System Factors Affecting Intraoperative Risk and Resilience: Applying a Novel Integrated Approach to Study Surgical Performance and Patient Safety.

OBJECTIVE: To identify and categorize system factors in complex laparoscopic surgery that have the potential to either threaten patient safety or support system resilience. BACKGROUND: The operating room is a uniquely complex sociotechnical work system wherein surgical successes prevail despite pervasive safety threats. Holistically characterizing intraoperative factors that thus support system resilience in addition to those that threaten patient safety using contextual methodologies is critical for optimizing surgical safety overall. METHOD: In this prospective descriptive interdisciplinary study, 19 audio/video recordings of complex laparoscopic general surgical procedures were directly observed and transcribed. Using a qualitative systems-based approach, intraoperative human factors with the potential to impact patient safety, either as a safety threat or as a support for resilience, were identified. Adverse events were further assessed for shared threats and supports. Data collection was guided by the Systems Engineering Initiative for Patient Safety 2.0 work system model. RESULTS: A total of 1083 relevant observations were made over 39.8 hours of operative time, enabling the identification of 79 distinct safety threats and 67 resilience supports within the surgical system. Safety threats associated with the physical environment, tasks, organization, and equipment were prevalent and observed in equal measure, whereas supports for resilience were predominantly attributed to clinician behaviors, including proactive team management and skills coaching. Two subclinical adverse events were identified; shared safety threats included suboptimal technology design, whereas shared resilience supports included calm clinician behavior and redundant intraoperative resourcing. CONCLUSIONS: Safety threats and resilience supports were found to be systematic in the surgical setting. Identified safety threats should be prioritized for remediation, and clinician behaviors that contribute to fostering resilience should be valued and protected.

Characterization of device-related interruptions in minimally invasive surgery: need for intraoperative data and effective mitigation strategies.

BACKGROUND: The burden of device-related interruptions is expected to increase as modern surgical practices adopt complex minimally invasive surgery devices. Currently, there is a paucity of empiric data that examined the nature of device-related interruptions using comprehensive intraoperative data. METHODS: We performed a cross-sectional study of consecutive elective laparoscopic general surgery cases performed in one operating room (OR) at a referral center between April 2014 and April 2016. The included cases were directly observed using a comprehensive multiport data recorder called the OR Black Box. The data were synchronized, encrypted, and reviewed by expert surgeon assessors. The assessors characterized device-related interruptions that occurred during operations. The prevalence of the cases with device-related interruptions was calculated. Device-related interruptions were classified into a priori categories of (1) absent/wrong device; (2) improper assembly; (3) loss of sterility; (4) disconnection; and (5) device failure. RESULTS: In a cohort of 210 cases, 64 (30%) had at least one device-related interruption. Sleeve gastrectomy (52%) and oncologic gastrectomy (43%) procedures experienced the highest prevalence of device-related interruptions. Device failure was the most frequently chosen category with laparoscopic staplers implicated in more than half of these failures. Three failure modes were described for laparoscopic stapler, of which stapler malfunction (46%) was the most common. CONCLUSIONS: Device-related interruptions occurred frequently in the OR and could be characterized into one of the five categories. Understanding the nature of the device-related interruptions can help guide implementation of safety interventions and user training in the future.

Analysis of the hemostatic potential of modern topical sealants on arterial and venous anastomoses: an experimental porcine study.

