Blood salvage and autotransfusion during orthotopic liver transplantation for hepatocellular carcinoma: A systematic review and meta-analysis.

BACKGROUND: Hepatocellular carcinoma (HCC) is a significant cause of oncologic mortality worldwide. Liver transplantation represents a curative option for patients with significant liver dysfunction and absence of metastases. However, this therapeutic option is associated with significant blood loss and frequently requires various transfusions and intraoperative blood salvage for autotransfusion (IBS-AT) with or without a leukocyte reduction filter. This study aimed to analyze available evidence on long-term oncologic outcomes of patients undergoing liver transplantation for HCC with and without IBS-AT. METHODS: Per PRISMA guidelines, a systematic review of keywords "Blood Salvage," "Auto-transfusion," "Hepatocellular carcinoma," and "Liver-transplant" was conducted in PubMed, EMBASE, and SCOPUS. Studies comparing operative and postoperative outcomes were screened and analyzed for review. RESULTS: Twelve studies totaling 1704 participants were included for analysis. Length of stay, recurrence rates, and overall survival were not different between IBS-AT group and non IBS-AT group. CONCLUSION: IBS-AT use is not associated with increased risk of recurrence in liver transplant for HCC even without leukocyte filtration. Both operative and postoperative outcomes are similar between groups. Comparison of analyzed studies suggest that IBS-AT is safe for use during liver transplant for HCC.

Rapid metastatic recurrence after pancreatic cancer resection: a multi-center, regional analysis of trends in surgical failure over two decades.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAc) is a lethal malignancy, attributed in part to high rates of rapid recurrence (rrPDAc) following resection. We sought to characterize recurrence rates over time and investigate factors predictive of rrPDAc. METHODS: A regional multi-institutional cancer registry, augmented with data from the National Surgical Quality Improvement Program database, was queried for patients with PDAc from 1996 to 2020. rrPDAc was defined as recurrence within 6 months following curative-intent resection. RESULTS: We identified 924 patients who underwent resection for PDAc; rrPDAc occurred in 236 (26%) patients. Median incidence of rrPDAc was 25.3% (IQR 22-30.2%) per year. Median survival in rrPDAc, non-rapid recurrence, and no recurrence was 10.3, 25.2, and 56.1 months respectively (p < 0.001). Variables independently associated with greater odds of rrPDAc included surgical site infection (SSI) (OR 2.06) and nodal positivity (OR 2.05); adjuvant therapy was associated with lower odds (OR 0.38). Neoadjuvant chemotherapy did not alter risk of rrPDAc. Three-year post-recurrence survival was no different in rrPDAc versus those without. CONCLUSION: Despite therapeutic advances, incidence of rrPDAc remains unchanged. SSIs and nodal positivity are independently associated with increased risk of rrPDAc, while adjuvant chemotherapy is associated with lower risk. Strategies focused on preventing rapid recurrence may improve survival.

Endovascular Treatment of Transplant Renal Artery Stenosis: A Systematic Review and Meta-analysis.

OBJECTIVE: Endovascular treatment through either percutaneous transluminal angioplasty (PTA) alone or stenting has been previously used as a treatment for transplant renal artery stenosis (TRAS). This review aimed to investigate the results of endovascular treatment for renal artery stenosis in transplanted kidneys as compared with the outcomes of interventions, medical management, and graft survival in non-TRAS patients. METHODS: A systematic review of PubMed, Google Scholar, Cochrane, and Scopus was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in which studies that reported outcomes of the treatment of TRAS via the endoluminal approach were identified, and their results were meta-analyzed. RESULTS: Fifty-four studies with a total of 1522 patients were included. A significant reduction of serum creatinine level was found, favoring the stenting group, with a mean difference of 0.68 mg/dL (95% confidence interval (CI), 0.17-1.19; Z=2.60, p=0.0009). Comparison of pre- and post-intervention values of any intervention revealed a significant decrease in overall serum creatinine level (0.65 mg/dL; 95% CI, 0.40-0.90; Z=5.09, p=0.00001), overall blood pressure, with a mean difference of 11.12 mmHg (95% CI, 7.29-14.95; Z=5.59, p=0.00001), mean difference in the use of medications (0.77; 95% CI, 0.29-1.24; p=0.002), and peak systolic velocity (190.05; 95% CI, 128.41-251.69; p<0.00001). The comparison of serum creatinine level between endovascular interventions and best medical therapy favored endovascular intervention, with a mean difference of 0.23 mg/dL (95% CI, 0.14-0.32; Z=5.07, p<0.00001). Graft survival was similar between the treated patients and those without TRAS (hazard ratio, 0.98; 95% CI, 0.75-1.28; p=0.091). The overall pooled success rate was 89%, and the overall complication rate was 10.4%, with the most prevalent complication being arterial dissection. CONCLUSION: The endovascular treatment of TRAS improves graft preservation and renal function and hemodynamic parameters. PTA + stenting appears to be a more effective option to PTA alone in the stabilization of renal function, with additional benefits from decreased restenosis rates. Further high-quality studies could expand on these findings.

