein perfusion at graft procurement is still unclear. This was a prospective study on double aortic and portal perfusion (DP) of liver grafts stratified by donor's decade (<60 yo; 60-69 yo; 70-79 yo and ≥80 yo) versus similar historical cohorts of primary, adult grafts procured with single aortic perfusion (SP) only. The primary study aim was to assess the role of DP on the incidence of ITBL. There was no difference in the incidence of overall biliary complications according to procurement technique for recipients of grafts <80 years. A higher incidence of ITBL was observed for patients receiving grafts ≥80 years and perfused through the aorta only (1.9 vs. 13.4%; P = 0.008). When analysing octogenarian grafts, donor male gender (HR = 6.4; P = 0.001), haemodynamic instability (HR = 4.9; P = 0.008), and type-2 diabetes mellitus (DM2) (HR = 3.0; P = 0.03) were all independent risk factors for ITBL, while double perfusion at procurement (HR = 0.1; P = 0.04) and longer donor intensive care unit (ICU) stay (HR = 0.7; P = 0.04) were protective factors. Dual aortic and portal perfusion has the potential to reduce post-transplant ITBL incidence for recipients of octogenarian donor grafts. Larger series are needed to confirm this preliminary experience.

Liver Transplantation Today: Where We Are Now and Where We Are Going.

Liver transplantation was made a reality through the bravery, innovation, and persistence of Dr. Thomas Starzl. His death in 2017, at the age of 90, makes us pause to consider how far the field has come since its inception by this remarkable pioneer. It also is an opportunity to evaluate the continued novel innovations which contribute to the growth and potential for liver transplantation in the future. The liver transplant community in 2017 continued to be most significantly challenged by an overwhelming disparity between the need for liver transplant and the shortage of donor organs. The many ways in which this critical shortage are being addressed are examined in this article. The continued debate about equitable and efficacious organ allocation, "the liver wars," has dominated much of the recent past, while efforts to optimize current organ availability have also been aggressively pursued. Efforts to optimize the use of marginal and expanded criteria organs have escalated in recent years and have been accompanied by rigorous scientific evaluation. The ongoing opioid epidemic, combined with the approval and availability of highly effective hepatitis C treatment options, has allowed the increased use of HCV positive organs in HCV positive and negative recipients. Machine perfusion, both cold and warm, has moved solidly into the liver transplant world potentiating optimization of marginal donors and also offering potential modulation of liver grafts (ie, gene therapy, stem cell therapy, and defatting). Finally, pharmacological and mechanical interventions in DCD procurement techniques have contributed to improved outcomes in DCD transplants. All of these are explored in this article as a tribute to innovative spirit of Dr. Starzl and his continued impact on liver transplant today.

Outcomes Following Heart Transplantation from Circulatory Dead Donors - A Single Centre Experience

Background Heart transplantation from donation after circulatory (DCD) death donors is now recognized as a viable strategy to expand the donor pool. DCD adult heart transplantation with distant procurement has been established in multiple centres in the UK and is also practiced in Australia. In addition, DCD heart transplantation in the paediatric population has been practiced in the USA with promising results. The world's largest single centre experience of adult DCD heart transplantation is reported. Methods Donation after circulatory death hearts were retrieved from Maastricht III donors using established DCD heart procurement techniques of either Direct Procurement and Perfusion (DPP) or Normothermic Regional Perfusion (NRP) between February 2015 and March 2018. Distant procurement was enabled with the use of continuous machine perfusion. Inclusion criteria for suitable donors included the use of only a single inotropic agent at the time of withdrawal of life supportive therapy (WLST) and an echocardiogram demonstrating an ejection fraction of greater than 50% with no structural abnormalities. The time allowed for circulatory cessation was initially limited to 3 hours and subsequently extended to 4 hours. Primary outcomes included 30-day survival, length of stay on intensive care and length of stay in hospital. Secondary out-comes included the use of post-operative mechanical circulatory support with an intra-aortic balloon pump (IABP), ECMO or ventricular assist device. Results During the 37-month study, 44 DCD hearts were transplanted. The median donor age was 36 years and the median recipient age was 57.5 years. Thirty-day survival was 100% and survival to discharge from hospital was 95%. The median length of stay on intensive care was 5 days with a median hospital stay of 20 days. A post-operative IABP was used in 9 patients (20%) with 5 patients (11%) requiring ECMO support. Twenty-eight patients have been followed up for one year post-transplant with a 1-year survival of 86%. Conclusions Heart transplantation can be safely undertaken utilizing organs from DCD donors and is associated with excellent early clinical outcomes. The use of DCD heart donors increased local transplant activity by more than 35% over the 3-year period. Adoption of clinical programs of DCD heart transplantation in North America may allow for a similar increase in heart transplant activity.