One of the widely accepted adjunctive agents in the variety of surgical modalities are sealants. Our study aim was to compare four commonly used modern sealants in a standardized experimental setting to assess their feasibility, and hemostatic efficacy in vascular anastomosis. Forty landrace pigs (weight: 24.7 ± 3.8 kg) were randomized into the control (n = 8) and four sealant groups; TachoSil® (n = 8), Tissucol Duo® (n = 8), Coseal® (n = 8), and FloSeal® (n = 8). After doing a portal vein end-to-end anastomosis as well as stitches of aortic incision, the sealants were applied on anastomotic site. The control group was left intact. In portal vein anastomosis, the sealants led to a complete hemostasis significantly better than control group. The mean of blood loss was also significantly reduced. In successful subgroups, there was a difference in the mean-time to reach complete hemostasis ranging from 15 s in Coseal® to 76 s in FloSeal® group (p < 0.05). In aortotomy experiments, except Tissucol Due®, which had insufficient hemostasis, other sealants led to a complete hemostasis. The mean blood loss was significantly reduced in sealants groups as well. The four sealants are effective in reducing the suture-hole bleeding in portal vein anastomosis. However, the hemostatic potential is heterogeneous among sealants. This means that "one-size-fits-all" approach is not appropriate for application of sealants in diversity of vascular surgery and it should be based on the type and the severity of injury and the structure of tissue. Comparison of hemostasis efficacy of four modern sealants (TachoSil®, Tissucol Duo®, Coseal®, and FloSeal®) in vascular anastomosis in porcine model. The figures below show the total blood loss (g) in the control and sealant groups after aortotomy (left) and portal vein anastomosis (right). The mean of blood loss decreased significantly by the usage of sealants in both experiment groups as compared to control group (*: p < 0.05; sealant groups vs. control group). 1. The right column shows the mean of blood loss (g) in all experiments in each group. 2. The middle column presents the subgroup with unsuccessful hemostasis at the end of observation time (Tmax = 20 sec. for aortotmy and 300 sec. for portal vein anastomosis). 3. The left column shows mean of total blood loss in subgroups with successful hemostasis during observation time (20 sec for aortotomy and 300 sec for portal vein).

Is Canadian surgical residency training stressful?

BACKGROUND: Surgical residency has the reputation of being arduous and stressful. We sought to determine the stress levels of surgical residents, the major causes of stress and the coping mechanisms used. METHODS: We developed and distributed a survey among surgical residents across Canada. RESULTS: A total of 169 participants responded: 97 (57%) male and 72 (43%) female graduates of Canadian (83%) or foreign (17%) medical schools. In all, 87% reported most of the past year of residency as somewhat stressful to extremely stressful, with time pressure (90%) being the most important stressor, followed by number of working hours (83%), residency program (73%), working conditions (70%), caring for patients (63%) and financial situation (55%). Insufficient sleep and frequent call was the component of residency programs that was most commonly rated as highly stressful (31%). Common coping mechanisms included staying optimistic (86%), engaging in enjoyable activities (83%), consulting others (75%) and exercising (69%). Mental or emotional problems during residency were reported more often by women (p = 0.006), who were also more likely than men to seek help (p = 0.026), but men reported greater financial stress (p = 0.036). Foreign graduates reported greater stress related to working conditions (p < 0.001), residency program (p = 0.002), caring for family members (p = 0.006), discrimination (p < 0.001) and personal and family safety (p < 0.001) than Canadian graduates. CONCLUSION: Time pressure and working hours were the most common stressors overall, and lack of sleep and call frequency were the most stressful components of the residency program. Female sex and graduating from a non-Canadian medical school increased the likelihood of reporting stress in certain areas of residency.

Early detection of metabolic changes using microdialysis during and after experimental kidney transplantation in a porcine model.

BACKGROUND: Microdialysis (MD) can detect organ-related metabolic changes before they become measurable in plasma through the biochemical parameters. This study aims to evaluate the early detection of metabolic changes during experimental kidney transplantation (KTx). MATERIAL AND METHODS: During preparation of 8 donor kidneys, one MD catheter was inserted in the renal cortex and samples were collected. After a 6-hour cold ischemia time (CIT), kidneys were implanted in the 8 recipient pigs. Throughout the warm ischemia time (WIT) and after reperfusion, kidneys were monitored. The interstitial glucose, lactate, pyruvate, glutamate, and glycerol concentrations were evaluated. RESULTS: A significant decline in glucose level was observed at the end of CIT. The lactate level was reduced to the minimum point of 0.35 ± 0.08 mmol/L in CIT. After reperfusion, lactate values raised significantly. During the WIT, the pyruvate level increased, continued until the end of the WIT. For glutamate, a steady increase was noted during explantation, CIT, WIT, and early reperfusion phases. The increase of glycerol value continued in the early postreperfusion, which was then followed by a sharp decline. CONCLUSION: MD is a fast and simple minimally invasive method for measurement of metabolic substrates in renal parenchyma during KTx. MD offers the option of detecting minor changes of interstitial glucose, lactate, pyruvate, glutamate, and glycerol in every stage of KTx. Through the use of MD, metabolic changes can be continuously monitored during the entire procedure of KTx.

