Age Matters: What Affects the Cumulative Lifespan of a Transplanted Liver?

OBJECTIVE: Assess factors affecting the cumulative lifespan of a transplanted liver. SUMMARY BACKGROUND DATA: Liver ageing is different from other solid organs. It is unknown how old a liver can actually get after liver transplantation (LT). METHODS: Deceased donor liver transplants from 1988-2021 were queried from the United States (US) UNOS registry. Cumulative liver age was calculated as donor age + recipient graft survival. RESULTS: In total, 184,515 livers were included. Most were DBD-donors (n=175,343). The percentage of livers achieving >70, 80, 90 and 100years cumulative age was 7.8% (n=14,392), 1.9% (n=3,576), 0.3% (n=528), and 0.01% (n=21), respectively. The youngest donor age contributing to a cumulative liver age >90years was 59years, with post-transplant survival of 34years. In pediatric recipients, 736 (4.4%) and 282 livers (1.7%) survived >50 and 60years overall, respectively. Transplanted livers achieved cumulative age >90years in 2.86-per-1000 and >100years in 0.1-per-1000. The US population at-large has a cumulative "liver age" >90years in 5.35-per-1000 persons, and >100y in 0.2-per-1000. Livers aged>60 years at transplant experienced both improved cumulative survival ( P <0.0001) and interestingly improved survival after transplantation ( P <0.0001). Recipient warm-ischemia-time of >30minutes was most predictive of reduced cumulative liver survival overall (n=184,515, HR=1.126, P <0.001) and excluding patients with mortality in the first 6month (n=151,884, HR=0.973, P <0.001). CONCLUSIONS: In summary, transplanted livers frequently get as old as those in the average population despite ischemic-reperfusion-injury and immunosuppression. The presented results justify using older donor livers regardless of donation type, even in sicker recipients with limited options.

Acute rejection after liver transplantation with machine perfusion versus static cold storage: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Acute cellular rejection (ACR) is a frequent complication after liver transplantation. By reducing ischemia and graft damage, dynamic preservation techniques may diminish ACR. We performed a systematic review to assess the effect of currently tested organ perfusion (OP) approaches versus static cold storage (SCS) on post-transplant ACR-rates. APPROACH AND RESULTS: A systematic search of Medline, Embase, Cochrane Library, and Web of Science was conducted. Studies reporting ACR-rates between OP and SCS and comprising at least 10 liver transplants performed with either hypothermic oxygenated perfusion (HOPE), normothermic machine perfusion, or normothermic regional perfusion were included. Studies with mixed perfusion approaches were excluded. Eight studies were identified (226 patients in OP and 330 in SCS). Six studies were on HOPE, one on normothermic machine perfusion, and one on normothermic regional perfusion. At meta-analysis, OP was associated with a reduction in ACR compared with SCS [OR: 0.55 (95% CI, 0.33-0.91), p =0.02]. This effect remained significant when considering HOPE alone [OR: 0.54 (95% CI, 0.29-1), p =0.05], in a subgroup analysis of studies including only grafts from donation after cardiac death [OR: 0.43 (0.20-0.91) p =0.03], and in HOPE studies with only donation after cardiac death grafts [OR: 0.37 (0.14-1), p =0.05]. CONCLUSIONS: Dynamic OP techniques are associated with a reduction in ACR after liver transplantation compared with SCS. PROSPERO registration: CRD42022348356.

State of the Art: Pouch Surgery in the 21st Century.

BACKGROUND: An ileoanal pouch with IPAA is the preferred method to restore intestinal continuity in patients who require a total proctocolectomy. Pouch surgery has evolved during the past decades thanks to increased experience and research, changes in the medical management of patients who require an ileal pouch, and technological innovations. OBJECTIVE: To review the main changes in pouch surgery over the past 2 decades, with a focus on staging, minimally invasive and transanal approaches, pouch design, and anastomotic configuration. RESULTS: The decision on the staging approach depends on the patient's conditions, their indication for surgery, and the risk of anastomotic leak. A minimally invasive approach should be performed whenever feasible, but open surgery still has a role in this technically demanding operation. Transanal IPAA may be performed in experienced centers and may reduce conversion to open surgery in the hostile pelvis. The J-pouch is the easiest, fastest, and most commonly performed design, but other designs may be used when a J-pouch is not feasible. A stapled anastomosis without mucosectomy can be safely performed in the majority of cases, with a low incidence of rectal cuff neoplasia and better functional outcomes than handsewn. Finally, Crohn's disease is not an absolute contraindication to an ileoanal pouch, but pouch failure may be higher compared to other indications. CONCLUSIONS: Many technical nuances contribute to the success of an ileoanal pouch. The current standard of care is a laparoscopic J-pouch with double-stapled anastomosis, but this should not be seen as a dogma, and the optimal approach and design should be tailored to each patient. See video from symposium.

Third Time's the Charm? Indications and Outcomes for Redo-Redo IPAA.

