Cystic Lymph Node Identification Is More Reliable Than Critical View of Safety in Difficult Cholecystectomies.

BACKGROUND: The cystic lymph node (CLN) represents an anatomic safety marker and a surrogate marker of technique during laparoscopic cholecystectomy (LC). We aim to demonstrate the value of CLN in comparison to the critical view of safety (CVS) and study the effects of increasing difficulty on the 2 approaches. METHODS: A prospective study of consecutive LC was conducted. Patient demographics, type of admission, clinical presentation, operative difficulty grade, visualization of CLN, identification of CVS, operative time, and complications were recorded and analyzed. RESULTS: Of 393 LCs, half of the admissions were emergencies. Thirty-four percent had obstructive jaundice or acute cholecystitis. The CLN was visually identified in 81.7% with a small difference between operative difficulty grades 1 to 3 versus 4 to 5. Although CVS was unachievable in 62 patients, 43 (69.4%) still had an identifiable CLN. The median operating time was 68 minutes with 1 mortality but no conversions or intraoperative complications. CONCLUSIONS: Identifying the CLN during LC could compliment the CVS in avoiding major ductal injury. Dissecting lateral to the CLN to commence the process of displaying the cystic pedicle structures may be a strategy in safely achieving the CVS. During the more difficult LC where displaying the CVS is impossible, the CLN may be the key anatomic landmark.

Mortality Rates in Transplant Recipients and Transplantation Candidates in a High-prevalence COVID-19 Environment.

BACKGROUND: The risk of COVID-19 infection in transplant recipients (TRs) is unknown. Patients on dialysis may be exposed to greater risk of infection due to an inability to isolate. Consideration of these competing risks is important before restarting suspended transplant programs. This study compared outcomes in kidney and kidney/pancreas TRs with those on the waiting list, following admission with COVID-19 in a high-prevalence region. METHODS: Audit data from all 6 London transplant centers were amalgamated. Demographic and laboratory data were collected and outcomes included mortality, intensive care (ITU) admission, and ventilation. Adult patients who had undergone a kidney or kidney/pancreas transplant, and those active on the transplant waiting list at the start of the pandemic were included. RESULTS: One hundred twenty-one TRs and 52 waiting list patients (WL) were admitted to hospital with COVID-19. Thirty-six TR died (30%), while 14 WL patients died (27% P = 0.71). There was no difference in rates of admission to ITU or ventilation. Twenty-four percent of TR required renal replacement therapy, and 12% lost their grafts. Lymphocyte nadir and D-dimer peak showed no difference in those who did and did not die. No other comorbidities or demographic factors were associated with mortality, except for age (odds ratio of 4.3 [95% CI 1.8-10.2] for mortality if aged over 60 y) in TR. CONCLUSIONS: TRs and waiting list patients have similar mortality rates after hospital admission with COVID-19. Mortality was higher in older TRs. These data should inform decisions about transplantation in the COVID era.

Adverse Outcomes After Bile Spillage in Incidental Gallbladder Cancers: A Population-based Study.

OBJECTIVE: To determine the effect of bile spillage during cholecystectomy on oncological outcomes in incidental gallbladder cancers. BACKGROUND: Gallbladder cancer (GBC) is rare, but lethal. Achieving complete resection offers the best chance of survival. About 30% of GBCs are discovered incidentally after cholecystectomy for benign pathology. There is an anecdotal association between peritoneal dissemination and bile spillage during the index cholecystectomy. However, no population-based studies are available that measure the consequences of bile spillage on patient outcomes. METHODS: We conducted a retrospective cohort comparison of patients with incidental GBC. All cholecystectomies and cases of GBC in Alberta, Canada, from 2001 to 2015, were identified. GBCs discovered incidentally were included. Operative events leading to bile spillage were reviewed. Patient outcomes were compared between cases of bile spillage versus no contamination. RESULTS: In all, 115,484 cholecystectomies were performed, and a detailed analysis was possible in 82 incidental GBC cases. In 55 cases (67%), there was bile spillage during the index cholecystectomy. Peritoneal carcinomatosis occurred more frequently in those with bile spillage (24% vs 4%; P = 0.0287). Patients with bile spillage were less likely to undergo a radical re-resection (25% vs 56%; P = 0.0131) and were less likely to achieve an R0 resection margin [odds ratio 0.19, 95% confidence interval (CI) 0.06-0.55]. On Cox regression modeling, bile spillage was an independent predictor of shorter disease-free survival (hazard ratio 1.99, 95% CI 1.07-3.67). CONCLUSION: For incidentally discovered GBC, bile spillage at the time of index cholecystectomy has measureable adverse consequences on patient outcomes. Early involvement of a hepatobiliary specialist is recommended where concerning features for GBC exist.

