Textbook outcome in short bowel syndrome.

BACKGROUND: Textbook outcome (TO) is a single composite score representing ideal care for a procedure or medical condition. Short bowel syndrome (SBS) patients are at high risk for complications and death. Our aim was to determine the incidence of and predictive factors for a TO in SBS patients. METHODS: 515 adults with SBS were followed for 12 months after initial hospital discharge for SBS. TO was defined based on eight outcome parameters. Demographic data, intestinal anatomy, and nutritional outcome were compared in patients with and without TO. RESULTS: 78 (15 â€‹%) patients had a TO. The frequency of the different components of TO were: PN â€‹< â€‹1 year (39 â€‹%), BMI >18.5 â€‹kg/m2 (89 â€‹%), no stoma (59 â€‹%), no surgical intervention (71 â€‹%), no hospital readmission (56 â€‹%), no vascular access infection (62 â€‹%), absence of end stage liver disease (96 â€‹%), and survival (97 â€‹%). Intestinal remnant length and anatomy type were predictive of a TO. CONCLUSIONS: A TO is achieved in 15 â€‹% SBS patients using the selected criteria. This is largely attributable to continued need for PN. Intestinal length and anatomy were independent predictors of TO.

Ursodiol Prophylaxis in Recipients of Liver Transplant From Donors After Cardiac Death.

OBJECTIVES: This study aimed to assess the efficacy of ursodiol in preventing biliary complications after transplant of livers from donors after cardiac death. MATERIALS AND METHODS: This was a single-center, nonrandomized, retrospective study that evaluated biliary complication rates in patients who received ursodiol (13-15 mg/kg/day) for 30 days (n = 32; post-ursodiol group) compared with patients who did not receive ursodiol after liver transplant from a cardiac death donor (n = 36; pre-ursodiol group [before introduction of ursodiol in the prophylaxis regimen]). Data were collected from September 2012 to September 2021. Patients were included if they were at least 19 years old and received a liver transplant from a donor after cardiac death. The primary endpoint of this study was to determine whether ursodiol decreased biliary complications within 30 days posttransplant. Secondary endpoints included change in biochemical serum liver tests (aspartate aminotransferase, alanine amino-transferase, total bilirubin, and alkaline phosphatase) and time to identification of hepatobiliary complications at posttransplant days 7, 14, and 28, acute graft loss, biopsy-proven acute rejection, and patient survival at 1 and 6 months. RESULTS: Biliary complications were similar between groups. Four patients (12.5%) experienced biliary complications in the post-ursodiol group versus 1 patient (2.9%) in the pre-ursodiol group (not significant, P = .19). Biochemical liver enzymes at days 7, 14, and 28 were also not significant different between groups. Acute graft loss, biopsy-proven acute rejection, and patient survival at 1 and 6 months were similar between the 2 groups. CONCLUSIONS: Ursodiol prophylaxis did not show a diffrence in preventing biliary complications for recipients of liver transplant from donors after cardiac death.

American Society of Transplant Surgeons Normothermic Regional Perfusion Standards: Ethical, Legal, and Operational Conformance.

BACKGROUND: The American Society of Transplant Surgeons convened a multidisciplinary working group to address operational, ethical, and legal considerations surrounding normothermic regional perfusion (NRP) procurement. METHODS: The working group, comprising members from American Society of Transplant Surgeons and AST across various disciplines including transplant surgery, hepatology, critical care, and bioethics, collaborated to formulate recommendations and guidance for NRP procurement. RESULTS: The following topics were identified by the group as essential standards that need to be addressed for ethical, legal, and operational conformance: terminology; conceptualization of death in the context of NRP; and communication, logistics, and training and competency. CONCLUSIONS: Fourteen recommendations that support the ethical and legal acceptability of NRP in the United States and set expectations for the conduct of NRP procedures are provided.

Liver Transplant Costs and Activity After United Network for Organ Sharing Allocation Policy Changes.