Analysis of potential contamination factors in musculoskeletal tissues.

Tissue Banks have become the main source for bone grafts, due to preference for homologous tissues. Notwithstanding the use of aseptic techniques for procurement of tissues and judicious selection of donors, microorganisms are frequently found in procured bones. Purpose of this study is to evaluate the factors that increase safety of procurement and minimize discard of procured tissues. Microbiological contamination was analyzed in 1271 musculoskeletal tissues removed from 138 multi-organ donors over a period extending from 2006 to 2016. Effects of various risk factors related with contamination were estimated using a logistic regression model. Microbiological contamination rate in the tissues was 17.1%; low pathogenic microorganisms were cultivated in 12.9% of the tissues, while highly pathogenic ones were cultivated in 4.2% of the tissues. Evolution of one single team was monitored during that period, verifying a fall in the general contamination level from 22.5 to 9.2%. Absence of antibiotics increased low pathogenic contamination risk. Every additional day in intensive care unit (ICU) increased the risk of highly pathogenic contamination. Time elapsed between death and the beginning of removal procedures was found to be relevant for both low pathogenic and highly pathogenic microorganisms. Among the studied factors, the following contributed for a significant increase in contamination by microorganisms in removed tissues: lack of use of prophylactic antibiotic therapy in donors, quantity of removed tissues, length of admission in ICU and the time elapsed between aortic clamping and beginning of the removal procedure.

Kidney Transplantation Utilising Donors After Circulatory Death – The First Report from the African Continent

Introduction At Groote Schuur Hospital, the number of deceased donors have declined over the last two decades, necessitating more liberal donor selection. In 2007, measures to expand the deceased kidney donor pool were implemented, including a HIV positive to positive transplant program, the utilisation of Extended Criteria Donors (ECD) as well as a Donation after Circulatory Death (DCD) program (Figure 1). Despite the successful implementation of DCD programs across Europe and the United Sates, other African centres have not adopted this mode of donation. The aim of this study was to report on our institutional experience with DCD kidney transplants and to encourage this approach among other African centres to improve access to transplantation. Materials and methods Retrospective, descriptive study of consecutive DCD renal transplants at Groote Schuur Hospital over a 10 year period (1 January 2007 to 31 December 2016). Data was obtained from donor referral and recipient registries. Primary end-points were defined as 1, 2 and 5 year graft- (censored for death with functioning graft) and patient survival. Kaplan-Meier method was used for survival analysis. Secondary end-points included the incidence of delayed graft function (DGF), 30-day morbidity, length of stay and donor and recipient clinical characteristics. Results 13 DCD procurements were performed, with no kidneys discarded. Utilised donors were young (median age 22 years; IQR 21-32) with well-preserved renal function (median terminal serum creatinine 86 umol/l; IQR 73-181). 26 Renal transplants were performed with a mean cold ischaemic time of 11 hours (IQR 8-14). Cumulative incidence of DGF was 65.4%. The median length of stay was 20 days (IQR 16-28) in those who experienced DGF and 11 days (IQR 9-16) in those who did not. 30-Day morbidity (other than DGF) was 19.2% (Figure 2). Graft survival at 1, 2 and 5 years were 100%, 95.8% (95% CI 73.9% - 99.4%) and 83.6% (95% CI 56.1%-94.8%) respectively (Figure 3). Patient survival at 1, 2 and 5 years was 92.3% (95% CI 72.6-98.0), as no deaths occurred between 1 and 5 years post-transplant (Figure 4). Discussion Long term graft- and patient survival were comparable with international literature. The incidence of DGF was 65,4%. Possible explanations may include a high incidence of donor vasopressor requirements (46.2%), an initial learning curve with procurement technique and relatively long cold ischaemic times. Nevertheless, DCD may present an unique opportunity to expand deceased donation throughout Africa, particularly in areas hampered by a lack of brain death legislation and religious and/or cultural concerns regarding Donation after Brain Death. Conclusion Results from this study reaffirm the potential of DCD to expand deceased donation throughout Africa, in a religiously and culturally sensitive way.

Uterus transplantation: organ procurement in a deceased donor model

To demonstrate our technique of uterine procurement from a deceased donor. This video uses live action footage from surgery and detailed illustrations to review the steps and techniques involved in deceased donor procurement surgery. Academic medical center. A deceased multiorgan donor. Trial organ procurement of a viable uterus from a deceased donor. Procurement time and associated features of suitability of dissected specimen. This video article describes the advantages of a deceased donor model over a live donor model, including eliminating the risk of surgical complications to a living donor, avoidance of ethical issues inherent in live donation, easier access to generous vascular pedicles for anastomosis, and faster procurement time. This video also outlines the key steps to a successful uterine procurement using illustrations and live action footage from a trial organ procurement. Uterine transplantation is an emerging surgical treatment for patients with absolute uterine factor infertility. Continued practice is essential in preparing for a deceased donor uterine procurement. The process continues to be refined and adapted as new information becomes available toward the goal of safe, efficient, ethical, and effective surgical treatment of absolute uterine factor infertility.

