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.

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.

Segmental Colectomy in Ulcerative Colitis.

BACKGROUND: Segmental colectomy in ulcerative colitis is performed in select patients who may be at increased risk for postoperative morbidity. OBJECTIVE: To identify ulcerative colitis patients who underwent segmental colectomy and assess their postoperative and long-term outcomes. DESIGN: Retrospective case series. SETTING: A tertiary-care inflammatory bowel disease center. PATIENTS: Ulcerative colitis patients who underwent surgery between 1995 and 2022. INTERVENTION: Segmental colectomy. MAIN OUTCOME MEASURES: Postoperative complications, early and late colitis, metachronous cancer development, completion proctocolectomy-free survival rates and stoma at follow-up. RESULTS: Fifty-five patients were included [20 (36.4%) female; 67.8 (57.4-77.1) years of age at surgery; body mass index 27.7 (24.2-31.1) kg/m2; median follow-up 37.3 months]. ASA score was III in 32 (58.2%) patients, 48 (87.3%) had at least one comorbidity, 48 (87.3%) had Mayo endoscopic subscore of 0-1. Patients underwent right hemicolectomy (28, 50.9%), sigmoidectomy (17, 30.9%), left hemicolectomy (6, 10.9%), low anterior resection (2, 3.6%), or a non-anatomic resection (2, 3.6%) for; endoscopically unresectable polyps (21, 38.2%), colorectal cancer (15, 27.3%), symptomatic diverticular disease (13, 23.6%), and stricture (6, 10.9%). Postoperative complications occurred in 16 (29.1%) patients [7 (12.7%) Clavien-Dindo Class III-V]. Early and late postoperative colitis rates were 9.1% and 14.5%, respectively. Metachronous cancer developed in 1 patient. 4 (7.3%) patients underwent subsequent completion proctocolectomy with ileostomy. Six (10.9%) patients had stoma at the follow-up. Two and 5-year completion proctocolectomy-free survival rates were 91% and 88%, respectively. LIMITATIONS: Retrospective study, small sample size. CONCLUSIONS: Segmental colectomy in ulcerative colitis is associated with low postoperative complication rates, symptomatic early colitis and late colitis rates, metachronous cancer development and the need for subsequent completion proctocolectomy. Therefore, it can be safe to consider select patients, such as the elderly with quiescent colitis and other indications for colectomy. See Video Abstract.

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.

Laparoscopic versus open resection of primary colorectal cancers and synchronous liver metastasis: a systematic review and meta-analysis.

PURPOSE: Combined resection of primary colorectal cancer and associated liver metastases is increasingly common. This study compares peri-operative and oncological outcomes according to surgical approach. METHODS: The study was registered with PROSPERO. A systematic search was performed for all comparative studies describing outcomes in patients that underwent laparoscopic versus open simultaneous resection of colorectal primary tumours and liver metastases. Data was extracted and analysed using a random effects model via Rev Man 5.3 RESULTS: Twenty studies were included with a total of 2168 patients. A laparoscopic approach was performed in 620 patients and an open approach in 872. There was no difference in the groups for BMI (mean difference: 0.04, 95% CI: 0.63-0.70, p = 0.91), number of difficult liver segments (mean difference: 0.64, 95% CI:0.33-1.23, p = 0.18) or major liver resections (mean difference: 0.96, 95% CI: 0.69-1.35, p = 0.83). There were fewer liver lesions per operation in the laparoscopic group (mean difference 0.46, 95% CI: 0.13-0.79, p = 0.007). Laparoscopic surgery was associated with shorter length of stay (p < 0.00001) and less overall postoperative complications (p = 0.0002). There were similar R0 resection rates (p = 0.15) but less disease recurrence in the laparoscopic group (mean difference: 0.57, 95% CI:0.44-0.75, p < 0.0001). CONCLUSION: Synchronous laparoscopic resection of primary colorectal cancers and liver metastases is a feasible approach in selected patients and does not demonstrate inferior peri-operative or oncological outcomes.