Optimising the outcomes of index admission laparoscopic cholecystectomy and bile duct exploration for biliary emergencies: a service model.

AIMS: The rate of acute laparoscopic cholecystectomy remains low due to operational constraints. The purpose of this study is to evaluate a service model of index admission cholecystectomy with referral protocols, refined logistics and targeted job planning. METHODS: A prospectively maintained dataset was evaluated to determine the processes of care and outcomes of patients undergoing emergency biliary surgery. The lead author has maintained a 28 years prospective database capturing standard demographic data, intraoperative details including the difficulty of cholecystectomy as well as postoperative outcome parameters and follow up data. RESULTS: Over five thousand (5555) consecutive laparoscopic cholecystectomies were performed. Only patients undergoing emergency procedures (2399,43.2% of entire group) were analysed for this study. The median age was 52 years with 70% being female. The majority were admitted with biliary pain (34%), obstructive jaundice (26%) and acute cholecystitis (16%). 63% were referred by other surgeons. 80% underwent surgery within 5 days (40% within 24 h). Cholecystectomies were performed on scheduled lists (44%) or dedicated emergency lists (29%). Two thirds had suspected bile duct stones and 38.1% underwent bile duct exploration. The median operating time was 75 min, median hospital stay 7 days, conversion rate 0.8%, morbidity 8.9% and mortality rate 0.2%. CONCLUSION: Index admission cholecystectomy for biliary emergencies can have low rates of morbidity and mortality. Timely referral and flexible theatre lists facilitate the service, optimising clinical results, number of biliary episodes, hospital stay and presentation to resolution intervals. Cost benefits and reduced interval readmissions need to be weighed against the length of hospital stay per episode.

Prophylaxis of Wound Infections-antibiotics in Renal Donation (POWAR): A UK Multicentre Double Blind Placebo Controlled Randomised Trial.

BACKGROUND: Postoperative infection after hand-assisted laparoscopic donor nephrectomy (HALDN) confers significant morbidity to a healthy patient group. Current UK guidelines cite a lack of evidence for routine antibiotic prophylaxis. This trial assessed if a single preoperative antibiotic dose could reduce post HALDN infections. METHODS: Eligible donors were randomly and blindly allocated to preoperative single-dose intravenous co-amoxiclav or saline. The primary composite endpoint was clinical evidence of any postoperative infection at 30 days, including surgical site infection (SSI), urinary tract infection (UTI), and lower respiratory tract infection (LRTI). FINDINGS: In all, 293 participants underwent HALDN (148 antibiotic arm and 145 placebo arm). Among them, 99% (291/293) completed follow-up. The total infection rate was 40.7% (59/145) in the placebo group and 23% (34 of 148) in the antibiotic group (P = 0.001). Superficial SSIs were 20.7% (30/145 patients) in the placebo group versus 10.1% (15/148 patients) in the antibiotic group (P = 0.012). LRTIs were 9% (13/145) in the placebo group and 3.4% (5/148) in the antibiotic group (P = 0.046). UTIs were 4.1% (6/145) in the placebo group and 3.4% (5/148) in the antibiotic group (P = 0.72).Antibiotic prophylaxis conferred a 17.7% (95% confidence interval 7.2%-28.1%), absolute risk reduction in developing postoperative infection, with 6 donors requiring treatment to prevent 1 infection. INTERPRETATION: Single-dose preoperative antibiotic prophylaxis dramatically reduces post-HALDN infection rates, mainly impacting SSIs and LRTIs.

Laparoscopic Training Opportunities in an Emergency Biliary Service.

