Reanimating Pancreatic Grafts Subjected to Prolonged Cold Ischemic Injury Using Normothermic Ex Vivo Perfusion.

Background: Pancreas transplant volumes are limited because of poor utilization of "extended criteria grafts." Prolonged cold ischemia is a risk factor associated with poor allograft survival. We aimed to establish the feasibility of transplantation using grafts subjected to prolonged cold ischemia and determine whether these grafts could be optimized using normothermic ex vivo perfusion (NEVP) in a porcine model. Methods: The study population consisted of 35 to 40 kg male Yorkshire pigs in an allotransplantation model with a 3-d survival plan for recipients. Control grafts were subjected to cold storage (CS) in a University of Wisconsin solution for 21 to 24 h (n = 6), whereas the test group received an additional 3 h NEVP after CS of 21 h (n = 5). Results: The 3-d survival was 60% in the NEVP arm versus 0% in the control arm (P = 0.008; log rank). Graft parenchyma was 60% to 70% preserved in the NEVP arm at necropsy on gross appearance. In addition, the islet function was well preserved, and both the pancreas (including the islets) and the duodenal morphology were maintained histologically. The intravenous glucose tolerance test on the day of euthanasia was in the normoglycemic range for 80% of cases in the NEVP arm. Conclusions: Optimization of pancreas grafts exposed to extended CS with NEVP seems promising at rescuing and reanimating these grafts for transplantation, resulting in significantly improved survival in a porcine pancreas transplant model.

Should advanced donor age be a deterrent in the utilization of grafts from donation after cardiac death in deceased donor liver transplantation? The Toronto experience.

BACKGROUND: Advanced donor age paired with donation after cardiac death (DCD) increases the risk of transplantation, precluding widespread use of grafts from such donors worldwide. Our aim was to analyze outcomes of liver transplantation using grafts from older DCD donors and donation after brain death (DBD) donors. METHODS: Patients who underwent liver transplantation using grafts from deceased donors between January 2016 and December 2021 were included in the study. Short-and long-term outcomes were analyzed for 4 groups of patients: those who received DCD and DBD grafts from younger (< 50 yr) and older (≥ 50 yr) donors. RESULTS: Of the 807 patients included in the analysis, 44.7% (n = 361) of grafts were received from older donors, with grafts for older DCD donors comprising 4.7% of the total cohort (n = 38). Patients who received grafts from older donors had a lower incidence of biliary strictures than those who received grafts from younger donors (7.9% v. 20.0% for DCD donation, p = 0.14, and 4.9% v. 6.8% for DBD donation, p = 0.34), with a significantly lower incidence of ischemic-type biliary strictures in patients who received grafts from older versus younger DCD donors (2.6% v. 18.0%, p = 0.04). There was no difference in 1- and 3-year graft survival rates among patients who received grafts from older and younger DCD donors (92.1% v. 90.8% and 80.2% v. 80.9%, respectively) and those who received grafts from older and younger DBD donors (90.1% v. 93.2% and 85.3% v. 84.4%, respectively) (p = 0.85). Pretransplantation admission to the intensive care unit (hazard ratio [HR] 9.041, p < 0.001) and nonalcoholic steatohepatitis (HR 2.197, p = 0.02) were found to significantly affect survival of grafts from older donors. CONCLUSION: Donor age alone should not be the criterion to determine the acceptability of grafts in liver transplantation. With careful selection criteria, older DCD donors could make a valuable contribution to expanding the liver donor pool, with grafts that produce comparable results to those obtained with standard-criteria grafts.

Impact of organizational learning on sustainable firm performance: Intervening effect of organizational networking and innovation.

This research has analyzed the role of learning in an organization while measuring and managing sustainable organizational performance. Furthermore, our research has also included the intervening role of organizational networking and organizational innovation while analyzing the relationship between organizational learning and sustainable organizational performance. Our research has adopted a quantitative approach while using the survey method to collect data from 710 owners of the manufacturing sector belonging to the Small and Medium Enterprises SMEs operating in Laos. Informed consent was obtained from all participants for your research. Structure equation modeling SEM was used through partial least square PLS software to test the collected data's reliability and validity and test the hypothesis to meet the research objectives. The study's findings reveal that organizational learning is vital to organizational performance and success. Information sources (networks) moderate the relationship between innovation and organizational performance. Our findings confirm that innovation is disruptive if it is not well-informed and well-processed. The research concludes that organizational learning is very vital for sustainable organizational performance. The current research contributes to the body of knowledge by examining sustainable organizational performance from an entirely different perspective.