Single-incision laparoscopic clockwise continuous total abdominal colectomy with end ileostomy in ulcerative colitis; surgical technique and results of a 7-year experience.

BACKGROUND: Total abdominal colectomy with end ileostomy is the first stage of the three-stage surgical treatment of medically refractory ulcerative colitis. Laparoscopic surgery is a safe approach offering several benefits. Single-incision laparoscopic surgery is an alternative minimally invasive approach providing excellent cosmetic results. Literature on single-incision laparoscopic clockwise continuous total abdominal colectomy in the treatment of ulcerative colitis is limited. Aim of the study is to describe our surgical technique and report the outcomes. METHODS: Medically refractory ulcerative colitis patients who underwent single-incision laparoscopic clockwise continuous total abdominal colectomy with end ileostomy by a single surgeon between January 2013 and December 2020 at our tertiary care center are included. Patient charts were reviewed retrospectively. RESULTS: 52 patients were included in the final analysis. 51.9% patients were male with the median age of 31.5 years and body mass index of 22.2 kg/m2. Median duration of operation was 100 min with estimated blood loss of 50 ml. There were no intraoperative complications, conversions to conventional laparoscopy or open surgery. Postoperative complications were reported in 13 (25%) patients with most common being ileus (17.3%). 3 patients had surgical site infections. 2 patients had postoperative bleeding requiring blood transfusion. 2 patients had reoperation within postoperative 30 days. Median length of hospital stay was 2 days. No mortalities were reported. CONCLUSION: Single-incision laparoscopic clockwise continuous approach is safe and effective in ulcerative colitis patients undergoing total abdominal colectomy with end ileostomy. Further prospective randomized studies are warranted.

Risk Factors Associated With Postoperative Mortality Among COVID-19 Positive Patients: Results of 3027 Operations and Procedures.

OBJECTIVE: To investigate the predictors of postoperative mortality in coronavirus disease 2019 (COVID-19)-positive patients. BACKGROUND: COVID-19-positive patients have more postoperative complications. Studies investigating the risk factors for postoperative mortality in COVID-19-positive patients are limited. METHODS: COVID-19-positive patients who underwent surgeries/procedures in Cleveland Clinic between January 2020 and March 2021 were identified retrospectively. The primary outcome was postoperative/procedural 30-day mortality. Secondary outcomes were length of stay, intensive care unit admission, and 30-day readmission. RESULTS: A total of 2543 patients who underwent 3027 surgeries/procedures were included. Total 48.5% of the patients were male. The mean age was 57.8 (18.3) years. A total of 71.2% had at least 1 comorbidity. Total 78.7% of the cases were elective. The median operative time was 94 (47.0-162) minutes and mean length of stay was 6.43 (13.4) days. Postoperative/procedural mortality rate was 4.01%. Increased age [odds ratio (OR): 1.66, 95% CI, 1.4-1.98; P <0.001], being a current smoker [2.76, (1.3-5.82); P =0.008], presence of comorbidity [3.22, (1.03-10.03); P =0.043], emergency [6.35, (3.39-11.89); P <0.001] and urgent versus [1.78, (1.12-2.84); P =0.015] elective surgery, admission through the emergency department [15.97, (2.00-127.31); P =0.009], or inpatient service [32.28, (7.75-134.46); P <0.001] versus outpatients were associated with mortality in the multivariable analysis. Among all specialties, thoracic surgery [3.76, (1.66-8.53); P =0.002] had the highest association with mortality. Total 17.5% of the patients required intensive care unit admission with increased body mass index being a predictor [1.03, (1.01-1.05); P =0.005]. CONCLUSIONS: COVID-19-positive patients have higher risk of postintervention mortality. Risk factors should be carefully evaluated before intervention. Further studies are needed to understand the impact of pandemic on long-term surgical/procedural outcomes.

Factors associated with stoma closure after cytoreductive surgery.