Live donor liver transplantation in high MELD score recipients.

BACKGROUND: In 2002, the New York State Committee on Quality Improvement in Living Liver Donation prohibited live liver donation for potential recipients with Model for End-stage Liver Disease (MELD) scores greater than 25. Despite the paucity of evidence to support this recommendation, many centers in North America remain reluctant to offer living donor (LD) to patients with moderate to high MELD scores. METHODS: We analyzed 271 consecutive adult-to-adult right lobe LD liver transplants performed at our institution between 2002 and 2008 to study the relationship, between recipient MELD scores and the outcome of LD liver transplantation. The recipients were categorized according to their MELD score into a low (Low: <25)and high (Hi: >or=25) MELD group. We compared short-term donor morbidity, graft loss within 30 days, length of hospital stay, biochemical markers of hepatocyte injury and graft function, and 90 day posttransplant complications including infection, rejection, bleeding, and renal failure. Long-term posttransplant outcome was measured by graft and patient survival after 1-, 3-, and 5-years. RESULTS: Donor and recipient characteristics were similar between groups. Donor outcomes were similar in both groups. Peak recipient aspartat aminotransferase, alanine aminotransferase, and length of hospital stay were similar between both groups. The proportional decrease in postoperative INR and creatinine within the first week was greater in the high versus low MELD score group. High MELD score recipients had more frequent postoperative pneumonia (Low: 2.2% vs. Hi: 14%, P = 0.003), while no differences were observed in rates of biliary complications, rejection, renal failure, or overall infections. Recipients with a MELD <25 versus >or=25 had a similar 1-year (Low: 92% vs. Hi: 83%), 3-year (Low: 86% vs. Hi: 80%), and 5-year (Low: 78% vs. Hi: 80%) graft survival after LD liver transplantation (P = 0.51). CONCLUSION: LD liver transplantation can provide excellent graft function and survival rates in high MELD score recipients. Thus, when deceased donor organs are scare, a high MELD score alone should not be an absolute contraindication to living liver donation.

A single-center experience of 500 liver transplants using the modified piggyback technique by Belghiti.

Over the past 4 decades, the surgical techniques of liver transplantation (LTx) have permanently evolved and been modified. Among these, the modified piggyback (MPB) technique by Belghiti offers specific advantages. The objective of this study was to present our single-center experience with the MPB technique in 500 cases. Recipients' perioperative data were prospectively collected and evaluated. Postoperative and specific complications, stay in the intensive and intermediate care unit, and the mortality rate with cause of death were analyzed. Most recipients were classified as Child C (49.1%). For the patients who underwent LTx for the first time, alcoholic (23.9%) and viral (22.2%) cirrhosis and hepatocellular carcinoma (15.1%) were the prevalent indications. The overall median warm ischemia time, anastomosis duration, and operative time were 45, 108, and 320 minutes, respectively. The median intraoperative blood loss was 1500 mL. A venovenous bypass was never needed to maintain hemodynamic stability. Only in a few cases was temporary inferior vena cava clamping necessary. Most prominent surgical complications were hemorrhage, hematoma, and wound dehiscence. Renal failure occurred in 6.2% of patients. The overall median stay in the intensive and intermediate care unit was 14 days. The mortality rates within 30 and 90 days were 6.3% and 13.3%, respectively. No technique-related death occurred. The MPB technique by Belghiti is a feasible and simple LTx technique. The caval flow is preserved during the anhepatic phase, and this minimizes the need for venovenous bypass or portocaval shunt. This technique requires only 1 caval anastomosis, which is easy to perform with a short anhepatic phase. To minimize the risk of outflow obstruction, attention should be paid by doing a wide cavocavostomy cranially to the donor inferior vena cava in a door-lock manner. This technique can be applied in almost all patients undergoing LTx for the first time and liver retransplantation as well.