Normothermic Ex Vivo Machine Perfusion of Discarded Human Pancreas Allografts: A Feasibility Study.

Pancreas transplantation is the only curative treatment for patients with complicated diabetes, and organ shortage is a common and increasing problem. Strategies to expand the donor pool are needed, and normothermic ex vivo perfusion of the pancreas has the potential to test and repair grafts before implantation. Between January 2021 and April 2022, six human pancreases, declined for transplantation or islet isolation, were perfused using a previously established method by our group. All 6 cases were successfully perfused for 4 h, with minimal edema. The mean age of the donors was 44.16 ± 13.8 years. Five grafts were obtained from neurological death donors, and one was obtained from a donation after cardiac death. The mean glucose and lactate levels decreased throughout perfusion and insulin levels increased. All 6 grafts were metabolically active during perfusion and histopathology showed minimal tissue injury and no edema. Human normothermic ex vivo perfusion of the pancreas is feasible and safe and has the potential to expand the donor pool. Future studies will focus on tests and biomarkers for the assessment of grafts.

Outcomes of pancreas transplantation in patients with underlying inflammatory bowel disease: a retrospective case series.

Despite having emerged as a definitive treatment for diabetes mellitus (DM), pancreas transplantation remains a formidable surgical task owing to complications like graft pancreatitis, enteric leaks, and rejection. This becomes more challenging in the setting of underlying bowel pathology, such as inflammatory bowel disease (IBD), which has a strong immune-genomic association of co-existence with DM. Risk of anastomotic leaks, dose adjustments of immunosuppressants and biologicals, and management of IBD flares constitute some of the major perioperative challenges calling for a protocol-based, systematic, multidisciplinary approach. Patients and methods: This was a retrospective case series of patients between January 1996 and July 2021, with all patients being followed up until December 2021. All consecutive patients with end-stage DM who underwent pancreas transplantation (alone, simultaneous with kidney transplantation or after kidney transplantation) and had pre-existing IBD were included in the study. A Comparison of 1-, 5-, 10-year survival was done with pancreas transplant recipients without underlying IBD using Kaplan-Meir curves. Results: Of the total 630 pancreas transplants performed between 1996 and 2021, eight patients had IBD, mostly Crohn's disease. Following pancreas transplantation, two of the eight patients had duodenal leaks, with one a requiring graft pancreatectomy. The 5-year graft survival rate for the cohort was 75% compared to 81.6% for the overall cohort of patients undergoing pancreas transplantation (P=0.48) with a median graft survival of 48.4 months compared to 68.1 months in the latter (P=0.56). Conclusion: The findings of the series provide a snapshot of the outcome of pancreas transplantation in the background of IBD, suggesting a graft and overall patient survival rates comparable with pancreas transplantation in patients without underlying IBD, with further validation of the findings required in a larger cohort of patients in the future.

Evaluating the Influences of Health Expenditure, Energy Consumption, and Environmental Pollution on Life Expectancy in Asia.

This study examines the effects of health expenditure, energy consumption, CO2 emissions, population size, and income on health outcomes in 46 Asian nations between 1997 and 2019. Cross-sectional dependence (CSD) and slope heterogeneity (SH) tests are utilized due to the close linkages between Asian nations as a result of commerce, tourism, religion, and international agreements. The research uses unit root and cointegration tests of the second generation after validating CSD and SH issues. Due to the results of the CSD and SH tests, it is clear that conventional methods of estimation are inappropriate, so a new panel method, the inter autoregressive distributive lag (CS-ARDL) model, is used instead. In addition to CS-ARDL, the study's results were checked with a common correlated effects mean group (CCEMG) method and an augmented mean group (AMG) method. According to the CS-ARDL study, higher rates of energy use and healthcare spending lead to better health outcomes for Asian countries over the long run. CO2 emissions are shown to be harmful to human health, according to the study. The influence of a population's size on health outcomes is shown to be negative in the CS-ARDL and CCEMG, but favorable in the AMG. Only the AMG coefficient is significant. In most instances, the results of the AMG and CCEMG corroborate the results of the CS-ARDL. Among all the factors influencing life expectancy in Asian countries, healthcare spending is the most influential. Hence, to improve health outcomes, Asian countries need to take the required actions to boost health spending, energy consumption, and long-term economic growth. To achieve the best possible health outcomes, Asian countries should also reduce their CO2 emissions.

