Satisfaction and wellbeing of general surgery trainees in the Saudi Arabian residency educational environment: A mixed-methods study.

Background: Surgical residency training is prominently demanding and stressful. This can affect the residents' wellbeing, work-life balance and increase the rates of burnout. We aimed to assess rates of satisfaction and burn-out among GS residents in the national training programs and provide a subsequent in-depth analysis of the potential reasons. Method: A sequential explanatory mixed-methods study was conducted using an online survey and virtual interviews. The validated abbreviated Maslach Burnout Inventory (aMBI) was used to assess burnout while satisfaction was assessed via 5-points Likert scale. Results: After excluding incomplete responses from the total 74 received, 53 were analyzed. The average participant age was 27.4 ± 2 years, with females comprising 52 % of the sample. Junior residents made up 58.5 %, and nearly half -45 %- considered quitting GS training. Moderate to high burnout rates were noted on each aMBI subscale, ranging from 41.7 % to 62.5 %. The majority of residents expressed dissatisfaction with the level of research engagement (81.1 %), supervision, and mentorship. However, operative exposure was a source of satisfaction. Dissatisfaction rates with intra-operative learning, academia, teaching, and clinical exposure were 62.3 %, 52.8 %, 50.9 %, and 35.8 %, respectively. Interviews revealed surgical case flow and a friendly work environment as major satisfaction sources. Conversely, lack of academic supervision and suboptimal hands-on training were major dissatisfaction sources. Conclusion: Dissatisfaction and burn-out is prevalent among national GS training programs. Sub-optimal educational delivery and low-quality hands-on operative exposure -rather than lack of exposure to cases- seem to be the culprit.

Semi-simultaneous hand-assisted laparoscopic (HAL) bilateral nephrectomy and kidney transplantation from the same incision in ADPKD, first case report in Saudi Arabia.

This case report discusses the management of a 46-year-old male patient with autosomal dominant polycystic kidney disease and a high body mass index, who underwent a semi-simultaneous procedure involving hand-assisted laparoscopic bilateral nephrectomy to alleviate severe abdominal symptoms and prepare for a kidney transplantation, all using the same incision. This is the first reported occurrence of such a procedure in Saudi Arabia. Post-operatively, the patient made a successful recovery with excellent kidney function and no complications.

An unusual hernia postkidney transplantation led to intermittent ureteric obstruction.

A 53-year-old man underwent a living donor kidney transplantation in the right iliac fossa 25 years prior to presentation. He had been noting an inguinal bugle that became more prominent as the day progressed, and it regressed at night. Upon further investigations, an ultrasound of the allograft revealed moderate-to-severe hydronephrosis. A computed tomography scan revealed herniation of the bladder and part of the transplanted ureter within the supravesical/direct inguinal space. Lichtenstein-like fashion of repair was performed, and the patient continues to enjoy satisfactory graft function with no recurrence. The case illustrates a rare hernia as a late complication of the kidney transplant incision leading to ureteric obstruction and a successful attempt at operative repair.

Enhancing Transplant Awareness and Acceptance Through Targeting Knowledge Gaps and Common Misconceptions.

Introduction Organ transplantation is a critical intervention for patients with end-stage organ failure, but misconceptions and knowledge gaps often hinder organ donation. This study evaluates the acceptability and effectiveness of an organ donation campaign focusing on addressing knowledge gaps and misconceptions in Riyadh, Saudi Arabia. Methods A two-day awareness campaign was conducted in a shopping mall, featuring four stations providing information on various aspects of organ donation. Participants completed a self-administered, researcher-developed, questionnaire before and after the tour. Results Of the 201 participants, 167 completed the questionnaire (83% response rate). The majority (92.9%) reported learning new information and indicated that the knowledge improved their perspective on organ donation. A high percentage (93.5%) felt the campaign answered their questions, with 90.9% deciding to register as organ donors. Conclusion A knowledge-enhancing campaign can effectively improve public perception and promote awareness of organ donation and transplantation. However, the study is limited by its short timeframe, location, and subjective data. Future research should explore the impact of such campaigns on donor registrations and evaluate their effectiveness in different cultural contexts.