BACKGROUND: Up to 20% to 40% cases of redo IPAA procedures will result in pouch failure. Whether to offer a second redo procedure to maintain intestinal continuity remains a controversial decision. OBJECTIVE: To report our institutional experience of second redo IPAA procedures. DESIGN: This was a retrospective review. Patient-reported outcomes were compared between patients undergoing second redo procedures and those undergoing first redo procedures using propensity score matching to balance the 2 cohorts. SETTINGS: Tertiary referral center. PATIENTS: Patients who underwent second redo IPAA procedures between 2004 and 2021 were included in this study. INTERVENTIONS: Second redo IPAA. MAIN OUTCOME MEASURES: Pouch survival and patient-reported outcomes were measured using the Cleveland Global Quality of Life survey. RESULTS: Twenty-three patients were included (65% women), 20 (87%) with an index diagnosis of ulcerative colitis and 3 (13%) with indeterminate colitis. The final diagnosis was changed to Crohn's disease in 8 (35%) cases. The indication for pouch salvage was the same for the first and second redo procedures in 21 (91%) cases: 20 (87%) patients had both redo IPAAs for septic complications. After a median follow-up of 39 months (interquartile range, 18.5-95.5 months), pouch failure occurred in 8 (30%) cases (7 cases due to sepsis, of whom 3 never had their stoma closed, and 1 case due to poor function); all patients who experienced pouch failure underwent the second redo procedure due to septic complications. Overall pouch survival at 3 years was 76%: 62.5% in patients with a final diagnosis of Crohn's disease versus 82.5% in patients with ulcerative/indeterminate colitis ( p = 0.09). Overall quality-of-life score (0-1) was 0.6 (0.5-0.8). Quality of life and functional outcomes were comparable between first and second redo procedures, except incontinence, which was higher in second redo procedures. LIMITATIONS: Single-center retrospective review. CONCLUSIONS: A second pouch salvage procedure may be offered with acceptable outcomes to selected patients with high motivation to keep intestinal continuity. See Video Abstract . LA TERCERA ES LA VENCIDA INDICACIONES Y RESULTADOS DE LA RERECONFECCION DE LA ANASTOMOSIS ANAL CON BOLSA ILEAL: ANTECEDENTES:Hasta un 20-40% de los casos de rehacer anastomosis anal con bolsa ileal (IPAA) resultarán en falla de la bolsa. La posibilidad de ofrecer un segundo procedimiento para mantener la continuidad intestinal sigue siendo una decisión controvertida.OBJETIVO:Reportar nuestra experiencia institucional de una segunda re-confección de la anastomosis anal con bolsa ileal.DISEÑO:Revisión retrospectiva; los resultados informados por los pacientes se compararon entre los pacientes que se sometieron a una segunda re-confeccion con los de los pacientes que se sometieron a una la primera re-confeccion utilizando el puntaje de propensión para equilibrar las dos cohortes.AJUSTES ENTORNO CLINICO:Centro de referencia terciario.PACIENTES:Pacientes que se sometieron a una segunda re-confeccion de de la anastomosis anal con bolsa ileal entre 2004 y 2021.INTERVENCIONES:Segunda re-confeccion de la anastomosis anal con bolsa ileal.PRINCIPALES MEDIDAS DE RESULTADO:Supervivencia de la bolsa, resultados informados por los pacientes medidos mediante la encuesta Cleveland Global Quality of Life.RESULTADOS:Se incluyeron veintitrés pacientes (65% mujeres), 20 (87%) con diagnóstico inicial de colitis ulcerosa y 3 (13%) con colitis indeterminada. El diagnóstico final se cambió a enfermedad de Crohn en ocho (35%) casos. La indicación para el rescate de la bolsa fue la misma para la primera y segunda re-confeccion en 21 (91%) casos: 20 (87%) pacientes tuvieron ambas re-confecciones de la anastomosis anal con bolsa ileal por complicaciones sépticas. Después de una mediana de seguimiento de 39 meses (RIC 18,5 - 95,5), se produjo falla de la bolsa en 8 (30%) casos (7 casos debido a sepsis, de los cuales 3 nunca cerraron el estoma y 1 caso debido a una mala función); todos los pacientes que experimentaron falla de la bolsa se sometieron a una segunda re-confeccion debido a complicaciones sépticas. La supervivencia global de la bolsa a los 3 años fue del 76%: 62,5% en pacientes con diagnóstico final de enfermedad de Crohn, versus 82,5% en colitis ulcerativa/indeterminada ( p = 0,09). La puntuación general de calidad de vida (0 -1) fue 0,6 (0,5 - 0,8). La calidad de vida y los resultados funcionales fueron comparables entre la primera y la segunda re-confeccion, excepto la incontinencia, que fue mayor en la segunda re-confeccion.LIMITACIONES:Revisión retrospectiva de un solo centro.CONCLUSIONES:Se puede ofrecer un segundo procedimiento de rescate de la bolsa con resultados aceptables a pacientes seleccionados con alta motivación para mantener la continuidad intestinal. (Traducción- Dr. Francisco M. Abarca-Rendon ).

Salvage Surgery: An Effective Therapy in the Management of Ileoanal Pouch Prolapse.