Financial, vocational, and interpersonal impact of living liver donation.

The ability to inform prospective donors of the psychosocial risks of living liver donation is currently limited by the scant empirical literature. The present study was designed to examine donor perceptions of the impact of donation on financial, vocational, and interpersonal life domains and identify demographic and clinical factors related to longer recovery times and greater life interference. A total of 143 donors completed a retrospective questionnaire that included a standardized measure of life interference [Illness Intrusiveness Rating Scale (IIRS)] and additional questions regarding the perceived impact of donation. Donor IIRS scores suggested that donors experience a relatively low level of life interference due to donation [1.60 +/- 0.72, with a possible range of 1 ("not very much" interference) to 7 ("very much" interference)]. However, approximately 1 in 5 donors reported that donating was a significant financial burden. Logistic regression analysis revealed that donors with a psychiatric diagnosis at or prior to donation took longer to return to their self-reported predonation level of functioning (odds ratio = 3.78, P = 0.016). Medical complications were unrelated to self-reported recovery time. Multiple regression analysis revealed 4 independent predictors of greater life interference: less time since donation (b = 0.11, P < 0.001), income lower than CAD$100,000 (b = 0.28, P = 0.038), predonation concerns about the donation process (b = 0.24, P = 0.008), and the perception that the recipient is not caring for the new liver (b = 0.12, P = 0.031). In conclusion, life interference due to living liver donation appears to be relatively low. Donors should be made aware of risk factors for greater life disruptions post-surgery and of the potential financial burden of donation.

Recipient age affects long-term outcome and hepatitis C recurrence in old donor livers following transplantation.

We studied the role of donor and recipient age in transplantation/ischemia-reperfusion injury (TIRI) and short- and long-term graft and patient survival. Eight hundred twenty-two patients underwent deceased donor liver transplantation, with 197 donors being > or = 60 years old. We evaluated markers of reperfusion injury, graft function, and clinical outcomes as well as short- and long-term graft and patient survival. Increased donor age was associated with more severe TIRI and decreased 3- and 5-year graft survival (73% versus 85% and 72% versus 81%, P < 0.001) and patient survival (77% versus 88% and 77% versus 82%, P < 0.003). Hepatitis C virus (HCV) infection and recipient age were the only independent risk factors for graft and patient survival in patients receiving an older graft. In the HCV(+) cohort (297 patients), patients > or = 50 years old who were transplanted with an older graft versus a younger graft had significantly decreased 3- and 5-year graft survival (68% versus 83% and 64% versus 83%, P < 0.009). In contrast, HCV(+) patients < 50 years old had similar 3- and 5-year graft survival if transplanted with either a young graft or an old graft (81% versus 82% and 81% versus 82%, P = 0.9). In conclusion, recipient age and HCV status affect the graft and patient survival of older livers. Combining older grafts with older recipients should be avoided, particularly in HCV(+) patients, whereas the effects of donor age can be minimized in younger recipients.

A graft to body weight ratio less than 0.8 does not exclude adult-to-adult right-lobe living donor liver transplantation.