Would a 6-Month Wait Time for Patients With Hepatocellular Carcinoma Improve Organ Allocation in Centers With Active Living Related Liver Transplant Activity?

OBJECTIVES: The Model for End-Stage Liver Disease score is used to prioritize patients awaiting liver transplant. Since hepatocellular carcinoma does not affect the score, patients with hepatocellular carcinoma are given exception points to promote fairness. In the United States,this practice has resulted in overcorrection; hence, a 6-month delay to grant exceptions was implemented. A similar flaw may exist in Saudi Arabia. MATERIALS AND METHODS: We retrospectively reviewed data for 214 adults listed for liver transplant from January 2016 to July 2020 at King Abdulaziz Medical City, Riyadh. Data included diagnoses, Model for End-Stage Liver Disease scores, wait times, and outcomes. Comparative analyses were performed to contrast patients with hepatocellular carcinoma versus patients without hepatocellular carcinoma. RESULTS: Mean age was 55.2 ± 11.6 years, and 61% were male patients. Outcomes were that the patient received a transplant(77%; n = 165/214), dropped out (18%; n = 38/214), or remained on the wait (5%; n = 11/214). Of the hepatocellular carcinoma group, 84% (n = 56/68) received transplant versus 74% (n = 108/146) in the control group (P = .11). There was no significant difference in dropout rates (P = .33). Patients with hepatocellular carcinoma constituted 32% (n = 68/214) ofthe waitlist, yetthey received 40% of deceased organ offers (P = .015). Most patients in the hepatocellular carcinoma group received pretransplant bridging therapy for a median of 166 days (101-329.5 days). Median time from listing to transplant was shorter for the control group, 57 days versus 148 days (P < .001). Long-term outcomes were comparable between both groups. CONCLUSIONS: This study suggests that implementation of the 6-month wait time for patients with hepatocellular carcinoma before granting exception points may not be necessary for active living related liver transplant programs. Nevertheless, this remains a sound strategy to follow.

Graft and Patient Outcomes of Kidney Transplant Tourism: A Single-Center Experience.

Background The supply-demand mismatch between organ donor and patient waiting for transplant has led to the growth of transplant tourism. This type of transplant is considered unethical and illegal, as it is usually performed in poor environments and carries a higher risk of infectious, vascular, and immunological complications. Methods In this single-centered retrospective cohort study, we compared patients who underwent transplant tourism to patients who were transplanted locally and followed up in our hospital from January 2015 to December 2018. Result A total of 254 local transplants and 60 patients from the transplant tourism group were included. Transplant tourism recipients were younger otherwise both groups were similar in gender, body mass index, diabetes, and hypertension. Recipients in the transplant tourism group had a significantly higher rate of delayed graft function (18.3% vs. 6.3%, p 0.005), acute rejection (40% vs. 7.9%, p < 0.001), and higher posttransplant infection in general. With more urological complications and higher graft failure at 3-years' follow-up (11.7% vs. 0.8%, p < 0.001). Conclusion Transplant tourism is associated with a higher risk of infection and poor graft outcomes. Extra efforts are required to cut down transplant tourism by educating patients about its clinical risk and ethical considerations. In addition, measures to increase the number of deceased donor pool to provide a better alternative options for patients are essential.

Weight gain after renal transplant: Incidence, risk factors, and outcomes.