Importance: A new liver allocation policy was implemented by United Network for Organ Sharing (UNOS) in February 2020 with the stated intent of improving access to liver transplant (LT). There are growing concerns nationally regarding the implications this new system may have on LT costs, as well as access to a chance for LT, which have not been captured at a multicenter level. Objective: To characterize LT volume and cost changes across the US and within specific center groups and demographics after the policy implementation. Design, Setting, and Participants: This cross-sectional study collected and reviewed LT volume from multiple centers across the US and cost data with attention to 8 specific center demographics. Two separate 12-month eras were compared, before and after the new UNOS allocation policy: March 4, 2019, to March 4, 2020, and March 5, 2020, to March 5, 2021. Data analysis was performed from May to December 2022. Main Outcomes and Measures: Center volume, changes in cost. Results: A total of 22 of 68 centers responded comparing 1948 LTs before the policy change and 1837 LTs postpolicy, resulting in a 6% volume decrease. Transplants using local donations after brain death decreased 54% (P < .001) while imported donations after brain death increased 133% (P = .003). Imported fly-outs and dry runs increased 163% (median, 19; range, 1-75, vs 50, range, 2-91; P = .009) and 33% (median, 3; range, 0-16, vs 7, range, 0-24; P = .02). Overall hospital costs increased 10.9% to a total of $46 360 176 (P = .94) for participating centers. There was a 77% fly-out cost increase postpolicy ($10 600 234; P = .03). On subanalysis, centers with decreased LT volume postpolicy observed higher overall hospital costs ($41 720 365; P = .048), and specifically, a 122% cost increase for liver imports ($6 508 480; P = .002). Transplant centers from low-income states showed a significant increase in hospital (12%) and import (94%) costs. Centers serving populations with larger proportions of racial and ethnic minority candidates and specifically Black candidates significantly increased costs by more than 90% for imported livers, fly-outs, and dry runs despite lower LT volume. Similarly, costs increased significantly (>100%) for fly-outs and dry runs in centers from worse-performing health systems. Conclusions and Relevance: Based on this large multicenter effort and contrary to current assumptions, the new liver distribution system appears to place a disproportionate burden on populations of the current LT community who already experience disparities in health care. The continuous allocation policies being promoted by UNOS could make the situation even worse.

Considerations for the use of porcine organ donation models in preclinical organ donor intervention research.

Use of animal models in preclinical transplant research is essential to the optimization of human allografts for clinical transplantation. Animal models of organ donation and preservation help to advance and improve technical elements of solid organ recovery and facilitate research of ischemia-reperfusion injury, organ preservation strategies, and future donor-based interventions. Important considerations include cost, public opinion regarding the conduct of animal research, translational value, and relevance of the animal model for clinical practice. We present an overview of two porcine models of organ donation: donation following brain death (DBD) and donation following circulatory death (DCD). The cardiovascular anatomy and physiology of pigs closely resembles those of humans, making this species the most appropriate for pre-clinical research. Pigs are also considered a potential source of organs for human heart and kidney xenotransplantation. It is imperative to minimize animal loss during procedures that are surgically complex. We present our experience with these models and describe in detail the use cases, procedural approach, challenges, alternatives, and limitations of each model.

US Liver Transplant Outcomes After Normothermic Regional Perfusion vs Standard Super Rapid Recovery.

