Remote ischaemic preconditioning in orthotopic liver transplantation (RIPCOLT trial): a pilot randomized controlled feasibility study.

BACKGROUND: Ischaemia Reperfusion (IR) injury is a major cause of morbidity, mortality and graft loss following Orthotopic Liver Transplantation (OLT). Utilising marginal grafts, which are more susceptible to IR injury, makes this a key research goal. Remote Ischaemic Preconditioning (RIPC) has been shown to ameliorate hepatic IR injury in experimental models. Whether RIPC can reduce IR injury in human liver transplant recipients is unknown. METHODS: Forty patients undergoing liver transplantation were randomized to RIPC or a sham. RIPC was induced through three 5 min cycles of alternate ischaemia and reperfusion of the left leg prior to surgery. Data on clinical outcomes was collected prospectively. Per-operative cytokine levels were measured. RESULTS: Fourty five of 51 patients approached (88%) were willing to enroll in the study. Five patients were excluded and 40 randomized, of which 20 underwent RIPC which was successfully completed in all patients. There were no complications following RIPC. Median day 3 AST levels were slightly higher in the RIPC group (221 IU vs 149 IU, p = 1.00). CONCLUSIONS: RIPC is acceptable and safe in liver transplant recipients. This study has not demonstrated evidence of a reduction in short-term measures of IR injury. Longer follow up will be required and consideration of an altered protocol.

Ureteric obstruction of solitary kidney following endovascular repair of infrarenal abdominal aortic aneurysm: a case report.

Endovascular treatment of abdominal aortic aneurysm is commonplace at present. It has got lower mortality and morbidity compared to open surgical repair. However, it requires long-term follow-up. The main complications are endoleaks, stent migrations, kinks, and rupture. Ureteric obstruction is uncommon but an important complication following endovascular treatment of abdominal aortic aneurysms. We present a case of ureteric obstruction in a solitary kidney following endovascular repair of abdominal aortic aneurysm and its successful management by ureteric stenting.

Mesh erosion into caecum following laparoscopic repair of inguinal hernia (TAPP): a case report and literature review.

Repair of inguinal hernia is the most commonly performed surgical procedure. Both open and laparoscopic methods are accepted modalities of surgical treatment. Transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) are the two types of laparoscopic repair of the inguineal hernia. The main advantages of laparoscopic repair, as compared to open repair, are a shorter hospital stay and a quicker recovery to normal activities. However, laparoscopic repairs are associated with a higher incidence of visceral and vascular injuries. One particular complication is the migration and erosion of mesh into the adjacent viscera. Although the total numbers of cases are small, compared to the total numbers of inguinal hernia repairs, they are important, as they often presented with a diagnostic dilemma. Most of the mesh migrations reported in the literature involves the urinary bladder. In this paper, we present a case of erosion of mesh into the caecum. The patient (a 66-year-old male) underwent TAPP repair of a right inguinal hernia in 1996 with polypropelene mesh. He also underwent an open appendicectomy in 1980. During the laparoscopic repair, he was found to have multiple intra-abdominal adhesions. He presented with intermittent diarrhea, for which he was investigated, and a benign caecal lesion was found. He was initially managed conservatively. However, his symptoms persisted and he underwent a right hemicolectomy in February 2006 in our hospital. The offending lesion was found to be the prolene mesh having eroded into the caecum.

Protocol for a prospective randomized controlled trial of recipient remote ischaemic preconditioning in orthotopic liver transplantation (RIPCOLT trial).

ABSTRACT: Ischaemic reperfusion (IR) injury is a major cause of graft loss, morbidity and mortality following orthotopic liver transplantation (OLT). Demand for liver transplantation has resulted in increasing use of marginal grafts that are more prone to IR injury. Remote ischaemic preconditioning (RIPC) reduces IR injury in experimental models, but recipient RIPC has not been evaluated clinically. METHODS: A single-centre double-blind randomized controlled trial (RCT) is planned to test the hypothesis that recipient RIPC will reduce IR injury. RIPC will be performed following recipient anaesthetic induction but prior to skin incision. The protocol involves 3 cycles of 5 min of lower limb occlusion with a pneumatic tourniquet inflated to 200 mmHg alternating with 5 min of reperfusion. In the control group, the sham will involve the cuff being placed on the thigh but without being inflated. The primary endpoint is ability to recruit patients to the trial and safety of RIPC. The key secondary endpoint is a reduction in serum aspartate transferase levels on the third post-operative day. DISCUSSION: RIPC is a promising strategy to reduce IR injury in liver transplant recipients as there is a clear experimental basis, and the intervention is both inexpensive and easy to perform. This is the first trial to investigate RIPC in liver transplant recipients. TRIAL REGISTRATION: Clinicaltrials.gov NCT00796588.