Many centers require a minimal graft to body weight ratio (GBWR) >or= 0.8 as an arbitrary threshold to proceed with right-lobe living donor liver transplantation (RL-LDLT), and there is often hesitancy about transplanting lower volume living donor (LD) liver grafts into sicker patients. The data supporting this dogma, based on the early experience with RL-LDLT at Asian centers, are weak. To determine the effect of LD liver volume in the modern era, we investigated the impact of GBWR on the outcome of RL-LDLT with a GBWR as low as 0.6 at the University of Toronto. Between April 2000 and September 2008, 271 adult-to-adult RL-LDLT procedures and 614 deceased donor liver transplants were performed. Twenty-two living donor liver transplantation (LDLT) cases with a GBWR of 0.59 to 0.79 (group A) were compared with 249 LDLT cases with a GBWR >or= 0.8 (group B) and with 66 full-graft deceased donor liver transplants (group C), who were matched 3:1 according to donor and recipient age, Model for End-Stage Liver Disease score, and presence of hepatitis C and hepatocellular carcinoma with the low-GBWR group. Portal vein shunts were not used. Markers of reperfusion injury [aspartate aminotransferase (AST) and alanine aminotransferase (ALT)], graft function (international normalized ratio and bilirubin), complications graded by the Clavien score, and graft and patient survival were compared. As expected, LD recipients had a significantly shorter cold ischemia time (94 +/- 43 minutes for A, 96 +/- 57 minutes for B, and 453 +/- 152 minutes for C, P = 0.0001). However, the peak AST, peak ALT, absolute decrease in the international normalized ratio, day 7 bilirubin level, postoperative creatinine clearance, complication rate graded by the Clavien score, and median hospital stay were similar in all groups. The rate of biliary complications was higher with LD grafts than deceased donor grafts (19% for A versus 10% for B and 0% for C, P = 0.2). Patient survival was similar in all groups at 1, 3, and 5 years (91% for A versus 89% for B and 93% for C at 1 year, 87% for A versus 81% for B and 89% for C at 3 years, and 83% for A versus 81% for B and 87% for C at 5 years, P = 0.63). A Cox proportional regression analysis revealed only hepatitis C virus as a risk factor for poorer graft survival and not GBWR as a continuous or categorical variable. In conclusion, we found no evidence of inferior outcomes with smaller size grafts versus larger size LD grafts or full-size deceased donor grafts. Further studies are warranted to examine the factors affecting the function of smaller grafts for living liver donation and thereby define the safe lower limits for transplantation.

Histopathological effects of modern topical sealants on the liver surface after hepatectomy: an experimental swine study.

The present study aimed to determine the impact of different sealant materials on histopathological changes to the liver surface after liver resection. Thirty-six landrace pigs underwent left anatomical hemihepatectomy and were assigned to a histopathological control group (HPC, n = 9) with no bleeding control, a clinically simulated control group (CSC, n = 9) with no sealant but bipolar cauterization and oversewing of the liver surface, and two treatment groups (n = 9 each) with a collagen-based sealant (CBS) or a fibrinogen-based sealant (FBS) on resection surface. After postoperative day 6, tissue samples were histologically examined. There were no significant differences in preoperative parameters between the groups. Fibrin production was higher in sealant groups compared with the HPC and CSC groups (both p < 0.001). Hepatocellular regeneration in sealant groups was higher than in both control groups. A significantly higher regeneration was seen in the FBS group. Use of sealants increased the degree of fibrin exudation at the resection plane. Increased hepatocellular necrosis was seen in the CBS group compared with the FBS group. The posthepatectomy hepatocellular regeneration rate was higher in the FBS group compared with the CBS group. Randomized studies are needed to assess the impact of sealants on posthepatectomy liver regeneration in the clinical setting.

Mechanical strength of biliary defect closure after topical sealing: Comparison of four sealants in a porcine model.