Importance: Normothermic regional perfusion (NRP) is an emerging recovery modality for transplantable allografts from controlled donation after circulatory death (cDCD) donors. In the US, only 11.4% of liver recipients who are transplanted from a deceased donor receive a cDCD liver. NRP has the potential to safely expand the US donor pool with improved transplant outcomes as compared with standard super rapid recovery (SRR). Objective: To assess outcomes of US liver transplants using controlled donation after circulatory death livers recovered with normothermic regional perfusion vs standard super rapid recovery. Design, Setting, and Participants: This was a retrospective, observational cohort study comparing liver transplant outcomes from cDCD donors recovered by NRP vs SRR. Outcomes of cDCD liver transplant from January 2017 to May 2023 were collated from 17 US transplant centers and included livers recovered by SRR and NRP (thoracoabdominal NRP [TA-NRP] and abdominal NRP [A-NRP]). Seven transplant centers used NRP, allowing for liver allografts to be transplanted at 17 centers; 10 centers imported livers recovered via NRP from other centers. Exposures: cDCD livers were recovered by either NRP or SRR. Main Outcomes and Measures: The primary outcome was ischemic cholangiopathy (IC). Secondary end points included primary nonfunction (PNF), early allograft dysfunction (EAD), biliary anastomotic strictures, posttransplant length of stay (LOS), and patient and graft survival. Results: A total of 242 cDCD livers were included in this study: 136 recovered by SRR and 106 recovered by NRP (TA-NRP, 79 and A-NRP, 27). Median (IQR) NRP and SRR donor age was 30.5 (22-44) years and 36 (27-49) years, respectively. Median (IQR) posttransplant LOS was significantly shorter in the NRP cohort (7 [5-11] days vs 10 [7-16] days; P < .001). PNF occurred only in the SRR allografts group (n = 2). EAD was more common in the SRR cohort (123 of 136 [56.1%] vs 77 of 106 [36.4%]; P = .007). Biliary anastomotic strictures were increased 2.8-fold in SRR recipients (7 of 105 [6.7%] vs 30 of 134 [22.4%]; P = .001). Only SRR recipients had IC (0 vs 12 of 133 [9.0%]; P = .002); IC-free survival by Kaplan-Meier was significantly improved in NRP recipients. Patient and graft survival were comparable between cohorts. Conclusion and Relevance: There was comparable patient and graft survival in liver transplant recipients of cDCD donors recovered by NRP vs SRR, with reduced rates of IC, biliary complications, and EAD in NRP recipients. The feasibility of A-NRP and TA-NRP implementation across multiple US transplant centers supports increasing adoption of NRP to improve organ use, access to transplant, and risk of wait-list mortality.

Improved Early Post-Transplant Outcomes and Organ Use in Kidney Transplant Using Normothermic Regional Perfusion for Donation after Circulatory Death: National Experience in the US.

BACKGROUND: Normothermic regional perfusion (NRP) is a technique that is intended to enhance organ transplant outcomes from donation circulatory death (DCD) donors. STUDY DESIGN: A retrospective analysis of data from the Scientific Registry of Transplant Recipients was performed. DCD donors were screened for inclusion based on date of donation 2020 or later, and whether the heart was also recovered for transplantation. We grouped donors as either donation after brain death or DCD. DCD donors were further divided into groups including those in which the heart was not recovered for transplant (Non-Heart DCD) and those in which it was, based on recovery technique (thoracoabdominal-NRP [TA-NRP] Heart DCD and Super Rapid Recovery Heart DCD). RESULTS: A total of 219 kidney transplant recipients receiving organs from TA-NRP Heart DCD donors were compared to 436 SRR Super Rapid Recovery DCD, 10,630 Super Rapid Recovery non-heart DCD, and 27,820 donations after brain death recipients. Kidney transplant recipients of TA-NRP DCD allografts experienced shorter length of stay, lower rates of delayed graft function, and lower serum creatinine at the time of discharge when compared with recipients of other DCD allografts. CONCLUSIONS: Our analysis demonstrates superior early kidney allograft function when TA-NRP is used for DCD organ recovery.

Evaluation of serial monitoring of donor-specific antibodies in pediatric and adult intestinal/multivisceral transplant recipients.