BACKGROUND AND OBJECTIVES: Optimizing single-session management of biliary emergencies whilst maximizing laparoscopic training opportunities is challenging. We analyzed training opportunities available in an emergency biliary department and its impact on service provision and patient outcomes. METHODS: A single surgeon's practice of 2049 emergency laparoscopic cholecystectomies and common bile duct explorations was prospectively analyzed. Training involved a modular stepwise approach incorporating access, gallbladder bed dissection, pedicle dissection, intra- corporeal tying, and cholangiogram ± common bile duct exploration. Training cases were identified, trainee involvement ascertained, and parameters predictive of a training case were established. RESULTS: Thirty percent of laparoscopic cholecystectomies were performed in part or completely by trainees, with a training component in 30% of bile duct explorations. Trainee involvement increased mean operating time by approximately 10 minutes. There was no difference in minor (5% vs 5%, P = .8) or major complications (1% vs 0.9%, P = .7) on trainee versus consultant cases. Postoperative hospital stay was greater in consultant cases (2.87 vs 4.44 days, P = .0025).Multivariate analysis identified predictors of trainee cases including lower age (OR, 1.3; 95% CI, 1.1-1.7), female sex (OR, 1.6; 95% CI, 1.3-2), normal-weight subjects (OR, 1.54; 95% CI, 1.3-1.9), lower difficulty grade (1-2) (OR, 1.8; 95% CI, 1.4-2.2), and American Society of Anesthesiologists score ≤ 2 (OR, 1.8; 95% CI, 1.4-2.4). CONCLUSIONS: Surgical training is possible in a singlesession biliary emergency service without significantly impacting theatre utilization times or early patient outcomes. Further dedicated studies will allow individual learning curves to be determined.

Insights in Transplanting Complex Pediatric Renal Recipients With Vascular Anomalies.

BACKGROUND: Children with end-stage kidney disease may have coexisting iatrogenic or congenital vascular anomalies making transplantation difficult. We describe our approach in 5 recipients with vascular anomalies and significant comorbidities, including one case of blood group incompatibility. METHODS: Five children aged 3 to 17 years (median, 7 years), weighing 14 to 34 kg (median, 18 kg) kg of whom 4 had occluded inferior vena cava or iliac veins and 2 had previous complex vascular reconstructions before transplantation for midaortic syndrome and multiple aortic aneurysms, respectively underwent renal transplantation. To establish implant feasibility surgery was commenced in 2 recipients before the donor surgery. RESULTS: There was 4 (80%) of 5 patient survival after 1 death from sepsis (with a functioning graft) and 2 cases of delayed graft function. At the latest median follow-up of 19 months, there was 100% (death-censored) renal allograft survival with estimated glomerular filtration rates (mL/min per 1.73 m) of 43 to 72 (median, 55). CONCLUSIONS: We conclude that major vascular anomalies do not necessarily preclude transplantation in complex pediatric patients and that surgical exploration of the recipient before commencing the donor surgery is valuable where feasibility and safety are uncertain. In addition, we have developed a novel classification system of congenital vascular abnormalities and propose its use in complex pediatric transplantation.

Post-listing survival for highly sensitised patients on the UK kidney transplant waiting list: a matched cohort analysis.

BACKGROUND: More than 40% of patients awaiting a kidney transplant in the UK are sensitised with human leucocyte antigen (HLA) antibodies. Median time to transplantation for such patients is double that of unsensitised patients at about 74 months. Removing antibody to perform an HLA-incompatible (HLAi) living donor transplantation is perceived to be high risk, although patient survival data are limited. We compared survival of patients opting for an HLAi kidney transplant with that of similarly sensitised patients awaiting a compatible organ. METHODS: From the UK adult kidney transplant waiting list, we selected crossmatch positive living donor HLAi kidney transplant recipients who received their transplant between Jan 1, 2007, and Dec 31, 2013, and were followed up to Dec 31, 2014 (end of study). These patients were matched in a 1:4 ratio with similarly sensitised patients cases listed for a deceased-donor transplant during that period. Data were censored both at the time of transplantation (listed only), and at the end of the study period (listed or transplant). We used Kaplan-Meier curves to compare patient survival between HLAi and the matched cohort. FINDINGS: Of 25 518 patient listings, 213 (1%) underwent HLAi transplantation during the study period. 852 matched controls were identified, of whom 41% (95% CI 32-50) remained without a transplant at 58 months after matching. We noted no difference in survival between patients who were in the HLAi group compared with the listed only group (log rank p=0·446), or listed or transplant group (log rank p=0·984). INTERPRETATION: Survival of sensitised patients undergoing HLAi in the UK is comparable with those on dialysis awaiting a compatible organ, many of whom are unlikely to be have a transplant. Choosing a direct HLAi transplant has no detrimental effect on survival, but offers no survival benefit, by contrast with similar patients studied in a North American multicentre cohort. FUNDING: UK National Health Service Blood & Transplant and Guy's & St Thomas' National Institute for Health Research Biomedical Research Centre.