Peptidic vaccines: The new cure for heart diseases?

Cardiovascular disease continues to be the most common cause of death worldwide. The global burden is so high that numerous organizations are providing counseling recommendations and annual revisions of current pharmacological and non-pharmacological treatments as well as risk prediction for disease prevention and further progression. Although primary preventive interventions targeting risk factors such as obesity, hypertension, smoking, and sedentarism have led to a global decline in hospitalization rates, the aging population has overwhelmed these efforts on a global scale. This review focuses on peptidic vaccines, with the known and not well-known autoantigens in atheroma formation or acquired cardiac diseases, as novel potential immunotherapy approaches to counteract harmful heart disease continuance. We summarize how cancer immunomodulatory strategies started novel approaches to modulate the innate and adaptive immune responses, and how they can be targeted for therapeutic purposes in the cardiovascular system. Brief descriptions focused on the processes that start as either immunologic or non-immunologic, and the ultimate loss of cardiac muscle cell contractility as the outcome, are discussed. We conclude debating how novel strategies with nanoparticles and nanovaccines open a promising therapeutic option to reduce or prevent cardiovascular diseases.

Laparoscopic vs open portoenterostomy in biliary atresia: a systematic review and meta-analysis.

Hepatoportoenterostomy remains the cornerstone of treatment for biliary atresia. Current employed techniques include laparoscopy and open surgery. This study aims to determine if either method provides an advantage. Following PRISMA guidelines, a systematic review was conducted. Nineteen studies were included. Mean operative time 34.98 (95% CI 20.10, 49.85; p ≤ 0.00001) was longer in laparoscopic while bleeding volumes - 16.63 (95% CI - 23.39, - 9.86; p ≤ 0.00001) as well as the time to normal diet - 2.42 (95% CI - 4.51, - 0.32; p = 0.02) were lower in the laparoscopic group. No differences were observed in mean length of stay - 0.83. Similar complication, transfusions, postoperative cholangitis 0.97, and transplant free survival rates 1.00 (0.63, 1.60; p = 0.99) were seen between groups. Laparoscopic portoenterostomy provides advantages on operative time and bleeding as well as to normal diet when compared to open procedures. Both procedures showed no differences in length of stay, complications, cholangitis, and importantly, native liver survival. Level of evidence: III.

Minimally invasive umbilical hernia repair is safe for patients with liver dysfunction: A propensity-score-matched analysis of approach and outcomes using ACS-NSQIP.

BACKGROUND: Umbilical hernias are highly prevalent in patients with liver dysfunction, ascites, and cirrhosis. This patient population carries significant perioperative risk and poses significant challenges because of their comorbidities. Literature suggests that elective repair of umbilical hernias can lead to better outcomes by reducing the risk of ascitic leak and compromised bowel. Medical optimization followed by open repair has been the standard approach; however, little is known about whether a laparoscopic approach may be equivalent or superior. METHODS: We retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2021 for umbilical hernia repairs in patients with liver dysfunction, as defined per the aspartate aminotransferase to platelet ratio index ≥1. We compare operative outcomes for open and laparoscopic repair, adjusting for confounders using propensity score matching and stratifying by case acuity. RESULTS: We identified 1,983 patients with liver dysfunction who underwent umbilical hernia repair. Most patients (86%) were operated via an open approach rather than laparoscopy. Operative outcomes between the laparoscopy and open group were comparable regarding mortality and serious complications. Notably, length of stay and need for blood transfusion intraoperatively or postoperatively were reduced in the laparoscopy group (P < .001). These findings remained significant after subgroup analysis with propensity matching stratified by elective and emergency case types. CONCLUSION: Minimally invasive umbilical hernia repair in liver dysfunction is as safe and, in some metrics, superior to open technique. We found no difference in mortality although hospital stays and the need for blood transfusions were lower in the laparoscopy groups. Prospective randomized trials are needed to validate these findings further.