BACKGROUND: The study purpose was to add to limited literature assessing anti-HLA donor-specific antibody (DSA) appearance, clearance, specificity, and impact in intestinal/multivisceral (MV) transplant as well as the value of serial monitoring following an institutional protocol shift implementing serial monitoring. METHODS: This single-center retrospective review included intestinal/MV recipients transplanted 1/1/15-9/31/17 with completed DSA testing. Patients were divided into groups based on DSA presence post-transplant. The primary outcome was biopsy-proven acute rejection (BPAR). Secondary outcomes included graft loss and death. Descriptive analysis of DSA was completed. RESULTS: Of the 35 intestinal/MV recipients (60% pediatric) with DSA testing, 24 patients had post-transplant DSA. Fifteen patients in the DSA(+) group had T-cell-mediated BPAR versus five in the DSA(-) group (63% vs 45%, p = .47). Days to BPAR were 25 [IQR 19-165] (DSA(+) group) versus 232 [IQR 25.5-632.5] (DSA(-) group) (p = .066). There were no differences between groups for graft loss or death. One hundred and five DSA were identified in the DSA(+) group with 63% being class II, and 54% cleared during follow-up. DSA were directed against 50 different HLA alleles, with the most common being directed against HLA- DQ (35%). Time to first DSA and to clearance did not differ between class I and II. CONCLUSION: Findings confirm previous data that suggest post-transplant DSA in this population may lead to increased BPAR or shorter time to BPAR, although not statistically significant. Most DSA were identified within the first month after transplant, and ahead of rejection identification on biopsy. DSA therefore may have utility as an early rejection biomarker and use may be considered in place of early protocol biopsies, particularly in pediatric patients. We identified novel findings of DSA directed against a large breadth of HLA in intestinal/MV patients.

Evaluation of Medicare Reimbursement and Surgical Patterns for Male and Female Colorectal Surgeons.

INTRODUCTION: There are documented differences in salary for male and female surgeons. Understanding the differences in the clinical practice, composition of male and female surgeons may provide a better understanding of reimbursement differences. We aim to evaluate the differences of Medicare reimbursement for different categories of clinical practice for male and female colorectal surgeons. METHODS: This retrospective cohort study compared Medicare claims made by male and female board-certified colorectal surgeons from the Medicare Provider Utilization and Payment Data between 2013 and 2017. Medicare claims were categorized by surgeon gender. Submitted claims were evaluated based on the following seven procedure categories: open abdominal surgery, laparoscopic abdominal surgery, anorectal surgery, diagnostic endoscopy, therapeutic endoscopy, and inpatient/outpatient services. The main outcomes were number of charges submitted by clinical activity category and procedural code variation billed through Medicare. Secondary outcome was category of procedure activity that each surgeon cohort had participated in. RESULTS: A total of 62,866 claims were reviewed, of which 10,058 (16.0%) were made by female surgeons and 52,808 (84.0%) were made by male surgeons. On average, male surgeons submitted more claims per year, a greater variety of claims per year, and higher revenue generating claims than female surgeons (P < 0.001). CONCLUSIONS: Male and female colorectal surgeons may participate in different categories of clinical activities that result in male surgeons performing more and higher relative value units-generating activity than female surgeons.

Kidney injury and status 1 liver transplantation: Outcomes, kidney function, and listing for kidney transplantation.

BACKGROUND: Effects of kidney injury (KI) at the time of liver transplantation (LT) for acute liver failure (ALF) remain poorly described. We hypothesized that patients with ALF and KI who undergo LT have persistent post-transplant KI, inferior survival, and increased rate of kidney transplantation (KT). METHODS: The US Scientific Registry of Transplant Recipients database was queried for patients transplanted with status 1 listing for LT between 2002 and 2021. KI was defined as estimated glomerular filtration rate (eGFR) ≤ 30 mL/min/1.73 m2 or dialysis in the week prior to LT. Outcomes evaluated were post-LT eGFR, listing for subsequent KT, and overall survival (OS) after LT. RESULTS: A total of 2984 patients underwent LT for ALF with 1241 (41.6%) having KI. KI patients had lower eGFR at 6 months post-LT (57.8 vs. 68.7, p < .001) that persisted out to 5 years (59.9 vs. 69.7, p < .001). KI patients were more likely to be listed for KT (4.3% vs. 1.9%, p < .001) and undergo listing sooner after LT (.8 vs. 3.7 years, p < .001). Patients without KI had higher adjusted post-transplant OS compared to those with KI (HR .75, p < .001). CONCLUSION: KI in the setting of ALF portends a worse prognosis for both kidney recovery and OS.

Cholecystectomy prior to short bowel syndrome does not alter nutritional prognosis.

