Tailoring the Use of Central Pancreatectomy Through Prediction Models for Major Morbidity and Postoperative Diabetes: International Retrospective Multicenter Study.

OBJECTIVE: To develop a prediction model for major morbidity and endocrine dysfunction after CP which could help in tailoring the use of this procedure. SUMMARY BACKGROUND DATA: Central pancreatectomy (CP) is a parenchyma-sparing alternative to distal pancreatectomy for symptomatic benign and pre-malignant tumors in body and neck of the pancreas CP lowers the risk of new-onset diabetes and exocrine pancreatic insufficiency compared to distal pancreatectomy but it is thought to increase the risk of short-term complications including postoperative pancreatic fistula (POPF). METHODS: International multicenter retrospective cohort study including patients from 51 centers in 19 countries (2010-2021). Primary endpoint was major morbidity. Secondary endpoints included POPF grade B/C, endocrine dysfunction, and the use of pancreatic enzymes. Two risk model were designed for major morbidity and endocrine dysfunction utilizing multivariable logistic regression and internal and external validation. RESULTS: 838 patients after CP were included (301 (36%) minimally invasive) and major morbidity occurred in 248 (30%) patients, POPF B/C in 365 (44%), and 30-day mortality in 4 (1%). Endocrine dysfunction in 91 patients (11%) and use of pancreatic enzymes in 108 (12%). The risk model for major morbidity included male sex, age, BMI, and ASA score≥3. The model performed acceptable with an area under curve (AUC) of 0.72(CI:0.68-0.76). The risk model for endocrine dysfunction included higher BMI and male sex and performed well (AUC:0.83 (CI:0.77-0.89)). CONCLUSIONS: The proposed risk models help in tailoring the use of CP in patients with symptomatic benign and premalignant lesions in the body and neck of the pancreas and are readily available via www.pancreascalculator.com.

Prophylactic administration of alpha-blockers for the prevention of post-operative urinary retention following inguinal hernia repair: A meta-analysis of randomized control trials.

BACKGROUND: Inguinal hernia repair is a commonly performed surgical procedure performed in adult males. Urinary retention following surgery is a known complication likely due to the adrenergic over-stimulation of smooth muscles in the bladder neck and prostate. This effect could potentially be mitigated by the use of alpha-blocker medications. A meta-analysis of randomized control trials (RCTs) was performed to analyse the evidence behind the use of alpha-blockers in the prevention of post-operative urinary retention (POUR). METHODS: A comprehensive search of PubMed, Embase, MedLine and Scopus was undertaken adhering to PRISMA guidelines. RCTs using alpha-blockers as a single point intervention were included. Data were analysed using a random-effects model. Risk of Bias (ROB) was assessed according to Cochrane guidelines. RESULTS: Seven RCTs including 680 patients were included. The use of alpha-blockade reduced the incidence of urinary retention requiring catheterization (OR:0.23, 95% CI:0.07-0.70, p:0.009). No serious side-effects of alpha-blockers were reported. CONCLUSION: Alpha-blockers are a safe and effective intervention to reduce the incidence of urinary retention following inguinal hernia repair surgery.

Visceral-to-subcutaneous fat ratio exhibits strongest association with early post-operative outcomes in patients undergoing surgery for advanced rectal cancer.

AIM: Despite their promise as prognostic factors in colorectal cancer, anthropometric data are frequently contradictory or difficult to interpret, with single body-composition parameters often investigated in isolation or heterogeneous clinical cohorts used in analyses. We sought to assess a spectrum of body-composition parameters in a highly selected cohort with locally advanced rectal cancer in a bid to determine those with strongest prognostic potential in this specific setting. MATERIALS/METHODS: Between 2014 and 2020, 78 individuals received neoadjuvant chemotherapy, or chemoradiotherapy, followed by radical surgery in the treatment of locally advanced rectal adenocarcinoma at Oxford University Hospitals Trust. Demographic, treatment-related, perioperative, and short-term outcomes data were assessed. Body-composition parameters included BMI, and those derived from pre-operative computed-tomography imaging: skeletal mass index (SMI), visceral fat area (VFA), subcutaneous fat area (SFA), perinephric fat area (PFA) visceral-to-subcutaneous fat ratio (V/S), sarcopenia, and sarcopenic obesity (SO). RESULTS: Pre-operative body-composition parameters exhibited particularly strong correlation with post-operative outcomes, with VFA (p = 0.002), V/S (p = 0.019), SO (p = 0.012), and PFA (p = 0.0016) all associated with an increased length of hospital stay. Univariate and multivariate analyses demonstrated V/S to be the sole independent body-composition risk factor to be associated with an increased risk of developing Clavien-Dindo complications ≥ 2 (p = 0.033) as well as an increased length of stay (p = 0.005). CONCLUSION: Among patients with locally advanced rectal cancer, high visceral-to-subcutaneous fat ratio is the body-composition parameter most strongly associated with poor early post-operative outcomes. This should be considered in patient selection and prehabilitation protocols. WHAT DOES THIS PAPER ADD TO THE LITERATURE? : Our study demonstrates that among body composition parameters, high visceral-to-subcutaneous fat ratio is strongly associated with increased risk of post-operative complications and increased length of stay in patients undergoing surgery for advanced rectal cancer.