Novel therapeutic regimens in previously untreated metastatic urothelial carcinoma: A systematic review and bayesian network meta-analysis.

Metastatic urothelial carcinoma (muC) has historically had few effective therapeutic options. Recently, immune checkpoint inhibitors (ICIs), were introduced as therapeutic options for cisplatin-ineligible patients, however, direct head-to-head trials comparing these treatments are lacking. To address this gap, this study employs a Bayesian framework to indirectly compare the performance of ICIs as first-line agents for muC. A systematic review was performed to identify randomized controlled trials evaluating different ICI for mUC. Data was inputted into Review Manager 5.4 for pairwise meta-analysis. Data was then used to build a network in R Studio. These networks were used to model 200,000 Markov Chains via MonteCarlo sampling. The results are expressed as hazard ratios (HR) with 95% credible intervals (CrI). Six studies with 5,449 patients were included, 3,255 received ICI monotherapy or combination. Moreover, a total of 3,006 had PD-L1 positive tumors and 2,362 were PD-L1 negative. Median overall survival (OS) ranged from 12.1 to 31.5 months across the studies, with the combination of enfortumab vedotin and pembrolizumab demonstrating the most substantial reduction in the risk of death (HR 0.47 [95% CrI: 0.38, 0.58]), followed by avelumab monotherapy (HR 0.69 [95% CrI: 0.56, 0.86]). The limitations of this network meta-analysis include variability in study follow-up duration, lack of standardized methods for assessing PD-L1 positivity, and potential bias introduced by control arms with poorer survival outcomes across included trials. The enfortumab vedotin/pembrolizumab combination significantly improved survival and response rates. Avelumab showed notable single-agent activity. These findings provide a valuable framework to guide clinical decision-making and highlight priority areas for future research, including biomarker refinement and novel combination strategies to enhance antitumor immunity in this challenging malignancy.

Intraoperative and postoperative impact of pretransplantation transjugular intrahepatic portosystemic shunts in orthotopic liver transplantations: A systematic review and meta-analysis.

Objectives: Orthotopic liver transplantation (OLT) remains the definitive treatment for patients afflicted with end-stage liver disease (ESLD). Transjugular intrahepatic portosystemic shunts (TIPS) have been adapted as a bridge to transplantation, allowing partial normalization of portal pressure and associated symptom improvement. Conflicting evidence exists on TIPS' impact on operative procedures. This study aimed to analyze available evidence on patients who underwent OLT with prior TIPS compared to OLT alone with the intent to determine TIPS' impact on surgical outcomes. Material and Methods: Following PRISMA guidelines, a systematic review was conducted, identifying studies comparing TIPS + OLT versus OLT alone in patients with ESLD. Data were analyzed using Review Manager 5.3. Results: Thirteen studies were included. Operative time, packed red blood cells transfusions, intensive care unit admission, length of stay, dialysis, serum creatinine levels, ascites, vascular complications, bleeding revisions, reintervention, and other complications rates were similar between both groups. Fresh frozen plasma transfusion -2.88 units (-5.42, -0.35; p= 0.03), was lower in the TIPS + OLT group. Conclusion: Our study found TIPS can be safely employed without having detrimental impacts on OLT outcomes, furthermore, these findings also suggest TIPS does not increase bleeding or complications.

Single-operator cholangioscopy and electrohydraulic lithotripsy for the treatment of Mirizzi syndrome.