Intubation, Central Venous Catheter, and Arterial Line Placement in Swine for Translational Research in Abdominal Transplantation Surgery.

Translational surgical research models in swine are crucial for developing safe preclinical protocols. However, the success of the experimental surgeries does not solely rely on the research team's surgical skills; perioperative care and management procedures, like intubation, central venous line, and arterial line placement, are necessary and of the utmost importance for favorable experiment results. As it is uncommon for research teams to have anesthesiologists or any other staff other than the surgical team, the surgical team involved in translational research must acquire and/or develop the skills to perform the perioperative care. The purpose of this paper is to show the techniques of intubation, central venous catheter, and arterial line placement used and perfected at the Toronto Organ Preservation Laboratory over the last 10 years, to be used as a reference for future researchers joining either this team or any other lab performing translational research protocols in swine and/or abdominal transplantation.

Medical Assistance in Dying (MAiD) as a Source of Liver Grafts: Honouring the Ultimate Gift.

OBJECTIVE: To report the clinical outcomes of liver transplants from donors after medical assistance in dying (MAiD) versus donors after cardiac death (DCD) and deceased brain death (DBD). SUMMARY BACKGROUND DATA: In North America, the number of patients needing liver transplants exceeds the number of available donors. In 2016, MAiD was legalized in Canada. METHODS: All patients undergoing deceased donor liver transplantation at Toronto General Hospital between 2016 and 2021 were included in the study. Recipient perioperative and postoperative variables and donor physiological variables were compared among 3 groups. RESULTS: Eight hundred seven patients underwent deceased donor liver transplantation during the study period, including DBD (n=719; 89%), DCD (n=77; 9.5%), and MAiD (n=11; 1.4%). The overall incidence of biliary complications was 6.9% (n=56), the most common being strictures (n=55;6.8%), highest among the MAiD recipients [5.8% (DBD) vs. 14.2% (DCD) vs. 18.2% (MAiD); P =0.008]. There was no significant difference in 1 year (98.4% vs. 96.4% vs. 100%) and 3-year (89.3% vs. 88.7% vs. 100%) ( P =0.56) patient survival among the 3 groups. The 1- and 3- year graft survival rates were comparable (96.2% vs. 95.2% vs. 100% and 92.5% vs. 91% vs. 100%; P =0.37). CONCLUSION: With expected physiological hemodynamic challenges among MAiD and DCD compared with DBD donors, a higher rate of biliary complications was observed in MAiD donors, with no significant difference noted in short-and long-term graft outcomes among the 3 groups. While ethical challenges persist, good initial results suggest that MAiD donors can be safely used in liver transplantation, with results comparable with other established forms of donation.

Normothermic Ex Vivo Pancreas Perfusion for the Preservation of Pancreas Allografts before Transplantation.

Pancreas transplantation (PTx) is a curative treatment for people who live with the burden of a diagnosis of diabetes mellitus (DM). However, due to organ shortages and increasing numbers of patients being listed for PTx, new strategies are needed to increase the number of available grafts for transplantation. Static cold storage (SCS) is considered the gold standard for standard criteria organs. However, standard criteria donors (SCD) are becoming scarce and new strategies that can increase the rate of organ acceptance from extended criteria donors (ECD) are urgently needed. Normothermic ex vivo perfusion (NEVP) is one of the strategies that has become increasingly popular over the past couple of decades. This preservation method has already been used successfully in other organs (liver, kidneys, and lungs) but has been minimally explored in pancreas transplantation. The few papers that describe the method for pancreas show little success, edema being one of the major issues. The following manuscript describes the successful NEVP method and setup developed by our group to perfuse swine pancreas.

Surgical Tips and Tricks for Performing Porcine Pancreas Transplantation.

Despite the promising results of pancreas transplantation in type 1 diabetes mellitus and metabolic syndrome, the biggest concern around this state-of-the-art technique remains the paucity of organs deemed fit for transplantation. High intravascular resistance, delicate intraparenchymal capillary framework, and complex lobular anatomy around the mesenteric vasculature are what make this organ more susceptible to injury and less tolerant to trivial trauma compared to organs such as the liver and kidney. Meticulous surgical dissection and judicious tissue handling form the cornerstone of the entire exercise of pancreas transplantation. Owing to morphological similarity between the anatomy of the porcine pancreas to the surrounding mesenteric vessels and the organs when compared to the human anatomy, demonstration of the technique in the porcine model could help to most accurately extrapolate this to a human setting. The present article aims to outline the essential surgical tips and tricks that need to be followed, in order to ensure a higher success rate of transplantation of this highly susceptible organ in a porcine 3-day survival model.