P.102 Endoscopic harvesting of a saphenous vein graft for EC-IC bypass followed by proximal artery occlusion of a pediatric giant fusiform MCA aneurysm

Background: Minimally invasive techniques for graft procurement are the norm in cardiac surgery and yet their use in neurosurgery is only in its infancy. We present the case of a 10-year-old boy presenting with fluctuating right facial and upper extremity weakness who was found to have a giant, partially thrombosed, fusiform aneurysm of the M1 segment of the left MCA. Methods: Endoscopic harvesting of the saphenous vein was performed with a procedure time of 30 minutes. The graft was used as an interposition graft between the common carotid artery and the superior M2 division of the MCA, which was tunneled subcutaneously. Once Doppler ultrasound confirmed good flow through the graft, an aneurysm clip was then secured on the M1, proximal to the saccular component of the fusiform aneurysm and just distal to the anterior temporal branch. Results: Intraoperative 2D and 3D angiogram confirmed a patent extracranial to intracranial bypass with thrombosis of the giant fusiform M1 aneurysm. By 1-month post-operatively, he had returned to school and routine activities. He continues to do well 6 months post-operatively with a minimal and well-healed donor site scar. Conclusions: Endoscopic graft harvesting is an emerging option in the pediatric population undergoing extracranial to intracranial bypass, associated with lower wound complications and improved cosmesis.

399 ENDOSCOPIC ULTRASOUND GUIDED LIVER BIOPSY USING A 22 GUAGE FINE NEEDLE BIOPSY NEEDLE: A PROSPECTIVE STUDY.

Endoscopic ultrasound guided liver biopsy (EUS-LB), is gaining traction as a safe and effective alternative to percutaneous and trans-jugular liver biopsy. EUS guided true-cut and 19-gauge needles can be technically difficult to maneuver, particularly when sampling the right lobe. Other factors that have curtailed the wide spread use of EUS guided liver biopsy are, fear and anxiety about the potential complications with the use of larger bore needles and tissue fragmentation of the histological specimen. We prospectively aimed at evaluating the diagnostic adequacy and safety of EUS-LB using a smaller (22-gauge) fine needle biopsy (FNB) needle while using proper technique of tissue expression from the needle to prevent fragmentation of the specimen. Patients referred for endosonographic evaluation of elevated liver enzymes, in whom no obstructive etiology was identified on EUS and did not require ERCP, were included in this prospective, non-randomized study at a single tertiary hospital. EUS-LB was performed using a 22-guage EUS-FNB needle. A total of three passes were made from both lobes. With each pass, 3-4 back and forth slow movements were made in a fanning fashion without the use of suction. The needle was kept straight while disengaging from the scope and during tissue expression. Tissue was slowly expressed from the needle over 3-4 minutes using only the stylet. This technique was used to prevent tissue fragmentation. The presence of visible core tissue from each pass was evaluated, formalin-fixed and sent for histopathological evaluation in separate containers. Core length (CL) from each pass was measured and complete portal triads (CPT’s) counted by a pathologist. Patients were followed for post procedure (2-4 hours), early (24 hours) and late (30 days) complications. 17 patients (median age, 57 years; 10 women) underwent EUS-LB. Adequate core tissue for histopathological evaluation was obtained in all 17 patients (100%) without the use of suction. 16 patients (94%) required the use of a single 22-gauge FNB needle. One patient required an additional similar needle due to needle dysfunction. 1 sample (5.8%) was described as bloody, but contained adequate core tissue. The overall tissue yield per pass was a median CL (longest fragment per pass) of 5 mm (range 2mm-33mm) and median CPT of 17 (range 8-65). Tissue procurement from right liver lobe was described as technically easier by the endosonographers. The most common minor complication was mild abdominal pain in 3 patients (17.6 %) at 24 hours. There were no major complications, and no immediate or delayed bleeding. EUS-LB using a 22-gauge FNB needle is safe and has an adequate diagnostic yield. Using proper technique for tissue procurement and expression from the needle can prevent tissue fragmentation.

Direct Heart Procurement After Donation After Circulatory Death With Ex Situ Reperfusion

The most extended technique of heart procurement from donors after circulatory death involves direct procurement and reperfusion in an ex situ normothermic platform using the Organ Care System (TransMedics, Inc, Andover, MA). This report describes a modified technique (at the Harefield Hospital, London, United Kingdom) with rapid donor blood drainage using a cell-saving device and synchronized perfusion on the Organ Care System.