BACKGROUND: Restorative proctocolectomy with IPAA is the surgical treatment of choice for patients requiring surgery for IBD and, less frequently, for other pathologies. Pouch prolapse is a rare complication that compromises pouch function and negatively affects patients' quality of life. OBJECTIVE: This study aimed to describe our experience from a single high-volume center in this infrequent condition. DESIGN: Restrospective cohort study of a prospectively maintained, Institutional Review Board-approved database. SETTINGS: All consecutive eligible patients with IPAA and pouch prolapse were identified from 1990 to 2021. PATIENTS: Patients with full-thickness prolapse treated by pouch pexy were included. INTERVENTIONS: Pouch pexy (with/without mesh). MAIN OUTCOME MEASURES: Success rate of pouch pexy, defined as no recurrence of prolapse. RESULTS: A total of 4791 patients underwent IPAA; 7 (0.1%) were diagnosed with full-thickness prolapse. An additional 18 patients who underwent IPAA and had full-thickness prolapse were referred from outside institutions. Among 25 included patients, 16 (64.0%) were women, and the overall mean age was 35.6 ± 13.4 years. The time interval from initial pouch formation to prolapse was 4.2 (interquartile range, 1.1-8.5) years. Nine patients (36.0%) underwent previous treatment for prolapse. All patients presented with symptoms and physical examination compatible with full-thickness prolapse. Twenty patients (80.0%) underwent surgical pouch pexy without mesh and 5 (20.0%) had pouch pexy with mesh placement. A diverting ileostomy was performed in 1 patient (4.0%) before pouch pexy and in 8 patients (32.0%) at the time of surgical prolapse correction. After surgery, recurrent prolapse was noted in 3 patients (12.0%) at a median of 6.9 (interquartile range, 5.2-8.3) months. LIMITATIONS: Retrospective study, small sample size thus prone to selection, and referral biases, which may limit the generalizability of our findings. CONCLUSION: Pouch prolapse can be effectively treated with salvage surgery. Surgical intervention is safe and provides acceptable outcomes. See Video Abstract. CIRUGA DE RESCATE UNA TERAPIA EFICAZ EN EL MANEJO DEL PROLAPSO DE LA BOLSA ILEOANAL: ANTECEDENTES:La proctocolectomía restauradora con anastomosis reservorio ileoanal es el tratamiento quirúrgico de elección para aquellos pacientes que requieren cirugía por enfermedad inflamatoria intestinal y, con menor frecuencia, por otras patologías. El prolapso de la bolsa es una complicación rara que compromete la función de la bolsa y afecta de manera negativa la calidad de vida de los pacientes.OBJETIVO:Describir nuestra experiencia de un solo centro de alto volumen en esta condición poco frecuente.DISEÑO:Estudio de cohorte retrospectivo de una base de datos mantenida prospectivamente aprobada por el IRB.AJUSTES/PACIENTES:Fueron identificados y elegibles de manera consecutiva todos los pacientes con anastomosis de bolsa ileoanal y prolapso de bolsa entre 1990 y 2021. Se incluyeron pacientes con prolapso de bolsa de espesor total tratados con pexia.INTERVENCIONES:Pexia de la bolsa (con/sin malla).PRINCIPALES MEDIDAS DE RESULTADO:Tasa de éxito de la pexia de la bolsa, definida como ausencia de recurrencia del prolapso.RESULTADOS:Un total de 4.791 pacientes fueron sometidos a anastomosis de bolsa ileoanal; siete (0,1%) fueron diagnosticados con prolapso de espesor total. Otros 18 pacientes con anastomosis de reservorio ileoanal fueron derivados de instituciones externas. De entre los 25 pacientes incluidos, 16 (64,0 %) eran mujeres y la edad media promedio fue de 35,6+/-13,4 años. El intervalo de tiempo desde la creación inicial de la bolsa hasta el prolapso fue de 4,2 (IQR 1,1-8,5) años. Nueve (36,0 %) pacientes fueron sometidos a tratamiento previo para el prolapso (fisioterapia n = 4, pexia de la bolsa n = 2, pexia de la bolsa con malla n = 2, resección de la mucosa n = 1). Todos los pacientes presentaron síntomas y exploración física compatibles con prolapso de espesor total. Veinte (80,0%) pacientes se sometieron a pexia de bolsa quirúrgica sin malla y cinco (20,0%) se sometieron a pexia de bolsa con colocación de malla. Se realizó una ileostomía de derivación en un (4,0%) paciente antes de la pexia de la bolsa y en ocho (32,0%) pacientes en el momento de la corrección quirúrgica del prolapso. Posterior a la cirugía, se observó prolapso recurrente en tres pacientes (12,0 %) con una mediana de 6,9 (IQR 5,2-8,3) meses.LIMITACIONES:Estudio retrospectivo, pequeño tamaño de muestra, por lo tanto, propenso a sesgos de selección y referencia que pueden limitar la generalización de nuestros hallazgos.CONCLUSIÓN:El prolapso de la bolsa ileoanal puede tratarse de manera efectiva mediante la cirugía de rescate. La intervención quirúrgica es segura y proporciona resultados aceptables. (Traducción-Dr. Mauricio Santamaria ).

Predictors of En Bloc, R0 Resection and Post-Procedural Complications Following Advanced Endoscopic Resections for Colorectal Neoplasms: Results of 1213 Procedures.