Immune Desensitization Allows Pediatric Blood Group Incompatible Kidney Transplantation.

BACKGROUND: Blood group incompatible transplantation (ABOi) in children is rare as pretransplant conditioning remains challenging and concerns persist about the potential increased risk of rejection. METHODS: We describe the results of 11 ABOi pediatric renal transplant recipients in the 2 largest centers in the United Kingdom, sharing the same tailored desensitization protocol. Patients with pretransplant titers of 1 or more in 8 received rituximab 1 month before transplant; tacrolimus and mycophenolate mofetil were started 1 week before surgery. Antibody removal was performed to reduce titers to 1 or less in 8 on the day of the operation. No routine postoperative antibody removal was performed. RESULTS: Death-censored graft survival at last follow-up was 100% in the ABOi and 98% in 50 compatible pediatric transplants. One patient developed grade 2A rejection successfully treated with antithymocyte globulin. Another patient had a titer rise of 2 dilutions treated with 1 immunoadsorption session. There was no histological evidence of rejection in the other 9 patients. One patient developed cytomegalovirus and BK and 2 others EBV and BK viremia. CONCLUSIONS: Tailored desensitization in pediatric blood group incompatible kidney transplantation results in excellent outcomes with graft survival and rejection rates comparable with compatible transplants.

Fluorocholangiography: reincarnation in the laparoscopic era-evaluation of intra-operative cholangiography in 3635 laparoscopic cholecystectomies.

BACKGROUND: The introduction of laparoscopic cholecystectomy (LC) resulted in the decline of routine intra-operative cholangiography (IOC). Common bile duct stones are being diagnosed preoperatively using magnetic resonance cholangiopancreatography (MRCP). We aim to evaluate the use and benefits of IOC during laparoscopic biliary surgery at a high-volume biliary surgery unit. METHODS: Prospective data from 4088 patients undergoing LC over 22 years were analysed. Referral protocols allow one firm to receive the great majority of biliary emergencies and all suspected ductal stones. All patients with gall stones on ultrasound scanning, fit for surgery, will undergo LC during the index admission. MRCP and ERCP are not part of preoperative investigation. A four-port LC is performed with a size 5Fr ureteric catheter within an open cannula to obtain an IOC through right sub-costal port. RESULTS: Of 4088 patients, IOC was attempted in 3691 (90.2 %) and 3635 had a successful IOC (98.4 %). 75 % were females. The mean age was 59 years. Patients presented with one or more of the following: chronic biliary pain in 60 %, acute pain 26.7 %, acute cholecystitis 8.4 %, gallstone pancreatitis 7.8 % and jaundice with or without cholangitis in 19.2 %. A total of 1328 patients (36.5 %) had risk factors for CBD stones. The IOC was abnormal in 975 cases (26.8 %), recording 1599 abnormalities. IOC identified 774 patients with CBD stones (21.3 %), including previously unsuspected CBD stones in 4.7 %. IOC was false negative in 20 cases (0.5 %) found to have stones on basket exploration. A decision not to perform IOC in 453 cases (11 %) was made preoperatively in 74.2 % and intra-operatively in 12.3 %. CONCLUSION: IOC can be safely and routinely performed in LC. It helps to identify CBD stones, even in patients with no known risk factors, delineate bile duct anatomy and facilitate single-stage management of CBD stones.

Sudden death of a patient with polycystic kidneys due to acute inferior vena cava thrombosis.

A management algorithm for large renal cyst in autosomal dominant polycystic kidney disease (ADPKD) is lacking despite the potential to cause widespread medical and surgical complications. We report the case of a 37-year-old gentleman with ADPKD and large (>5 cm diameter) cysts who suffered sudden death due to autopsy-proven inferior vena cava and pulmonary arterial thrombosis. In this article, we discuss the possible pathophysiological factors at play in this catostrophic complication of ADPKD. We also review available literature to establish the prevalence of such a complication and also establish current thoughts and opinions as to the optimal management strategy for giant cysts in the context of ADPKD.