BACKGROUND/OBJECTIVE: Biliary leakage is a potential complication of liver resection and is still a concern. The aim of the present study was to evaluate the effectiveness of four routinely used sealants in preventing bile leakage under pressure from an induced perforation of the gallbladder in a porcine model. METHODS: Forty Landrace pigs were randomly assigned to one of five groups. These included a control group (n = 8) and one group each for the sealants TachoSil®, TissuCol Duo®, Coseal®, and FloSeal® (n = 8 per group). In the control group, the perforation was left unsealed. To evaluate the biliostatic potential of the sealants, we measured the pressure that was needed to induce leakage (mmHg) and the gallbladder volume (cc) at the time of leakage in each group. RESULTS: A significantly higher mean pressure was required to induce leakage in the sealant groups compared with the control group. However, the biliostatic effects were heterogeneous among the sealant groups. Sealants with the highest to lowest effectiveness were TachoSil, Coseal, TissuCol, and FloSeal. The mean gallbladder volume at the time of leakage also varied between sealant groups. CONCLUSION: Biliostatic properties are markedly improved by the use of modern sealants compared with using no sealant. However, the advantages and disadvantages of using sealants should be carefully considered in each clinical situation. The effectiveness of the sealants should be evaluated in chronic and clinical studies.

Hemostatic efficiency of modern topical sealants: Comparative evaluation after liver resection and splenic laceration in a swine model.

Parenchymal transection during hepatobiliary surgery can disrupt small vasculature or bile ducts, which could be managed difficultly. Sealants are helpful tools to achieve better hemostasis. The aim of this study is to analyze the hemostatic efficiency of four modern sealants in a porcine model. In this study, 40 landrace pigs were assigned equally to the control (without sealant) and four sealant groups. Standardized liver resection and splenic lesions were performed and left without using sealant (control) or treated with one of the following sealants: TachoSil® , Tissucol Duo® , Coseal® , and FloSeal® . We measured relative and absolute bleeding times (seconds) as well as total blood loss (g) in a maximum observation time of 300 s. Sealants could show a significantly improved hemostasis comparing to the control group. However, hemostasis was heterogeneous among the sealant groups (liver resection: 60%-100%, spleen injury: 70%-100%). The mean blood loss decreased significantly using sealants comparing to control group (liver resection: 6-120 fold, spleen injury: 2.5-36 fold). The hemostatic time in groups that achieved complete hemostasis was different in each sealant group (liver resection: 30-166 s, spleen injury: 60-180 s). We conclude that the hemostatic efficacy of modern sealants is impressive but heterogeneous in liver resection or splenic lesion. To maximize the effectiveness of these tools, the indication of each sealant should be carefully considered in individual settings by the surgeons. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1307-1316, 2018.

Partial cholecystectomy as a safe and viable option in the emergency treatment of complex acute cholecystitis: a case series and review of the literature.

Partial cholecystectomy (PC) is an alternative choice to standard cholecystectomy in situations with increased risk of Calot's components injury. We reported our experience with the patients treated with PC and reviewed the literature. Fifty-four patients with complex acute cholecystitis underwent PC, including conventional partial cholecystectomy (CPC; n = 48) and laparoscopic partial cholecystectomy (LPC; n = 6). The clinical diagnosis was verified by ultrasonography. In addition, we reviewed 1190 published cases (1972-2005) who underwent a "nonconventional" surgery for severe cholecystitis, including cholecystostomy, CPC, or LPC. Review of the literature, including our cases, showed a male:female ratio of 1.3:1. The major operative indication was severe acute cholecystitis. Procedures included cholecystostomy (65.8%) and PC (34.2%). In the follow-up (n = 1190), biliary leak (4.8%), retained stones (4.6%), recurrent symptoms (2.3%), wound infections (1.9%), persistent biliary fistula (0.9%), and prolonged biliary drainage (0.2%) were found, with an overall mortality rate of 9.4 per cent. In 133 patients, because of postoperative complications (e.g., recurrent symptoms, remaining common bile duct stones, or persistence of bile fistula), reoperation was necessary, including 121 cases (90.1%) of cholecystectomy, whereas the other 11 patients underwent other procedures such as common bile duct exploration or closure of the fistula. The surgical trend for complex acute cholecystitis treatment has been changed from only cholecystostomy to a spectrum of cholecystostomy, CPC, and LPC with the progressive increase of PC. The proportion of the LPC compared with CPC has also increased during recent years. It seems that PC is a safe procedure for treating complicated acute cholecystitis. Whether the indication and need for alternative techniques to standard cholecystectomy is changing should be evaluated in future studies.