BACKGROUND: Previous cholecystectomy is common in patients with short bowel syndrome (SBS). An intact gallbladder is beneficial in preventing cirrhosis in SBS patients, but the nutritional consequences of cholecystectomy are largely unknown. Our aim was to evaluate the effect of pre-SBS cholecystectomy on need for chronic parenteral nutrition (PN). METHODS: We reviewed 485 adults with SBS: 267 underwent cholecystectomy prior to SBS and 218 patients had an intact gallbladder. Demographic data, intestinal anatomy, and nutritional outcome were compared. RESULTS: Pre-SBS cholecystectomy patients were more likely to have had postoperative SBS and BMI >35. Intestinal remnant length and anatomy type and performance of surgical rehabilitation procedures within the first year were similar. Overall, there was no significant difference in the need for PN > 1year between the two groups. There was also no significant difference in the need for PN > 1year in any specific subgroup of intestinal remnant length or intestinal anatomy. CONCLUSIONS: Cholecystectomy performed prior to the development of SBS does not influence the nutritional prognosis of SBS, regardless of the intestinal remnant length and anatomy type.

Liver Transplantation as a New Standard of Care in Patients With Perihilar Cholangiocarcinoma? Results From an International Benchmark Study.

OBJECTIVE: To define benchmark values for liver transplantation (LT) in patients with perihilar cholangiocarcinoma (PHC) enabling unbiased comparisons. BACKGROUND: Transplantation for PHC is used with reluctance in many centers and even contraindicated in several countries. Although benchmark values for LT are available, there is a lack of specific data on LT performed for PHC. METHODS: PHC patients considered for LT after Mayo-like protocol were analyzed in 17 reference centers in 2 continents over the recent 5-year period (2014-2018). The minimum follow-up was 1 year. Benchmark patients were defined as operated at high-volume centers (≥50 overall LT/year) after neoadjuvant chemoradiotherapy, with a tumor diameter <3 cm, negative lymph nodes, and with the absence of relevant comorbidities. Benchmark cutoff values were derived from the 75th to 25th percentiles of the median values of all benchmark centers. RESULTS: One hundred thirty-four consecutive patients underwent LT after completion of the neoadjuvant treatment. Of those, 89.6% qualified as benchmark cases. Benchmark cutoffs were 90-day mortality ≤5.2%; comprehensive complication index at 1 year of ≤33.7; grade ≥3 complication rates ≤66.7%. These values were better than benchmark values for other indications of LT. Five-year disease-free survival was largely superior compared with a matched group of nodal negative patients undergoing curative liver resection (n=106) (62% vs 32%, P <0.001). CONCLUSION: This multicenter benchmark study demonstrates that LT offers excellent outcomes with superior oncological results in early stage PHC patients, even in candidates for surgery. This provocative observation should lead to a change in available therapeutic algorithms for PHC.

Presentation of preclinical gastrointestinal anatomy via laparoscopic simulation.

In this report, the authors examine the integration of teaching anatomical science with clinical implications in minimally invasive surgery. The authors hypothesized that implementation of integrated laparoscopic simulation during undergraduate medical education would improve student learning of anatomical structures from in situ, laparoscopic orientations; and subsequently improve student preparation for clinical rotations and clerkships. During the fall of 2020 and 2021, 260 (130 students/year) second year medical students at the University of Nebraska Medical Center participated in a six-week gastrointestinal curriculum. Following a traditional anatomy dissection experience, students completed a laparoscopic event consisting of narrated laparoscopic videos and hands-on laparoscopic simulation. To examine the integrated curricular event, outcome measures focused on technical performance using grasping forceps, anatomical knowledge, and perception of the educational innovation. Outcomes were analyzed via timed performance and a pre and post assessment that was designed to assess student anatomical knowledge and perception. Completion of the technical performance assessment ranged from 1 min, 17 s to 6 min. Student knowledge of anatomical structures from in situ, laparoscopic orientations following the laparoscopic simulation sessions was significantly improved (53.3% pre vs 81.0% post), and almost all students (98.9%) agreed that the simulation sessions improved their understanding of laparoscopic anatomy and procedures. This report demonstrates the implementation of a multidisciplinary, integrated simulation that satisfied basic science anatomy teaching objectives, while enhancing student enthusiasm for the content. Future studies will examine the subsequent impact of the innovation on student preparedness for clinical rotations and clerkships.