BACKGROUND: The rate of stoma closure after cytoreductive surgery (CRS) â€‹± â€‹hypethermic intraperitoneal chemotherapy (HIPEC) is reportedly low. This study aimed to assess predictors of stoma reversal. METHODS: We retrospectively analyzed all patients who underwent CRS with temporary ostomy at our center between 2009 and 2021, and compared reversed versus non-reversed patients. RESULTS: Out of 625 CRS, 72 (11.5%) patients were included (median age 62 years, 65% female, 75% with HIPEC): 53 (74%) achieved stoma closure. Reversed patients had less high grade tumors, more appendiceal mucinous neoplasms, less ovarian primaries, and more loop ileostomies. The most common reason for non-reversal was disease progression or death (14 cases, 74%). At multivariate analysis, low/intermediate grade tumor differentiation was associated with higher stoma closure rate. CONCLUSION: In our study, 74% of patients achieved stoma closure after CRS with temporary ostomy. The strongest predictor of stoma closure was a low/intermediate grade tumor.

Stage IV Colorectal Cancer Management and Treatment.

(1) Background: Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer-related mortality worldwide. Up to 50% of patients with CRC develop metastatic CRC (mCRC). Surgical and systemic therapy advances can now offer significant survival advantages. Understanding the evolving treatment options is essential for decreasing mCRC mortality. We aim to summarize current evidence and guidelines regarding the management of mCRC to provide utility when making a treatment plan for the heterogenous spectrum of mCRC. (2) Methods: A comprehensive literature search of PubMed and current guidelines written by major cancer and surgical societies were reviewed. The references of the included studies were screened to identify additional studies that were incorporated as appropriate. (3) Results: The standard of care for mCRC primarily consists of surgical resection and systemic therapy. Complete resection of liver, lung, and peritoneal metastases is associated with better disease control and survival. Systemic therapy now includes chemotherapy, targeted therapy, and immunotherapy options that can be tailored by molecular profiling. Differences between colon and rectal metastasis management exist between major guidelines. (4) Conclusions: With the advances in surgical and systemic therapy, as well as a better understanding of tumor biology and the importance of molecular profiling, more patients can anticipate prolonged survival. We provide a summary of available evidence for the management of mCRC, highlighting the similarities and presenting the difference in available literature. Ultimately, a multidisciplinary evaluation of patients with mCRC is crucial to selecting the appropriate pathway.

Advanced endoscopic resections in the treatment of malignant colorectal lesions: Are early oncological outcomes impacted?

BACKGROUND: Limited data exists on the impact of advanced endoscopic resections on early oncological outcomes of malignant colorectal lesions, especially in the presence of perforation. METHODS: Retrospective chart review of patients who underwent advanced endoscopic resections and had adenocarcinoma was performed. The primary endpoint was cancer recurrence. RESULTS: 63 patients were included. Mean age was 64.6 years with 58.7% of the patients being male. Mean BMI was 30.2 kg/m2 12 patients underwent advanced endoscopic resections followed by surveillance, 5 patients had conversion to surgery due to intra-procedural perforation, and 5 patients due to incomplete resection. 41 patients underwent salvage surgery following a median of 5.4 weeks of initial endoscopic resection. Neither local nor distant recurrence was observed within a median follow-up of 21.2 months. CONCLUSION: Advanced endoscopic procedures do not have negative impact on the early oncological outcomes of patients with malignant colorectal lesions, even in the presence of perforation.

Targeted lateral pelvic lymph node excision in the setting of total neoadjuvant therapy for rectal cancer.

Targeted lateral pelvic node dissection in the era of total neoadjuvant therapy.

Endoluminal management of colon perforations during advanced endoscopic procedures.