Surgical treatment of primary hepatic epithelioid hemangioendothelioma.

Epithelioid hemangioendothelioma is a very rare tumor of vascular origin. It can develop in different tissues such as soft tissue, lung, or liver. Hepatic epithelioid hemangioendothelioma (HEH) mostly affects females. The malignant potential of HEH often remains unclear in the individual patient. It can range from benign hemangioma to malignant hemangioendotheliosarcoma. Here we present our experience with five patients with primary HEH, who were treated with curative intention in our department. All patients in our series with confirmed histological HEH did not show extrahepatic extension and consequently underwent surgical treatment. In three patients, liver transplantation (LTx) was performed (two cadaveric and one living related). In one patient, a right-sided hemihepatectomy with partial resection of the diaphragm was performed. One patient died while she was on the waiting list for LTx due to rapid tumor progression. Postoperative follow-up ranged from 1 to 13 years. No adjuvant chemotherapy was applied. Until now, no recurrence of local tumor or distant metastases could be observed during follow-up in our series. Early detection and surgical intervention in case of HEH can potentially offer curative treatment. The treatment of first choice appears to be radical liver resection. In our view, LTx represents a potentially important option for patients with a nonresectable tumor. Despite the long waiting time, its often unclear dignity, and a proven progressive growth pattern, living related LTx also plays a potentially important role. The 5-year overall survival rate of patients with HEH in the literature varies from 43% to 55%. Long-term survival of patients with HEH is significantly higher compared to other hepatic malignancies. The role of adjuvant therapy currently remains unclear.

Indications for liver transplantation in patients with amyloidosis: a single-center experience with 11 cases.

Familial amyloidotic polyneuropathy (FAP) is an inherited disorder with the systemic deposition of amyloid fibrils containing mutant transthyretin variants. The mutant form of transthyretin amyloidosis is produced mainly in the liver. Successful liver transplantation (LTx) could eliminate the source of the variant transthyretin molecule, and is now the only known curative treatment. The aim of this study is to evaluate the results of LTx for FAP at the University of Heidelberg. Eleven patients who underwent LTx between 1985 and 2004 with the diagnosis of FAP were evaluated. Of 11 patients, seven (64%) were male and four (36%) were female. The mean age was 49.5 years (range 27-70). Met 30 (n=5) was the most common type of amyloidosis followed by Arg 50 (n=3), Val 107 (n=2), and Phe 33 (n=1). All of the patients were selected for LTx and Domino LTx was performed in six patients. The majority (80%) of the patients with type Met 30 amyloidosis are alive, whereas in other types of amyloidosis only 33% are living. This finding emphasizes better prognosis of Met 30 variant of FAP in comparison to other variants such as Arg 50, Val 107, and Phe 33. After LTx, improvement of clinical symptoms (completely or partially) was observed in six patients (55%). In conclusion, LTx is considered as the only therapeutic alternative in patients with amyloidosis accompanied by hepatic synthesis of the amyloid protein. The most important risk factors for LTx can be predicted by assessing the nutritional condition of the patient, the duration of the disease, and the amyloid variant. Therefore, precise diagnostic measures are required before listing a patient for LTx. Domino LTx is an acceptable form of LTx that can preserve the pool of organ donors. In order to stop the progression of FAP, LTx would be justified in a subgroup of patients with amyloidosis. Based on our results, we support the idea that the effectiveness of extended preoperative period before LTx or the transplantation of other transthyretin variants other than Met 30 is questionable.

Correlation of cephalic anthropometric parameters and microsurgical anatomy of the optic nerves: a cadaveric morphometric study.