Laparoscopic vs. open feeding jejunostomy insertion in oesophagogastric cancer.

BACKGROUND: Jejunal feeding is an invaluable method by which to improve the nutritional status of patients undergoing neoadjuvant and surgical treatment of oesophageal malignancies. However, the insertion of a feeding jejunostomy can cause significant postoperative morbidity. The aim of this study is to compare the outcomes of patients undergoing placement of feeding jejunostomy by conventional laparotomy with an alternative laparoscopic approach. METHODS: A retrospective review of data prospectively collected at the Oxford Oesophagogastric Centre between August 2017 and July 2019 was performed including consecutive patients undergoing feeding jejunostomy insertion. RESULTS: In the study period, 157 patients underwent jejunostomy insertion in the context of oesophageal cancer therapy, 126 (80%) by open technique and 31 (20%) laparoscopic. Pre-operative demographic and nutritional characteristics were broadly similar between groups. In the early postoperative period jejunostomy-associated complications were noted in 54 cases (34.4%) and were significantly more common among those undergoing open as compared with laparoscopic insertion (38.1% vs. 19.3%, P = 0.049). Furthermore, major complications were more common among those undergoing open insertion, whether as a stand-alone or at the time of staging laparoscopy (n = 11/71), as compared with insertion at the time of oesophagectomy (n = 3/86, P = 0.011). CONCLUSIONS: This report represents the largest to our knowledge single-centre comparison of open vs. laparoscopic jejunostomy insertion in patients undergoing oesophagectomy in the treatment of gastroesophageal malignancy. We conclude that the laparoscopic jejunostomy insertion technique described represents a safe and effective approach to enteral access which may offer superior outcomes to conventional open procedures.

Human iPS derived progenitors bioengineered into liver organoids using an inverted colloidal crystal poly (ethylene glycol) scaffold.

Generation of human organoids from induced pluripotent stem cells (iPSCs) offers exciting possibilities for developmental biology, disease modelling and cell therapy. Significant advances towards those goals have been hampered by dependence on animal derived matrices (e.g. Matrigel), immortalized cell lines and resultant structures that are difficult to control or scale. To address these challenges, we aimed to develop a fully defined liver organoid platform using inverted colloid crystal (ICC) whose 3-dimensional mechanical properties could be engineered to recapitulate the extracellular niche sensed by hepatic progenitors during human development. iPSC derived hepatic progenitors (IH) formed organoids most optimally in ICC scaffolds constructed with 140 µm diameter pores coated with type I collagen in a two-step process mimicking liver bud formation. The resultant organoids were closer to adult tissue, compared to 2D and 3D controls, with respect to morphology, gene expression, protein secretion, drug metabolism and viral infection and could integrate, vascularise and function following implantation into livers of immune-deficient mice. Preliminary interrogation of the underpinning mechanisms highlighted the importance of TGFß and hedgehog signalling pathways. The combination of functional relevance with tuneable mechanical properties leads us to propose this bioengineered platform to be ideally suited for a range of future mechanistic and clinical organoid related applications.

Safety of nephrectomy in morbidly obese donors.

OBJECTIVES: To satisfy donor organ shortage, overweight and obese donors are becoming a greater proportion of the kidney donor pool. Although good safety data exist in overweight and moderately obese individuals (body mass index = 25 to 35 kg/m²), there is little information about outcomes in morbidly obese donors (body mass index ≥ 40 kg/m²). The purpose of this study was to review the experience with morbidly obese donors in a single center and assist in the discussion about the feasibility of nephrectomy in such cases. MATERIALS AND METHODS: Outcomes of nephrectomy in morbidly obese donors between January 2005 and June 2010 were reviewed retrospectively and compared with outcomes in nonobese donors. RESULTS: Of 386 nephrectomies, 7 involved morbidly obese donors. Mortality and major complication rates were low in all body mass index categories. A high incidence of minor postoperative complications was observed in the morbidly obese, with 57% morbidly obese patients requiring treatment for complications including respiratory infection, compared with 30% in nonobese donors (P < .05). There were no significant differences in mean operative time, estimated blood loss, and length of hospital stay between all body mass index categories. Limited follow-up data (mean, 20 mo) showed similar renal function parameters between groups. CONCLUSIONS: The limited data suggest that nephrectomy may be feasible in selected morbidly obese donors. Further study is needed before major conclusions can be made.