Impact of Portable Normothermic Blood-Based Machine Perfusion on Outcomes of Liver Transplant: The OCS Liver PROTECT Randomized Clinical Trial.

IMPORTANCE: Ischemic cold storage (ICS) of livers for transplant is associated with serious posttransplant complications and underuse of liver allografts. OBJECTIVE: To determine whether portable normothermic machine perfusion preservation of livers obtained from deceased donors using the Organ Care System (OCS) Liver ameliorates early allograft dysfunction (EAD) and ischemic biliary complications (IBCs). DESIGN, SETTING, AND PARTICIPANTS: This multicenter randomized clinical trial (International Randomized Trial to Evaluate the Effectiveness of the Portable Organ Care System Liver for Preserving and Assessing Donor Livers for Transplantation) was conducted between November 2016 and October 2019 at 20 US liver transplant programs. The trial compared outcomes for 300 recipients of livers preserved using either OCS (n = 153) or ICS (n = 147). Participants were actively listed for liver transplant on the United Network of Organ Sharing national waiting list. INTERVENTIONS: Transplants were performed for recipients randomly assigned to receive donor livers preserved by either conventional ICS or the OCS Liver initiated at the donor hospital. MAIN OUTCOMES AND MEASURES: The primary effectiveness end point was incidence of EAD. Secondary end points included OCS Liver ex vivo assessment capability of donor allografts, extent of reperfusion syndrome, incidence of IBC at 6 and 12 months, and overall recipient survival after transplant. The primary safety end point was the number of liver graft-related severe adverse events within 30 days after transplant. RESULTS: Of 293 patients in the per-protocol population, the primary analysis population for effectiveness, 151 were in the OCS Liver group (mean [SD] age, 57.1 [10.3] years; 102 [67%] men), and 142 were in the ICS group (mean SD age, 58.6 [10.0] years; 100 [68%] men). The primary effectiveness end point was met by a significant decrease in EAD (27 of 150 [18%] vs 44 of 141 [31%]; P = .01). The OCS Liver preserved livers had significant reduction in histopathologic evidence of ischemia-reperfusion injury after reperfusion (eg, less moderate to severe lobular inflammation: 9 of 150 [6%] for OCS Liver vs 18 of 141 [13%] for ICS; P = .004). The OCS Liver resulted in significantly higher use of livers from donors after cardiac death (28 of 55 [51%] for the OCS Liver vs 13 of 51 [26%] for ICS; P = .007). The OCS Liver was also associated with significant reduction in incidence of IBC 6 months (1.3% vs 8.5%; P = .02) and 12 months (2.6% vs 9.9%; P = .02) after transplant. CONCLUSIONS AND RELEVANCE: This multicenter randomized clinical trial provides the first indication, to our knowledge, that normothermic machine perfusion preservation of deceased donor livers reduces both posttransplant EAD and IBC. Use of the OCS Liver also resulted in increased use of livers from donors after cardiac death. Together these findings indicate that OCS Liver preservation is associated with superior posttransplant outcomes and increased donor liver use. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02522871.

Thoracoabdominal Normothermic Perfusion in Donation After Circulatory Death.

Donation after circulatory death is emerging as an alternative pathway to donation after brain death to expand the cardiac organ donor pool. We describe the surgical technique and circuit configuration for in-situ organ reperfusion with thoracoabdominal normothermic regional perfusion using portable venoarterial extracorporeal membrane oxygenation.

Successful lung transplantation with graft recovered after thoracoabdominal normothermic perfusion from donor after circulatory death.