Whipple's Pancreatoduodenectomy in the Background of Chronic Liver Disease (CLD): An Institutional Experience.

INTRODUCTION: Whipple's pancreatoduodenectomy (PD) is a formidable operation, associated with a high risk of morbidity and mortality. In the setting of an underlying chronic liver disease, the incidence of complications and mortality increases manifold. Patients and Outcomes. Of the 112 Whipple's PD performed between 2018 to 2020 at a high-volume HPB and liver transplant centre, 4 patients underwent the surgery in the background of an underlying chronic liver disease (CLD). All except one were performed in Child's A cirrhotics. There was a single 30-day mortality in this series of 4 patients that occurred in the background of Child's B cirrhosis. On follow-up at 1 year, there was one more mortality in the series, owing to liver decompensation following chemotherapy. CONCLUSION: Judicious preoperative selection criteria, adequate preoperative nutritional and physiological optimisation, and prudent weighing of risk vs. benefit of undergoing Whipple's PD in periampullary malignancies in the setting of CLD are the major determinants of the surgical outcome.

Intestinal obstruction in a tertiary care centre in India: Are the differences with the western experience becoming less?

BACKGROUND: Patients with intestinal obstruction consist of a major proportion of emergency room visits and the complication is associated with a significant morbidity and mortality. It has a diverse aetiology which varies from country to country. In developed countries it is mainly due to adhesions and in developing countries due to obstructed hernias. Although there are numerous studies from the western world on this subject there have been few recent publications from the developing world. PATIENTS AND METHODS: We retrospectively analyzed all the patients admitted with intestinal obstruction to our department from January 1996 to December 2019. Their demographic data, duration of symptoms before presenting to the hospital and interval between admission and surgery were noted along with the cause and level of obstruction. The type of procedure, post-operative complications, mortality or whether re-exploration was done were also noted. Post-operative complications were graded according to the Clavien Dindo classification. RESULTS: A total of 986 patients presented with intestinal obstruction during this period out of which 743 patients underwent surgery. The commonest cause of obstruction was adhesions in 273 (36.7%) - the proportion increased significantly from 23% in 1996-2004 to 51.6% in 2013-2019. This was followed by carcinoma [130(17.5%)], tuberculosis [111(14.9%)], strictures [94(12.7%)] and hernia (5.4%). Colorectal surgery was the most common previous procedure in the adhesions group [85(31.1%)].The overall operative mortality was 41 (5.5%). CONCLUSION: The aetiology of intestinal obstruction in our hospital is now mainly due to adhesions and is thus shifting towards the western pattern. But tuberculosis and obstructed inguinal hernias still constitute of a sizable proportion of our patients.

Blockchain and IPFS Integrated Framework in Bilevel Fog-Cloud Network for Security and Privacy of IoMT Devices.

Internet of Medical Things (IoMT) has emerged as an integral part of the smart health monitoring system in the present world. The smart health monitoring deals with not only for emergency and hospital services but also for maintaining a healthy lifestyle. The industry 5.0 and 5/6G has allowed the development of cost-efficient sensors and devices which can collect a wide range of human biological data and transfer it through wireless network communication in real time. This led to real-time monitoring of patient data through multiple IoMT devices from remote locations. The IoMT network registers a large number of patients and devices every day, along with the generation of huge amount of big data or health data. This patient data should retain data privacy and data security on the IoMT network to avoid any misuse. To attain such data security and privacy of the patient and IoMT devices, a three-level/tier network integrated with blockchain and interplanetary file system (IPFS) has been proposed. The proposed network is making the best use of IPFS and blockchain technology for security and data exchange in a three-level healthcare network. The present framework has been evaluated for various network activities for validating the scalability of the network. The network was found to be efficient in handling complex data with the capability of scalability.

Single stage repair of anorectal malformation with rectovestibular fistula in adult.

Anorectal malformations are a wide spectrum of disorders, affecting both genders and rare adult presentation as with increased knowledge and advancements, the majority of cases are diagnosed and rectified at birth. This case is a classic example of delayed presentation caused by illiteracy and a lack of adequate health care in rural locations and highlights the uniqueness of this disease, presentation in adult age group and its management and effect on patient psychology and mental health. Because all low anorectal abnormalities can be treated in a single stage, neonatal assessment at birth and early referral to advanced health care centres are critical, with anterior or posterior sagittal anorectoplasty performed by the age of six months. Concerning the anomaly, parent education is an important aspect of patient care.