BACKGROUND: This study was designed to elucidate the possible correlation of cranial anthropometric measurements with the chiasm to limbus sphenoidale distance to facilitate preoperative estimation of this distance and to choose a better surgical approach. METHODS: Thirty-three fresh adult cadaver heads (22 males and 11 females) were evaluated for cranial anthropometric measurements. The precraniotomy anthropometric measurements included (A) inion to nasion distance and (B) the longest intermeatal meridian. Subsequently, with a standard craniotomy, the following intervals were measured: (C) optic chiasm to falciform ligament, (D) anterior aspect of optic chiasm to limbus sphenoidale, and (E) limbus sphenoidale to inner nasion. A combined ratio parameter, labeled as (F), was calculated from the following equation: F = B/E x 10. RESULTS: The mean values and standard errors of the mean of parameters A to F were 195.8 +/- 14.53 mm, 374.7 +/- 25.29 mm, 10.47 +/- 1.89 mm, 9.93 +/- 2.01 mm, 38.46 +/- 3.17 mm, and 9.81 +/- 1.11, respectively. The parameter D had significant correlation to the parameters B, C, E, and F. The most significant correlation was seen between parameters D and F (p < 0.001). According to linear regression assessment between parameters D and F, the following regression equation was obtained: D = 4.24 + 0.58F. CONCLUSIONS: Optic nerve topography and dimensions show inter-personal variations that may be anticipated to some extent with cranial anthropometric data. Calculating of F ratio gives us an acceptable estimation of the actual distance of chiasm to limbus sphenoidale, which in turn can help the surgeon to select the approach to tumors of intrasellar region. However, the role of meticulous imaging studies cannot be overemphasized to confirm the anticipated estimations.

Cerebral phaeohyphomycosis masquerading as a parafalcian mass: case report.

BACKGROUND: Cerebral phaeohyphomycosis caused by Fonsecaea pedrosoi is a rarity. However, about four cases have been reported in the literature. The disease remains mostly fatal despite employment of new treatment modalities. CASE: An 18-year-old boy presented seizures of recent onset. Two years back, he developed cutaneous phaeohyphomycosis after a splinter scratch on his chest wall. Imaging revealed a contrast enhancing parafalcian solid mass. Right frontal parasagittal craniotomy was performed and the lesion resected as much as possible, followed by IV amphotericin B and oral itraconazole treatment. The patient has been doing well during a 15-month follow-up period. DISCUSSION: Cerebral phaeohyphomycosis is an extremely rare lesion, which could masquerade as a parafalcian mass. Radical surgical removal together with antimicrobials remains the cornerstone treatment of cerebral phaeohyphomycosis.

Appropriate donor size for porcine liver xenotransplant.

OBJECTIVES: Owing to an imbalance between demand and supply, which is more prominent in pediatric transplant, every year more patients lose their lives on waiting lists. In addition to the use of deceased-donor split and living-donor organs, xenotransplant could provide a solution if associated problems, such as immunologic and physiologic ones, are solved. This study sought to analyze the surgical aspects for liver xenotransplant in a porcine model. MATERIALS AND METHODS: Landrace pigs (n=22, 23 to 37 kg) underwent a laparotomy under general anesthesia. The hepatic hilum was prepared and the common bile ducts, common hepatic artery, portal vein, supra- and infrahepatic inferior vena cava were identified. The length and diameter of each vessel and bile duct and the weight of the liver were measured. RESULTS: Pearson tests showed a clear correlation between the increase of the pigs' weight and the livers' weight, and the length of the vessels and the bile ducts. We did not find a clear correlation between the increase of the pigs' liver weight and the diameters of the vessels and the bile duct. CONCLUSIONS: As the first reporting, this study on xenotransplants from the surgical point of view, we postulate that it could be possible to estimate the size of the liver and the proper length of its vessels and bile duct by weighing only the pigs. It was not feasible to match the diameter of mentioned structures by the livers' weight. However, the weight of pig's liver as well as vascular anatomy of pigs appeared to be suitable alternative for the human liver.