Long term outcomes of hepatic resection following orthotopic liver transplant.

BACKGROUND: Liver resection is sometimes used as a graft saving procedure following orthotopic liver transplantation. METHODS: In this single centre retrospective cohort study, 12 adult patients underwent resection over a 20 year period, including recipients of split livers and second grafts. RESULTS: Indications for resection were vascular (portal vein obstruction and hepatic artery thrombus), biliary (ischaemic cholangiopathy, chronic biliary obstruction, biliary-vascular fistula and biloma) and recurrence of disease (primary sclerosing cholangitis [PSC] and hepatocellular carcinoma [HCC]). There was no perioperative mortality. Median follow up was 89 months. At the completion of the study 40% of patients had functioning grafts. One third required retransplantation with a median 1 year 6 months post resection. Three patients were deceased (recurrent HCC n = 1, PSC n = 1 and unspecified causes n = 1). Total graft survival was 91.7% at 1 year, 73.3% at 5 years and 64.2% at 10 years. CONCLUSIONS: Liver resection following liver transplant in select patients may salvage the graft or delay the need for retransplantation.

Inter-surgeon Variability in Cystic Artery Lymph Node Excision during Laparoscopic Cholecystectomy.

Introduction Expert opinion recommends that surgeons perform a laparoscopic cholecystectomy (LC) in a standardized manner by dissecting the hepatobiliary triangle lateral to the cystic artery lymph node (LN) to minimize the rate of a major bile duct injury. Methods To determine whether surgeons performed a laparoscopic cholecystectomy in a standardized manner, the study assessed the variability in the frequency of an LN excision. All LCs that were performed at a single hospital were identified from a prospective dataset. The presence of an LN was retrospectively determined from the histology report. Results Twenty-seven surgeons were recorded to have performed 2332 laparoscopic cholecystectomies. Out of the total number of patients, 76.8% were female. The median patient age was 42.4 years. About 60.8% of the LCs were elective, while 39.2% of them were acute. Nineteen pathologists reported that in 99% of the specimens - the LN status of 1831 (78.5%) gallbladders was reported and analyzed. Overall, the LN yield per surgeon varied from 0% to 50% (mean 18.7%). Conclusion  The high inter-surgeon variability in the rate of LN excision during laparoscopic cholecystectomy shows that surgeons dissect the hepatobiliary triangle differently. The LN yield may also represent a surrogate marker of surgical technique (which is easy to measure).

Is cystic artery lymph node excision during laparoscopic cholecystectomy a marker of technique?

BACKGROUND: In order to minimize bile duct injury, experts suggest that dissection during laparoscopic cholecystectomy (LC) should be performed lateral to the lymph node (LN). This study aims to determine whether the frequency of excision of the LN is related to patient factors, disease severity or surgical difficulty. METHODS: All LCs performed or supervised by one surgeon were identified from a prospective database. The presence of LN was retrospectively determined by reviewing the gallbladder histology report. RESULTS: The LN was identified in 10.4% of 1332 cholecystectomies. The American Society of Anesthesiologists class 3 was associated with a lower rate of LN excision compared with class 1 (odds ratio: 0.36; P = 0.049) as was the presence of a senior surgical trainee (odds ratio: 0.18; P < 0.001). Rate of LN excision was independent of patient demographic and clinical characteristics, including indication for cholecystectomy, conversion to open, gallbladder perforation, cholangiography, bile duct exploration and overall surgical difficulty. CONCLUSIONS: The frequency with which the LN is excised during LC by the one surgeon is independent of the majority of clinical and surgical factors and may represent a surrogate marker of surgical technique. Whether this is related to the rate of bile duct injury remains to be determined.

Establishing a successful perioperative geriatric service in an Australian acute surgical unit.

BACKGROUND: The purpose of this study was to assess the impact of a perioperative geriatric service (PGS) in an acute surgical unit (ASU) on patient and organizational outcomes. METHODS: Single centre retrospective cohort study. Inclusion criteria were patients over the age of 65 admitted to the ASU between January and June 2014 (pre-PGS) and 2015 (post-PGS). Chart reviews were performed to identify outcomes of interest including in-hospital morbidity and mortality, length of stay (LOS), 30-day representation and mortality. RESULTS: Geriatric admissions increased by 32% over the two study periods (154 pre-PGS and 203 post-PGS). Surgical intervention increased by 11% (P = 0.01). Significantly more medical complications (14% versus 33%, P < 0.001) were identified after the implementation of the PGS. Recognition of delirium in the over 80s also increased by 57%. Rate of surgical complications was unchanged over the study (28% pre-PGS and 34% post-PGS, P = 0.6). In-hospital (<1%, P = 0.5) and 30-day mortality (<1%, P = 0.6) remained low, as did 30-day representation (10% versus 8%, P = 0.5). A trend towards decreased LOS of 1 day was identified after the implementation of the PGS (P = 0.07). CONCLUSION: This study demonstrated successful implementation of a PGS into an ASU. This multi-disciplinary approach has been effective in maintaining low numbers of surgical complications, in-hospital mortality, LOS and patient representations despite an increased number of medical complications. This likely reflects more timely recognition and intervention of medically unwell patients with the PGS.

Endometrial decidualization: a rare cause of acute appendicitis during pregnancy.

Appendicular endometriosis is a rare and poorly understood pathology that affects women in their reproductive years. In the gravid woman, ectopic endometrial tissue undergoes decidualization. This physiological process can result in acute appendicitis in exceptional cases. Here we describe a patient in her second trimester of pregnancy who presented with right iliac fossa pain and clinical, laboratory and imaging findings consistent with acute appendicitis. A laparoscopic appendectomy was performed with intraoperative findings suspicious for malignancy. Histological analysis made the surprising diagnosis of decidualized endometriosis causing luminal constriction resulting in acute appendicitis. We also detail the challenging diagnostic and management issues faced by clinicians in such cases.

Formation of functional areas in the cerebral cortex is disrupted in a mouse model of autism spectrum disorder.

BACKGROUND: Autism spectrum disorders (ASD) are a group of poorly understood behavioural disorders, which have increased in prevalence in the past two decades. Animal models offer the opportunity to understand the biological basis of these disorders. Studies comparing different mouse strains have identified the inbred BTBR T + tf/J (BTBR) strain as a mouse model of ASD based on its anti-social and repetitive behaviours. Adult BTBR mice have complete agenesis of the corpus callosum, reduced cortical thickness and changes in early neurogenesis. However, little is known about the development or ultimate organisation of cortical areas devoted to specific sensory and motor functions in these mice that may also contribute to their behavioural phenotype. RESULTS: In this study, we performed diffusion tensor imaging and tractography, together with histological analyses to investigate the emergence of functional areas in the cerebral cortex and their connections in BTBR mice and age-matched C57Bl/6 control mice. We found evidence that neither the anterior commissure nor the hippocampal commissure compensate for the loss of callosal connections, indicating that no interhemispheric neocortical connectivity is present in BTBR mice. We also found that both the primary visual and somatosensory cortical areas are shifted medially in BTBR mice compared to controls and that cortical thickness is differentially altered in BTBR mice between cortical areas and throughout development. CONCLUSIONS: We demonstrate that interhemispheric connectivity and cortical area formation are altered in an age- and region-specific manner in BTBR mice, which may contribute to the behavioural deficits previously observed in this strain. Some of these developmental patterns of change are also present in human ASD patients, and elucidating the aetiology driving cortical changes in BTBR mice may therefore help to increase our understanding of this disorder.