BACKGROUND: Advanced endoscopic resection techniques are used for treatment of colorectal neoplasms that are not amenable for conventional colonoscopic resection. Literature regarding the predictors of the outcomes of advanced endoscopic resections, especially from a colorectal surgical unit, is limited. OBJECTIVE: To determine the predictors of short- and long-term outcomes following advanced endoscopic resections. DESIGN: Retrospective case series. SETTINGS: Tertiary care center. PATIENTS: Patients who underwent advanced endoscopic resections for colorectal neoplasms from November 2011 to August 2022. INTERVENTION: Endoscopic mucosal resection, endoscopic submucosal dissection, hybrid endoscopic submucosal dissection, combined endoscopic laparoscopic surgery. MAIN OUTCOME MEASURES: Predictors of en bloc and R0 resection, bleeding, perforation was determined using univariable and multivariable logistic regression models. Cox regression models were used to determine the predictors of tumor recurrence. RESULTS: A total of 1213 colorectal lesions from 1047 patients were resected [median age 66 (58-72) years, 484 (46.2%) female, median body mass index 28.6 (24.8-32.6) kg/m 2]. Most neoplasms were in the proximal colon (898, 74%). Median lesion size was 30 (IQR: 20-40, range: 0-120) mm. 911 (75.1%) lesions had previous interventions. Most common Paris and Kudo classifications were 0-IIa flat elevation (444, 36.6%) and IIIs (301, 24.8%), respectively. En bloc and R0 resection rates were 56.6% and 54.3%, respectively. Smaller lesions, rectal location, and procedure type (endoscopic submucosal dissection) were associated with significantly higher en bloc and R0 resection rates. Bleeding and perforation rates were 5% and 6.6%, respectively. Increased age [1.06 (1.03-1.09), p < 0.0001] was a predictor for bleeding. Lesion size [1.02 (1.00-1.03), p = 0.03] was a predictor for perforation. Tumor recurrence rate was 6.6%. En bloc [HR 1.41 (95% CI 1.05-1.93), p = 0.02] and R0 resection [HR 1.49 (95% CI 1.11-2.06), p = 0.008] were associated with decreased recurrence risk. LIMITATIONS: Single center, retrospective study. CONCLUSIONS: Outcomes of advanced endoscopic resections can be predicted by patient and lesion-related characteristics. See Video Abstract.

Outcome of incidental versus preoperatively diagnosed colorectal cancer during total proctocolectomy with ileal pouch-anal anastomosis for inflammatory bowel disease.

AIM: Total proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the treatment of choice for colorectal cancer (CRC) in inflammatory bowel disease. CRC may also be discovered incidentally at IPAA for other indications. We sought to determine whether incidentally found CRC at IPAA was associated with worse outcomes. METHODS: Our institutional pouch registry (1983-2021) was retrospectively reviewed. Patients with CRC at pathology after IPAA were divided into two groups: a preoperative diagnosis (PreD) group and an incidental diagnosis (InD) group. Their long-term outcomes (overall survival, disease-free survival and pouch survival) were compared. RESULTS: We included 164 patients: 53 (32%) InD and 111 (68%) PreD. There were no differences in cancer staging, differentiation and location. After a median follow-up of 11 (IQR 3-25) years for InD and 9 (IQR 3-20) years for the PreD group, deaths were 14 (26%) in the InD group and 18 (16%) in the PreD group. Pouch failures were five (9%) in the InD group and nine (8%) in the PreD group, of which two (5%) and four (4%) were cancer related. Ten-year overall survival was 94% for InD and 89% for PreD (P = 0.41), disease-free survival was 95% for InD and 90% for PreD (P = 0.685) and pouch survival was 89% for InD and 97% for PreD (P = 0.80). Pouch survival at 10 years was lower in rectal versus colon cancer (87% vs. 97%, P = 0.01). No difference was found in outcomes in handsewn versus stapled anastomoses. CONCLUSION: Inflammatory bowel disease patients with incidentally found CRC during IPAA appear to have similarly excellent oncological and pouch outcomes to patients with a preoperative cancer diagnosis.

Redo IPAA for long rectal cuff syndrome after ileoanal pouch for inflammatory bowel disease.

ABTRACT: BACKGROUND: When constructing an ileal pouch-anal anastomosis (IPAA), the rectal cuff should ideally be 1-2 cm long to avoid subsequent complications. METHODS: We identified patients from our IBD center who underwent redo IPAA for a long rectal cuff. Long rectal cuff syndrome (LRCS) was defined as a symptomatic rectal cuff ≥ 4 cm. RESULTS: Forty patients met the inclusion criteria: 42.5% female, median age at redo surgery 42.5 years. The presentation was ulcerative proctitis in 77.5% of the cases and outlet obstruction in 22.5%. The index pouch was laparoscopically performed in 18 patients (45%). The median rectal cuff length was 6 cm. The pouch was repaired in 16 (40%) cases, whereas 24 (60%) required the creation of a neo-pouch. At the final pathology, the rectal cuff showed chronic active colitis in 38 (90%) cases. After a median follow-up of 34.5 (IQR 12-109) months, pouch failure occurred in 9 (22.5%) cases. The pouch survival rate was 78% at 3 years. Data on the quality of life were available for 11 (27.5%) patients at a median of 75 months after redo surgery. The median QoL score (0-1) was 0.7 (0.4-0.9). CONCLUSION: LRCS, a potentially avoidable complication, presents uniformly with symptoms of ulcerative proctitis or stricture. Redo IPAA was restorative for the majority.

Survival benefit of adequate lymphadenectomy in patients undergoing liver resection for clinically node-negative intrahepatic cholangiocarcinoma.