Laparoscopic Living Donor Left Lateral Sectionectomy: A New Standard Practice for Donor Hepatectomy.

OBJECTIVE: The aim of the study was to compare the short-term donor outcomes of laparoscopic left lateral sectionectomy (LLLS) for adult to child living donor liver transplantation (A-C LDLT) and laparoscopic donor nephrectomy (LDN). BACKGROUND: Although laparoscopy has become the standard approach in kidney donors, its use remains limited and controversial in LLS for A-C LDLT due to the lack of conclusive assessment of procedure-related morbidity. METHODS: From 2001 to 2014, 124 healthy donors undergoing laparoscopic LLLS for A-C LDLT at 5 tertiary referral centers in Europe, North America, and Asia, and 300 healthy donors undergoing LDN at 2 tertiary centers in Europe were retrospectively analyzed. The outcomes of LLLS were compared with those of LDN including the use of the comprehensive complication index (CCI). RESULTS: Although liver donors experienced significantly less overall (16.9% vs 31.7%, P = 0.002) and grade 1 to 2 (12.1% vs 24.7%, P = 0.004) complications than kidney donors, the rates of major complication (≥ grade 3) were similar between the 2 groups. In both groups, donors experiencing postoperative complications had similar CCI (19.3 vs 21.9 for liver and kidney donors, respectively, P = 0.29). After propensity score analysis allowing for matching donors on age, sex, and body mass index, the postoperative outcomes remained comparable between the 2 groups. CONCLUSION: Laparoscopic LLS for A-C LDLT yields at least similar short-term donor outcomes as LDN. These results provide the first validation for a laparoscopic donor hepatectomy and suggest that the laparoscopic approach should be considered a new standard practice for retrieval of left lateral section liver grafts as it is for kidney donation.

Difference in outcomes after antibody-mediated rejection between abo-incompatible and positive cross-match transplantations.

Graft survival seems to be worse in positive cross-match (HLAi) than in ABO-incompatible (ABOi) transplantation. However, it is not entirely clear why these differences exist. Sixty-nine ABOi, 27 HLAi and 10 combined ABOi+HLAi patients were included in this retrospective study, to determine whether the frequency, severity and the outcome of active antibody-mediated rejection (AMR) were different. Five-year death-censored graft survival was better in ABOi than in HLAi and ABOi+HLAi patients (99%, 69% and 64%, respectively, P = 0.0002). Features of AMR were found in 38%, 95% and 100% of ABOi, HLAi and ABOi+HLAi patients that had a biopsy, respectively (P = 0.0001 and P = 0.001). After active AMR, a declining eGFR and graft loss were observed more frequently in HLAi and HLAi+ABOi than in ABOi patients. The poorer prognosis after AMR in HLAi and ABOi+HLAi transplantations was not explained by a higher severity of histological lesions or by a less aggressive treatment. In conclusion, ABOi transplantation offers better results than HLAi transplantation, partly because AMR occurs less frequently but also because outcome after AMR is distinctly better. HLAi and combined ABOi+HLAi transplantations appear to have the same outcome, suggesting there is no synergistic effect between anti-A/B and anti-HLA antibodies.

Intrahepatic choledochoscopy during trans-cystic common bile duct exploration; technique, feasibility and value.

BACKGROUND: Transcystic laparoscopic common bile duct exploration (TC-LCBDE) is advantageous for exploring the bile duct. Choledochoscopy, however, may be quite challenging to perform transcystically because the cystic duct is usually narrow, duct anatomy may be unfavorable, and not all stones are amenable to transcystic extraction. Convention suggests that it is technically very difficult to visualize the intrahepatic bile ducts with transcystic choledochoscopy, due to the angle of insertion of the cystic into the common bile duct (CBD). However, we have performed intrahepatic choledochoscopy successfully, moving the choledochoscope from the CBD into the common hepatic duct by using what we have termed a "wiper blade maneuver". The purpose of this study was to confirm how often this was possible. METHODS: A search of a prospectively collected database of patients undergoing routine intraoperative cholangiography (IOC) and laparoscopic CBD exploration under the care of a single consultant surgeon was performed. RESULTS: A total of 592 LCBDEs were performed between September 1992 and January 2011; 325 were transcystic explorations. Of these, 72.5 % were female and 56 % were admitted acutely. Exploration and duct clearance was performed by blind Dormia basket trawling in 63 %. The choledochoscope was utilized in 120 cases (37 %). The 3-mm choledochoscope was used in 66 (55 %) and the 5-mm scope in 54 (45 %). Intrahepatic choledochoscopy was performed in 49 patients (40.8 %). Length of surgery was 40-350 min (median 90 min; standard deviation 49 min). CONCLUSIONS: It is technically challenging to perform intrahepatic choledochoscopy with a 3-mm choledochoscope due to its narrow gauge. The more rigid 5-mm scope is thus preferred, but is limited in TCE because its effective use depends on the presence of a dilated cystic duct. Despite the technical limitations of both caliber scopes, we have demonstrated that intrahepatic choledochoscopy during TCE is possible, with each, in 40 % of cases.