BACKGROUND: Advanced endoscopic procedures are gaining attraction despite a steep learning curve, need for high dexterity, and potential complications. Colonic perforation is the most concerning adverse event during advanced endoscopic procedures. This study presents our experience on endoluminal management of iatrogenic colonic perforations. METHODS: Patients who underwent advanced endoscopic procedures at a quaternary center from 2016 to 2021 were identified. Patients who had colonic perforations during advanced procedures and treated with endoscopic closure/clipping were included. Retrospective chart review was performed. Figures represent frequency (proportion) or median (interquartile range/range). RESULTS: There were 22 (2.3%) immediate colonic perforations treated with endoscopic clipping out of 964 advanced endoscopic resections. The median age was 64 (interquartile range = 57-71) years and 50% of the patients were female; 16 (73%) resections were proximal to the splenic flexure. Median polyp size was 36 (20-55) mm. Closure was performed with endoscopic clips in 18 (82%) patients, and over-the-scope clips in 4 patients. Median hospital stay was 0.8 (0-4) days, and 13 (59%) patients were discharged the same day; 2 patients were admitted to the emergency department ≤24 hours of procedure. They underwent subsequent laparoscopic suture repair the same day. No one had segmental colon resection, and there were no complications within postoperative 30 days. Pathology revealed 9 (41%) tubular adenomas, 7 (32%) tubulovillous adenomas, 6 (27%) sessile serrated lesions, and no adenocarcinoma. No recurrence was observed with median follow-up of 24 months (range = 0-90 months). CONCLUSION: Endoscopic management is an effective treatment approach for the management of iatrogenic colonic perforations.

The role of ischaemia-reperfusion injury and liver regeneration in hepatic tumour recurrence.

The risk of cancer recurrence after liver surgery mainly depends on tumour biology, but preclinical and clinical evidence suggests that the degree of perioperative liver injury plays a role in creating a favourable microenvironment for tumour cell engraftment or proliferation of dormant micro-metastases. Understanding the contribution of perioperative liver injury to tumour recurrence is imperative, as these pathways are potentially actionable. In this review, we examine the key mechanisms of perioperative liver injury, which comprise mechanical handling and surgical stress, ischaemia-reperfusion injury, and parenchymal loss leading to liver regeneration. We explore how these processes can trigger downstream cascades leading to the activation of the immune system and the pro-inflammatory response, cellular proliferation, angiogenesis, anti-apoptotic signals, and release of circulating tumour cells. Finally, we discuss the novel therapies under investigation to decrease ischaemia-reperfusion injury and increase regeneration after liver surgery, including pharmaceutical agents, inflow modulation, and machine perfusion.

Prospective randomized comparison of three-dimensional (3D) versus conventional laparoscopy in total colectomy for ulcerative colitis.

BACKGROUND: 3D laparoscopy has been proposed with the aim of improving the depth perception and overall operative performance. To aim of this study is to compare 3D laparoscopy with conventional 2D laparoscopy in terms of operative time and visual parameters. METHODS: This is a prospective, randomized, single-center trial designed to determine 10% reduction in the mean operative time. Ulcerative colitis patients >18 years of age who underwent laparoscopic total abdominal colectomy with end ileostomy between 2015 and 2020 were included. Patients were randomized into 3D and 2D laparoscopy groups. Duration of operation and surgeons' evaluation of the visualization system were the primary outcomes. RESULTS: Fifty-three subjects (26 in 2D, 27 in 3D group) were included in the analysis, with 56% being male. Mean age and body mass index were 40 (16.3) years and 23.5 (4.7) kg/m2 , respectively. Twenty-five subjects underwent single port laparoscopic surgery, of whom 13 were in 3D and 12 in 2D group. Mean operative time was 75.3 (30.8) versus 82.7 (38.6) minutes (P = 0.4) for 3D and 2D groups, respectively. Operative times spent for individual steps were comparable. Post-operative minor complications (8 in 3D versus 8 in 2D, P = 1) and median number of times for scope maintenance were also similar between the groups. 69% of the visual evaluation survey results favoured 3D over 2D (P = 0.014). CONCLUSION: Three-dimensional laparoscopy for total colectomy in ulcerative colitis patients is safe and feasible option providing better visualization with no difference in operative time.