BACKGROUND & AIMS: Lymph-nodal status is an important predictor of survival in intrahepatic cholangiocarcinoma (iCCA), but the need to perform lymphadenectomy in patients with clinically node-negative (cN0) iCCA is still under debate. The aim of this study was to determine whether adequate lymphadenectomy improves long-term outcomes in patients undergoing liver resection for cN0 iCCA. METHODS: We performed a retrospective cohort study on consecutive patients who underwent radical liver resection for cN0 iCCA at five tertiary referral centers. A propensity score based on preoperative data was calculated and used to generate stabilized inverse probability of treatment weight (IPTW). Overall and recurrence-free survival of patients undergoing adequate (≥6 retrieved lymph nodes) vs. inadequate lymphadenectomy were compared. Interactions between adequacy of lymphadenectomy and clinical variables of interest were explored through Cox IPTW regression. RESULTS: The study includes 706 patients who underwent curative surgery for cN0 iCCA. Four-hundred and seventeen (59.1%) received adequate lymphadenectomy. After a median follow-up of 33 months (IQR 18-77), median overall survival was 39 months (IQR 23-109) and median recurrence-free survival was 23 months (IQR 8-74). After stratification according to nodal status at final pathology, node-positive patients had longer overall survival (28 vs. 23 months; hazard ratio 1.82; 95% CI 1.14-2.90; p = 0.023) and disease-free survival (13 vs. 9 months; hazard ratio 1.35; 95% CI 1.14-1.59; p = 0.008) after adequate lymphadenectomy. Adequate lymphadenectomy significantly improved survival outcomes in patients without chronic liver disease, and in patients with less-advanced tumors (solitary tumors, tumor size <5 cm, carbohydrate antigen 19-9 <200 U/ml). CONCLUSIONS: Adequate lymphadenectomy provided better survival outcomes for patients with cN0 iCCA who were found to be node-positive at pathology, supporting the routine use of adequate lymphadenectomy for cN0 iCCA. IMPACT AND IMPLICATIONS: Lymphadenectomy is essential for the surgical staging of intrahepatic cholangiocarcinoma (iCCA). While its role in patients with preoperative suspicion of nodal metastases is implicit, the impact of lymphadenectomy on survival of patients with clinically node-negative (cN0) disease is still under debate. In this large retrospective study on patients who underwent surgical resection for cN0 iCCA, we show that adequate lymphadenectomy (i.e. retrieving ≥6 lymph nodes) significantly improves survival and lowers the risk of tumor recurrence. Lymphadenectomy during surgical resection of iCCA is actually underperformed by the surgical community, resulting in inadequate staging and possibly worse long-term outcomes. The results of this study should empower surgeons and clinicians to push for adequate lymphadenectomy even for cN0 iCCA. Since patients with no chronic liver disease and with less-advanced tumors receive a significant benefit from lymphadenectomy, our results might guide decision making in patients at high-risk of postoperative complications.

Ileal Pouch-anal Anastomosis in Primary Sclerosing Cholangitis-inflammatory Bowel Disease (PSC-IBD): Long-term Pouch and Liver Transplant Outcomes.

OBJECTIVE: To compare the effect of liver transplantation (LT) on ileal pouch-anal anastomosis (IPAA) outcomes in patients with primary sclerosing cholangitis and inflammatory bowel disease (PSC-IBD). BACKGROUND: Patients with PSC-IBD may require both IPAA for colitis and LT for PSC. METHODS: Patients with PSC-IBD from out institutional pouch registry (1985-2022) were divided according to LT status and timing of LT (before and after IPAA) and their outcomes analyzed. RESULTS: A total of 160 patients were included: 112 (70%) nontransplanted at last follow-up; 48 (30%) transplanted, of which 23 (14%) before IPAA and 25 (16%) after. Nontransplanted patients at IPAA had more laparoscopic procedures [37 (46%) vs 8 (18%), P =0.002] and less blood loss (median 250 vs 400 mL, P =0.006). Morbidity and mortality at 90 days were similar. Chronic pouchitis was higher in transplanted compared with nontransplanted patients [32 (67%) vs 51 (45.5%), P =0.03], but nontransplanted patients had a higher rate of chronic antibiotic refractory pouchitis. Overall survival was similar, but nontransplanted patients had more PSC-related deaths (12.5% vs 2%, P =0.002). Pouch survival at 10 years was 90% for nontransplanted patients and 100% for transplanted patients (log-rank P =0.052). Timing of LT had no impact on chronic pouchitis, pouch failure, or overall survival. PSC recurrence was 6% at 10 years. For transplanted patients, graft survival was similar regardless of IPAA timing. CONCLUSIONS: In patients with PSC-IBD and IPAA, LT is linked to an increased pouchitis rate but does not affect overall and pouch survival. Timing of LT does not influence short-term and long-term pouch outcomes.

Combined Liver Transplant and Cardiac Surgery: Long-Term Outcomes and Predictors of Success.