Laparoscopic transcystic bile duct exploration: the treatment of first choice for common bile duct stones.

BACKGROUND: This study was designed to explore the role of transcystic bile duct exploration (TCE) as a first line of treatment for patients with suspected or incidental common bile duct (CBD) stones. METHODS: A prospective, case-control study of clinically comparable groups of patients who underwent laparoscopic cholecystectomy (LC) alone (n = 1,854) and combined LC/TCE for CBD stones (n = 253) under the care of one surgeon was performed. Other than ultrasonography, no routine preoperative imaging was used; however, we performed routine intraoperative cholangiography on all patients. RESULTS: There was no difference in age (49 +/- 15 vs. 57 +/- 19, p = 0.7), sex (79% vs. 82% females, p = 0.6), and ASA grade (1.9 +/- 1 vs. 1.8 +/- 1, p = 0.7). A larger proportion of the TCE group presented as an emergency (TCE 45% vs. LC alone 27%, p = 0.03) and more often presented with acute biliary pain compared with LC alone (27% vs. 13%, p = 0.02). Although a majority of the patients in the TCE group had clinical or biochemical risk factors for CBD stones (86%), only 27% had suspected stones on preoperative ultrasound. The incidence of jaundice (6% vs. 20%, p = 0.01) was lower in the LC alone group compared with TCE patients. Previous abdominal surgery was noted in 34% patients who underwent LC alone and 30% in LC/TCE (p = 0.06). Significantly there was no difference in open conversion between the two groups (LC alone 0.5% vs. LC/TCE 0.6%, p = 0.07). Comparison of selected outcome parameters for LC versus TCE showed a postoperative hospital stay of 2 (1-14) vs. 2 (1-17) days (p = 0.07), presentation to resolution 1 (1-11) vs. 1 (1-11) weeks (p = 0.07), and morbidity 1.07% vs. 1.2% (p = 0.07). CONCLUSIONS: The study advocates single-session laparoscopic cholecystectomy with transcystic CBD exploration as a feasible first choice treatment and the logical next step in the management of patients with CBD stones.

Cross-linking of neutrophil CD11b results in rapid cell surface expression of molecules required for antigen presentation and T-cell activation.

Recent studies suggest that neutrophils may play a role in antigen presentation. In support of this hypothesis it has been shown that these cells appear to contain cytoplasmic stores of molecules required for this function, i.e. major histocompatibility complex class II (DR) antigen, CD80 and CD86. In this study we have considered a mechanism for the translocation of these preformed molecules onto the cell surface which does not require active synthesis. Cross-linking of the Mac-1 molecule (CD18 + CD11b) was shown to result in rapid cell surface expression of CD80, CD86 and DR antigen on the surface of normal human peripheral blood neutrophils. A distinct subpopulation (approximately 20%) of neutrophils appeared to be enlarged and were found to express significantly elevated levels of these molecules on the cell surface following cross-linking of CD11b when compared with control cells. The level of expression of CD80, CD86 and DR antigen on these large cells was comparable to, and in some cases greater than, the levels found expressed on the surface of monocytes obtained from the same donors. In addition, these cytoplasmic molecules were shown by confocal laser microscopy and by immunoelectron microscopy to be located within secretory vesicles. Following rapid translocation onto the cell surface, CD80 and CD86 appeared to be colocalized within large clusters reminiscent of the supramolecular antigen clusters previously found on conventional antigen-presenting cells. These findings therefore lend further support for the hypothesis that neutrophils may have a role to play in antigen presentation and/or T-cell activation.