INTRODUCTION: Mirizzi syndrome is an infrequent complication of long-standing cholelithiasis. Extrinsic compression of the common hepatic duct is usually caused by an impacted stone in Hartmann's pouch or cystic duct resulting in the development of cholecystobiliary fistula. This syndrome is classified based on the presence and severity of cholecystobiliary fistula. Mirizzi syndrome is challenging to diagnose preoperatively and may require complex biliary surgical procedures for resolution. RESULTS: We present three patients with Mirizzi syndrome with different clinical presentations. All were successfully treated by cholangioscopy with electrohydraulic lithotripsy. Endoscopic treatment is a safe alternative with a high success rate. Single-operator cholangioscopy combined with lithotripsy has been shown to have a 90-100% success rate in the treatment of biliary stones. CONCLUSION: Herein, we present our experience treating Mirizzi syndrome with single-operator cholangioscopy guided electrohydraulic lithotripsy. Difficult management of Mirizzi syndrome has led to research of new treatment options to minimize the risk of high-rate complications. Single-operator cholangioscopy in combination with laser lithotripsy is an adequate and safe alternative for the treatment of this condition.

Reversible sirolimus-induced pulmonary alveolar proteinosis in a renal transplant patient.

Pulmonary alveolar proteinosis (PAP) is characterized by accumulation of surfactant-like lipoprotein material within distal bronchioles and alveoli due to impaired clearance. Clinically, PAP presents with dyspnea and cough. A 58-year-old Hispanic man presented with 6 months of productive cough, weight loss, and progressively worsening dyspnea. He reported a long history of poorly controlled type 2 diabetes that led to diabetic nephropathy. The patient had a strong passive smoking history for over 30 years and exposure to woodsmoke. He had pulmonary tuberculosis in 2007 and 2012. In 2011, he was diagnosed with renal failure, was dialyzed for a year, and received a renal transplant in 2012. His posttransplant medication regimens included tacrolimus, mycophenolic acid, and prednisone. Six months after the transplant, he suffered graft rejection, managed with steroids and switching from tacrolimus to sirolimus. His physical examination demonstrated scattered inspiratory crackles, and a chest X-ray showed bilateral perihilar ground-glass opacities. PAP was diagnosed through lung biopsy, which showed eosinophilic granular infiltrate withing the alveoli. Sirolimus was switched back to tacrolimus 2 mg in September 2018. PAP diagnosis included hematoxylin and eosin and PAS. Clinical follow-up included oxygen saturation with pulse oximeter and chest X-rays. A 2-month follow-up showed only partial improvement in both symptoms and radiological findings. In January 2019, a follow-up showed complete radiological and symptomatologic resolution. After 5 months, the patient remains asymptomatic with adequate exertion tolerance. PAP remains a diagnosis of exclusion in patients undergoing immunomodulatory therapy with sirolimus and pulmonary symptoms. Reversal can be achieved by switching agents.

Cost analysis of materials used in the endovascular treatment of unruptured intracranial aneurysms in Mexico.

BACKGROUND: To prevent the potentially fatal consequences of intracranial aneurysmal rupture, exclusion from the circulation can be achieved through an endovascular approach. However, the elevated cost of such procedures can be prohibitive for patients in low resource settings. The objective of this study is to identify the factors that modify the cost of the materials used for endovascular treatment of unruptured intracranial aneurysms. METHODS: Medical records of patients who underwent an endovascular treatment for unruptured intracranial aneurysms between June 2013 and June 2019 in a hospital located in Northeast Mexico were reviewed. Descriptive statistics of the cost of consumable materials used during the procedure was performed, and a regression model was undertaken to examine potential associations between the studied variables and total cost of the intervention. RESULTS: A total of 128 patients were included in this analysis. The average intervention cost was $21,687.22 USD. The variables associated with increased material cost were aneurysm size (p = 0.03), aneurysm neck size (p < 0.001), and aneurysm localization in the cavernous segment of the internal carotid artery (p = 0.01). Other variables such as patient age and sex, other aneurysm localizations, laterality of the aneurysm, performing neurointerventionalist, and presence of intervention complications were not statistically significant. CONCLUSIONS: To our knowledge, this is the first study that examines the variables associated with the material cost of endovascular treatment of unruptured intracranial aneurysms. Awareness of which elements are important drivers of materials' costs provides a strategic advantage when making hospital administrative decisions and attempting to improve access to endovascular treatment in countries of low income.