OBJECTIVE: We aim to report our institutional outcomes of single-staged combined liver transplantation (LT) and cardiac surgery (CS). SUMMARY BACKGROUND DATA: Concurrent LT and CS is a potential treatment for combined cardiac dysfunction and end-stage liver disease, yet only 54 cases have been previously reported in the literature. Thus, the outcomes of this approach are relatively unknown, and this approach has been previously regarded as extremely risky. METHODS: Thirty-one patients at our institution underwent combined cardiac surgery and liver transplant. Patients with at least one-year follow-up were included. The Leave-One-Out Cross-Validation (LOOCV) machine-learning approach was used to generate a model for mortality. RESULTS: Median follow-up was 8.2 years (IQR 4.6-13.6 y). One- and five-year survival was 74.2% (N=23) and 55% (N=17), respectively. Negative predictive factors of survival included recipient age>60 years (P=0.036), NASH-cirrhosis (P=0.031), Coronary Artery Bypass-Graft (CABG)-based CS (P=0.046) and pre-operative renal dysfunction (P=0.024). The final model demonstrated that renal dysfunction had a relative weighted impact of 3.2 versus CABG (1.7), age ≥60y (1.7) or NASH (1.3). Elevated LT+CS risk score was associated with an increased five-year mortality after surgery (AUC=0.731, P=<0.001). Conversely, the widely accepted STS-PROM calculator was unable to successfully stratify patients according to 1- (P>0.99) or 5-year (P=0.695) survival rates. CONCLUSIONS: This is the largest series describing combined LT+CS, with joint surgical management appearing feasible in highly selected patients. CABG and pre-operative renal dysfunction are important negative predictors of mortality. The four-variable LT+CS score may help predict patients at high risk for post-operative mortality.

Impact of Indocyanine Green Fluorescence Imaging on Lymphadenectomy Quality During Laparoscopic Distal Gastrectomy for Gastric Cancer (Greeneye): An Adaptative, Phase 2, Clinical Trial.

BACKGROUND: Indocyanine green (ICG)-guided lymphadenectomy using near-infrared visualization (NIR) may increase nodal yield during gastrectomy. The purpose of this study was to evaluate the clinical benefit of NIR visualization on the quality of D2 lymphadenectomy during laparoscopic distal gastrectomy. METHODS: This single-arm, open-label, Simon's two-stage, adaptive, phase 2 trial included patients who underwent laparoscopic distal gastrectomy for gastric adenocarcinoma. Endoscopic peritumoral injection of ICG was performed 24 ± 6 h before surgery. Intraoperatively, after standard D2 lymphadenectomy and specimen extraction, NIR was used for eventual completion lymphadenectomy. The primary endpoint was clinical benefit of NIR (i.e., at least one additional harvested station containing lymph nodes, with negative points for every harvested station with no lymph nodes at final pathology). RESULTS: We enrolled 18 patients (61% female, median age 69 years). With NIR, an extra 23 stations were harvested: 9 contained no lymph nodes, 12 contained nonmetastatic lymph nodes, and 2 contained metastatic lymph nodes. The most commonly visualized station with NIR were station 6 (8 patients) and 1 (4 patients). The total number of harvested nodes per patient was 32 (interquartile range [IQR] 26-41), with a median of 1 (IQR 0-1) additional lymph node after NIR. Overall, seven (39%) patients had a clinical benefit from NIR, of which two (11%) had one metastatic lymph node harvested with NIR. CONCLUSIONS: NIR visualization improves the quality of D2 lymphadenectomy in distal gastrectomy for gastric cancer. Considering the limited improve in the number of harvested lymph nodes, its real oncological benefit is still questionable.

Gracilis Muscle Interposition for the Treatment of Rectovaginal Fistula: A Systematic Review and Pooled Analysis.

BACKGROUND: A rectovaginal fistula is a debilitating condition that often severely impacts quality of life. Despite many treatment options available, the best surgical treatment is far from being established, and many patients will undergo several procedures before fistula closure is achieved. Gracilis muscle interposition, which is the transposition of the gracilis muscle into the rectovaginal septum, is an option for complex and persistent fistulas, but literature on the subject is scarce, mainly consisting of small case series. OBJECTIVE: This study aimed to assess the success rate of gracilis muscle interposition for the surgical treatment of rectovaginal fistula. DATA SOURCES: MEDLINE, Embase, Cochrane Library, and Web of Science. STUDY SELECTION: Studies comprising at least 5 patients who underwent gracilis muscle interposition for rectovaginal fistula were included. No date or language restrictions was applied. INTERVENTION: Gracilis muscle interposition. MAIN OUTCOME MEASURES: The primary outcome is the fistula closure rate (%). Other domains analyzed are stoma closure rate, postoperative complications, quality of life, fecal continence, and sexual function. RESULTS: Twenty studies were included for a total of 384 patients. The pooled fistula closure rate for gracilis muscle interposition was 64% (95% CI, 53%-74%; range, 33%-100%). Risk factors for failure were smoking, underlying Crohn's disease, and more than 2 previous repairs, whereas stoma formation was associated with improved outcomes. Postoperative complications ranged from 0% to 37%, mostly related to surgical site occurrences at the harvest site and perineal area. No deaths occurred. Gracilis muscle interposition improved quality of life and fecal continence, but impairment of sexual function was common. LIMITATIONS: Most of the included studies were small case series. CONCLUSIONS: Gracilis muscle interposition is a safe and moderately effective treatment that could be taken into consideration as second- or third-line therapy for recurrent rectovaginal fistula. REGISTRATION NO: CRD42022319621.

Assessing prognostic factors of long-term survival after surgery for colorectal gastrointestinal stromal tumours.