Spectrum of presentation in primary anorectal malignant melanoma and its management.

The article presents a series of four patients with primary anorectal melanoma presenting to our institute between 2016 and 2021. The primary objective of the series is to give an overview of the variable presentation of this rare entity from a high-volume colorectal tertiary care centre in a developing country. The patients ranged in age from 55 to 73 years and were mostly women (except one). The clinical presentation varied from bleeding per rectum to tenesmus and mucus in stools, overlapping with those of inflammatory bowel disease and primary anorectal adenocarcinoma. All patients were treated with surgery (laparoscopic or open), ranging from local excision to abdominoperineal resection. All our patients had a good outcome after surgery with no mortality at 30 or 90 days after surgery. The article aims to present a comprehensive overview of the various options of management with evidence from the surgical literature.

Ectopic gall bladder: A case report.

Ectopic gall bladder under the left lobe of liver is a rare congenital anomaly of the position of gall bladder, which is mostly detected during surgery and causes technical difficulty at the time of operation. We operated a 64-year-old male who presented with gall stone disease and pre-operative ultrasound did not report any abnormality in position. On laparoscopy, it was found to be attached on the left side of falciform ligament under segment III. It was a true ectopic gall bladder without situs inversus. Early division of the falciform ligament and a careful and complete dissection of the gall bladder are advocated before clipping the cystic artery and duct to avoid complications. The present case report discusses about this rare anomaly and the available literature on the subject.

Rare Pseudopapillary Neoplasm of the Pancreas: A 10-Year Experience.

INTRODUCTION: The solid pseudopapillary epithelial neoplasm (SPN) is a rare form of pancreatic neoplasm with an incidence of 2-3% of all pancreatic tumours. The recent increase in incidence is attributed to the increasing use of imaging techniques for nonspecific abdominal complaints. We report our institutional experience in the management of this tumour over the last decade. METHOD: We retrospectively analyzed from a prospectively maintained database of patients from January 2011 to December 2020 who were operated upon for SPN. All the patients were followed till date. RESULTS: Of 479 patients operated on for various types of pancreatic tumours during this period, 15 (3.1%) had SPN. The mean age of presentation was 28 years with a female preponderance (12/15, 80%). The most common location was the body and tail of the pancreas (66%), and the mean size was 6.4 cm (2-15 cm). The tumour extent was defined as 'borderline resectable' in 20% of cases. Distal pancreatectomy was done in 11 patients with spleen preservation in 3. R0, R1, and R2 resection were done in 12, 2, and 1 patient(s), respectively. The operative mortality was 6.7%. All the patients are doing well on follow-up. CONCLUSION: SPN is a low-grade malignant tumour with a strong female predilection. Clinical manifestations have no specificity, imaging examination only contributes tumour location, and the final diagnosis rests on pathology. Surgery is the main modality of treatment and carries a good prognosis.

Recurrent giant retroperitoneal liposarcoma: Review of literature and a rare case report.

INTRODUCTION AND IMPORTANCE: Retroperitoneal liposarcomas (RPLS) are usually grow large with frequent recurrences. Complete surgical excision remains the gold standard treatment for primary and even recurrent tumours. Their prognosis depends on their histological type and grade. We report a recurrent giant de-differentiated RPLS weighing 18.55 kg which was completely excised. To the best of our knowledge, this is one of the largest liposarcoma reported in the literature. CASE PRESENTATION: A 40 year old female presented with a gradually progressing large abdominal lump for 1year. She had had a similar large lump twice in the past and undergone excision of the tumour elsewhere. Firm non-tender mass felt all over abdomen with edema noted over abdominal wall and bilateral lower limbs. PET CT showed large heterogeneously enhancing mass occupying almost the entire abdominopelvic cavity. 50 × 40 × 40cm tumour was completely excised and biopsy showed grade 2 dedifferentiated liposarcoma (DDLS). She is under close follow up with no recurrence at 12months. CLINICAL DISCUSSION: DDLS have lower risk of distant metastases but have a high risk of local recurrence. The most important favourable prognostic factor in these tumours is complete resection with negative margins. Because of the ineffectiveness of current chemotherapy and the requirement of intolerably high radiation doses, surgical excision remains the most effective treatment even for the localized recurrences of RPLS. CONCLUSION: The dedifferentiated subtype should be suspected in locally aggressive RPLS. Close follow up with early detection of recurrences and prompt excision with negative margins lowers the risk of recurrences and improves survival.