Lung transplantation with lungs procured from donors after circulatory death (DCD) has been established as an alternative technique to traditional donation after brain death (DBD) with comparable outcomes. Recently, in situ thoracoabdominal normothermic regional perfusion (TA-NRP) has emerged as a novel technique employed in the procurement of cardiac allografts after circulatory death. TA-NRP, in contrast to ex situ machine perfusion, has the advantage of allowing in situ assessment of donor organs prior to final acceptance. However, there are some concerns that this technique may adversely impact the quality of lung allografts. Here, we present a case of a successful bilateral sequential lung transplantation in a patient with postinflammatory pulmonary fibrosis due to acute respiratory distress syndrome (ARDS), with lungs procured after normothermic in situ lung perfusion. Apart from the lungs, heart, liver, and kidneys were also successfully transplanted from this donor.

Not as Rare as Initially Described: Transplant Ureter Incarceration Within Inguinal Hernia. Two Cases, Literature Review, and Management Algorithm.

BACKGROUND: Obstructive uropathy after kidney transplant can present as acute kidney injury, urosepsis, and more rarely kidney allograft failure. We present a recent series of 2 cases and a literature review of 1 late etiology of ureteric obstruction: incarceration of the transplant ureter within an inguinal hernia. METHODS: We reviewed 2 cases of patients with ureteric incarceration in an inguinal hernia after kidney transplant and conducted a contemporary structured literature review. Relevant patient factors, management decisions, operative approaches, and clinical outcomes were abstracted and summarized. RESULTS: Two cases of ureteric involvement in an inguinal hernia from 2 institutions as well as a literature review of 14 case reports are provided. The clinical features most commonly associated with this condition were male sex, obesity, and decade or more delay between kidney transplantation and presentation. Preoperative management with nephrostomy tube with or without antegrade ureteric stent was most frequently employed. Ultimately, most patients underwent surgical hernia repair, which occasionally required additional surgery for distal ureteric resection or re-anastomosis. CONCLUSIONS: Incarceration of a transplant allograft ureter in inguinal hernia is likely not as rare as initially described, although a true incidence rate has not been established. This surgically correctible condition most frequently presents as a late complication after kidney transplantation. We present a management algorithm that can be used for the workup and treatment of patients with history of kidney transplant who present with ureteric obstruction owing to incarceration within an inguinal hernia.

Increased Morbidity and Mortality of Patients with Non-cirrhotic Portal Vein Thrombosis After Abdominal and Pelvic Surgeries: a Study of the National Inpatient Sample 2002 to 2015.

BACKGROUND: A higher rate of postoperative morbidity and mortality in patients with portal hypertension from cirrhosis is well recognized; however, the rate of postoperative morbidity and mortality among patients with portal hypertension from non-cirrhotic portal vein thrombosis (NCPVT) is largely unknown. METHOD: All adults undergoing abdominal and pelvic surgery were identified from the National Inpatient Sample database from 2002 to 2015. Patients were then categorized into three groups: non-cirrhotic non-portal vein thrombosis (NCNPVT), NCPVT, and cirrhotic portal vein thrombosis (CPVT). Inpatient mortality, type of disposition, transfusions, length of stay, postoperative complications, and total charges were compared. Logistic regression and ordinary least squares regression analyses were performed for factors associated with inpatient mortality, transfusions, surgery-related complications, and log length of stay. RESULTS: Patients with NCPVT had significantly higher inpatient mortality rates, surgery-related complications, and longer length of stays compared with patients with NCNPVT (2.64% vs. 0.34%, 10.26% vs. 3.26%, 8 vs. 2 days) but less than patients with CPVT (2.64% vs. 6.31%, 10.26% vs. 17.48%, 8 vs. 11 days). In multiple logistic regression analyses, NCPVT groups remained associated with increased inpatient mortality rate, transfusions, and postoperative complications with odds ratios of 3.71 (1.88, 7.32), 3.43 (2.54, 4.62), and 3.08 (2.16, 4.39), respectively. NCPVT was also associated with 2.4 times increased length of stay. DISCUSSION: Patients with NCPVT had significantly higher risks of postoperative morbidity and mortality than patients with NCNPVT but less than patients with CPVT. Future studies with detail regarding the characteristics of PVTs are needed to confirm the findings in this study.