AIM: Due to their rarity, the management of colorectal gastrointestinal stromal tumours (CR GISTs) is still under debate. The aim of this study was to assess prognostic factors. METHOD: We performed a retrospective review of patients who underwent surgery with curative intent for CR GIST at our centre from 2002 to 2019. Factors associated with overall (OS) and recurrence-free survival (RFS) were analysed. RESULTS: Fifty-six patients were included [median age 63 years, 29 (52%) female, 30 (54%) Miettinen high-risk, 40 (71%) with rectal GIST]. Nineteen (34%) patients received perioperative (neoadjuvant and/or adjuvant) imatinib. All cases of colonic GIST had an R0 resection, compared with 28 (70%) of rectal GISTs. After a median follow-up of 97 months (interquartile range 48-155 months), 14 (25%) deaths and 14 (25%) recurrences occurred. In the high-risk cohort, factors associated with improved RFS were R0 resection (OR 0.19, 95% CI 0.1-0.5, p = 0.002) and perioperative imatinib (OR 0.33, 95% CI 0.42-0.97, p = 0.04). Patients who had received perioperative imatinib had longer RFS (60% vs. 11% at 5 years, p = 0.006) but not OS. In rectal GISTs, 5-year OS was 85% for R0 and 70% for R1 resections (p = 0.164) and 5-year RFS was 85% for R0 and 12% for R1 resection (p < 0.001). When stratifying patients by perioperative imatinib, there were no differences in OS or RFS in the R0 or R1 groups. CONCLUSION: Perioperative imatinib and R0 resection were associated with improved RFS in high-risk patients with CR GIST. In patients with rectal GIST, R1 resection was associated with worse RFS irrespective of perioperative imatinib treatment.

Patient-Reported Outcomes in Colorectal Surgery.

Given the increased life expectancy and improvements in the treatment of colorectal patients, the success of a treatment course can no longer be determined only by objective outcomes. Health care providers ought to take into consideration the impact an intervention will have on the quality of life of patients. Endpoints that take into account the patient's perspective are defined as patient-reported outcomes (PROs). PROs are assessed through patient-reported outcome measures (PROMs), usually in the form of questionnaires. PROs are especially important in colorectal surgery, whose procedures can often be associated with some degree of postoperative functional impairment. Several PROMs are available for colorectal surgery patients. However, while some scientific societies have offered recommendations, there is no standardization in the field and PROMs are seldom implemented in clinical practice. The routine use of validated PROMs can guarantee that functional outcomes are followed over time; this way, they can be addressed in case of worsening. This review will provide an overview of the most commonly used PROMs in colorectal surgery, both generic and disease specific, as well as a summary of the available evidence in support of their routine utilization.

Long-term outcomes of resection versus transplantation for neuroendocrine liver metastases meeting the Milan criteria.

Liver resection (LR) is considered the treatment of choice for resectable neuroendocrine liver metastases (NELM), while liver transplantation (LT) is currently reserved for highly selected unresectable patients. We retrospectively analyzed data from consecutive patients undergoing either curative resection or transplantation for liver-only NELM meeting Milan criteria at a single center between 1984 and 2019. Patients who fit Milan criteria were 48 in the transplantation group and 56 in the resection group. After a median follow-up of 158 months for the transplantation group and 126 for the resection group, the 10-year survival rate was 93% for transplantation and 75% for resection (p = .007). The 10-year disease-free survival rate was 52% for transplantation and 18% for resection (p < .001). Transplantation was associated with improved survival at univariate analysis. The median disease-free interval between surgery and recurrence was 78 months for transplantation vs. 24 months for resection (p < .001). The transplantation group had more multisite recurrences (12/25, 48% vs. 5/42, 12% in the resection group, p = .001), while most recurrences in the resection group were intra-hepatic (37/42, 88%, versus 2/25, 8% in the transplantation group). In conclusion, LT was associated with improved survival outcomes in NELM meeting the Milan criteria compared with LR.

Impact of Surgical Margins on Overall Survival after Gastrectomy for Gastric Cancer: A Validation of Japanese Gastric Cancer Association Guidelines on a Western Series.

PURPOSE: No consensus exists on the resection extent needed to ensure oncological safety in gastrectomy for gastric adenocarcinoma (GAC). This study aims to assess the impact of margin adequacy according to Japanese Gastric Cancer Association (JGCA) guidelines on overall survival (OS). PATIENTS AND METHODS: Patients who underwent surgery for stage I-III GAC at our institution between 2010 and 2017 were included. Margin adequacy according to JGCA, National Comprehensive Cancer Network (NCCN), and European Society for Medical Oncology (ESMO) guidelines was assessed, and their predictive value on OS was evaluated with Harrell's C-index. Patients were analyzed according to their margins' adherence to JGCA guidelines, and a propensity score matching (PSM) was run. Indication to either total gastrectomy (TG) or distal gastrectomy (DG) according to each guideline was also assessed. RESULTS: A total of 279 patients were included, of whom 220 (79%) underwent DG. Adequate margins according to JGCA were obtained in 209 patients (75%). On multivariate analysis, JGCA margin adequacy was independently associated with OS, together with American Society of Anesthesiologist class, neoadjuvant chemotherapy, lymphadenectomy extent, R0 resection, and postoperative N stage. After PSM, patients with JGCA adequate margins showed better OS, recurrence-free survival (RFS), and local RFS than patients with JGCA inadequate margins. For 220 DG, JGCA guidelines would have recommended TG in 25 patients (11%), NCCN in 30 (14%), and ESMO in 90 (41%) (p < 0.001). CONCLUSION: Adequacy of surgical resection margins to JGCA guidelines leads to improved survival outcomes and allows for a more organ-preserving approach than Western guidelines.

Laparoscopic ventral hernia repair in patients with obesity: should we be scared of body mass index?

BACKGROUND: Obesity is a risk factor for ventral hernia development and affects up to 60% of patients undergoing ventral hernia repair. It is also associated with a higher rate of surgical site occurrences and an increased risk of recurrence after ventral hernia repair, but data is lacking on the differences between obesity classes. METHODS: Between 2008 and 2018, 322 patients with obesity underwent laparoscopic ventral hernia repair in our department: class I n = 231 (72%), II n = 55 (17%), III n = 36 (11%). We compared short and long-term outcomes between the three classes. RESULTS: Patients with class III obesity had a longer median length of hospital stay compared to I and II (5 days versus 4 days in the other groups, p = 0.0006), but without differences in postoperative complications or surgical site occurrences. After a median follow up of 49 months, there were no significant differences in the incidence of seroma, recurrence, chronic pain, pseudorecurrence and port-site hernia. At multivariate analysis, risk factors for recurrence were presence of a lateral defect and previous hernia repair; risk factors for seroma were immunosuppression, defect > 15 cm and more than one previous hernia repair; the only risk factor for postoperative complications was chronic obstructive pulmonary disease. CONCLUSION: Class III obesity is associated with longer length of hospital stay after laparoscopic ventral hernia repair, but without differences in postoperative complications and long-term outcomes compared with class I and class II obesity.

Laparoscopic complete mesocolic excision versus conventional resection for right-sided colon cancer: a propensity score matching analysis of short-term outcomes.

BACKGROUND: Complete mesocolic excision (CME) for right-sided colon cancer (RCC) is a demanding operation, especially when performed laparoscopically. The potential impact of CME in increasing postoperative complications is still unclear. The aim of our study was to evaluate the safety and feasibility of laparoscopic CME compared with laparoscopic non-complete mesocolic excision (NCME) during colectomy for RCC. METHODS: Data from a prospectively collected database of patients who underwent laparoscopic right and extended right colectomy at our institution between January 2008 and February 2020 were retrieved and analyzed. Short-term outcomes of patients undergoing CME and NCME were compared. A 1:1 propensity score matching (PSM) was used to balance baseline characteristics between groups. RESULTS: A total of 663 consecutive patients underwent resection of RCC in the study period. Among these, 500 met the inclusion criteria and after PSM a total of 372 patients were correctly matched, 186 in each group. A similar rate of overall postoperative complications was found between the CME and NCME groups (21.5% and 18.3%, p = 0.436). No difference was found in terms of conversion rate, severe complications, reoperations, readmissions, and mortality. The median number of harvested lymph nodes was higher in the CME group (22 versus 19, p = 0.003), with a lower rate of inadequate sampling (7.0% and 15.1%, p = 0.013). CONCLUSION: Laparoscopic CME for RCC is technically feasible and safe. It does not seem to be associated with a higher rate of complications or mortality compared with the "traditional" approach, but it allows better nodal sampling.

Is routine CT scan after pancreaticoduodenectomy a useful tool in the early detection of complications? A single center retrospective analysis.

PURPOSE: The clinical impact of routine CT imaging after pancreaticoduodenectomy (PD) has not been properly investigated. The aim of this study was to investigate the role of routine CT scan after PD for the detection of postoperative complications. METHODS: Prospectively collected data of consecutive patients undergoing PD and receiving routine postoperative CT imaging were retrospectively analyzed. The primary endpoint was accuracy of CT imaging in identifying major complications. The secondary endpoint was identification of preoperative and intraoperative factors associated with severe complications. A subgroup analysis of CT scan accuracy in identifying severe complications in patients stratified by fistula risk score (FRS) and presence of early clinical alterations was also performed. RESULTS: A total of 145 patients were included. Routine CT scan had low specificity (Sp = 0.36) and high sensitivity (Sn = 0.98) for predicting major complications, with an accuracy of 0.57. At multivariate logistic regression analysis, only fistula moderate-high FRS (p = 0.029) was independently associated with severe complications. In patients with negligible-low FRS, CT scan showed a Sp of 0.63 and a Sn of 1.0 with an accuracy of 0.69. In patients with moderate-high FRS, CT scan had a Sp of 0.19, a Sn of 0.97 and an accuracy of 0.5. In the 20 (14%) patients with negligible-low FRS and no clinical alterations, no deaths or readmissions occurred regardless of CT findings, while one severe complication occurred in the positive CT scan group. In all other groups, no deaths or readmissions occurred in case of negative CT, with only one severe complication in the moderate-high FRS group with clinical alterations. In case of positive CT, the rate of severe complications was 47% in case of negligible-low FRS and clinical alterations, 40% in case of moderate-high FRS with no clinical alterations, and 45% in case of moderate-high FRS and clinical alterations. CONCLUSIONS: Routine postoperative CT scan after PD should not be performed in patients with negligible-low FRS and no clinical alterations. In all other patients, a negative CT scan appears to be highly accurate in identifying patients who will have an uneventful course and who could benefit from early discharge.