BACKGROUND: Renal transplantation is the definitive treatment for patients with end-stage renal disease (ESRD). It is associated with better quality of life and patient survival. Nevertheless, these benefits come with rising concerns about weight gain and metabolic abnormalities, which adversely impact transplant outcomes. OBJECTIVE: The objective of this study is to estimate the incidence of weight gain in the first year post-renal transplant in addition to the assessment of potential risk factors and the resulting outcome of the graft. METHODS: We conducted a single-center retrospective cohort study of all 295 patients who underwent kidney transplantation at King Abdulaziz Medical City (KAMC) between January 2016 and December 2019. Clinical and laboratory variables were collected from electronic records. Continuous variables were reported as mean ± standard deviation. Comparison between groups was assessed by unpaired t-test or Mann-Whitney U test while follow-up data were compared using paired t-test and repeated measures ANOVA. Association between the potential risk factors and the weight gain was assessed by means of binary logistic regression analysis. RESULTS: Significant weight gain was observed in 161 (54.6%) patients. Females were 119 (40.30%) of the cohort. The mean age was 45.3±15.1 years. The prevalence of diabetes was 234 (79.6%), while hypertensives constituted 77 (26.3%). The comparison between patients who gained weight significantly and patients with stable weight showed a numerical higher prevalence of female gender in patients who had more weight gain (44.1% vs. 35.8%), higher diabetes, higher rate of a living donor, and statistically significant lower dialysis duration before transplant. Other clinical and laboratory variables were comparable between the two groups. CONCLUSION: Our study showed a high incidence of clinically significant weight gain among patients post-renal transplantation. Patients with lower dialysis duration, a living kidney donor and those who are obese at baseline were at higher risk of gaining weight. Patients who underwent kidney transplantation should be monitored closely for weight gain and further studies are needed to determine the risk factors and appropriate interventions.

Salvage of an iatrogenic partial allograft nephrectomy during caesarean section-a case report.

Since transplanted kidney allografts are standardly placed in a heterotopic pelvic position, any surgical intervention in the pelvis carries the potential risk for allograft injury. A 41-year-old female G4P2 with history of prior kidney transplants presented for an elective cesarean sections (CS). During the CS, profound bleeding was encountered and was later realized to be from the transplanted kidney allograft. A complete transection of the upper pole with the injury extending to the hilar structures was noted. Careful intraoperative evaluation led to the decision favoring a salvage attempt of the remaining part of the allograft. The patient continues to enjoy sufficient allograft function 6 months after the incident. To conclude, although CS after kidney transplantation is considered safe, the risk of allograft injury remains possible with potentially catastrophic consequences. This case highlights the importance of rapid surgical expertise and appropriate preoperative evaluation, preparation and planning.

Usefulness of Controlled Attenuation Parameter and Liver Stiffness Measurement for the Identification of Extended-criteria Donors and Risk-assessment in Liver Transplantation.

BACKGROUND: Controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) are noninvasive surrogates for hepatic steatosis and fibrosis, respectively, and could help identify extended criteria donors in liver transplantation (LT). We aimed to determine the accuracy of CAP/LSM in deceased donors along with post-LT changes. METHODS: Accuracy of preprocurement CAP/LSM to grade/stage steatosis/fibrosis was determined using liver biopsy as reference. Transplant outcomes, including primary nonfunction (PNF) and early allograft dysfunction, were recorded. Recipients underwent CAP/LSM as outpatients. Areas under the receiver operating characteristic curve and regression models were constructed to analyze data. RESULTS: We prospectively evaluated 160 allografts (138 transplanted). Same-probe paired baseline/post-LT CAP was 231 dB/m (181-277)/225 (187-261) (P = 0.61), and LSM 7.6 kPa (6.3-10.8)/5.9 (4.6-8.7) (P = 0.002), respectively. CAP reading was affected by BMI and LSM by ALT, race and bilirubin. Although CAP did not correlate with steatosis from frozen sections (ρ = 0.08, P = 0.47), it correlated with steatosis from permanent sections (ρ = 0.32, P < 0.001) and with oil red O histomorphometry (ρ = 0.35, P = 0.001). CAP identified moderate-to-severe steatosis with an areas under the receiver operating characteristic curve curve of 0.79 (0.66-0.91), for a negative predictive value of 100% at a cutoff value of 230 dB/m. LSM correlated with fibrosis staging (ρ = 0.22, P = 0.007) and it identified discarded allografts with advanced fibrosis/cirrhosis. Patients with no to minimal fibrosis had an LSM of 7.6 (6-10.1) kPa. CONCLUSIONS: Our results are proof-of-concept of the utility of CAP/LSM during organ procurement. Establishing the precise role of these noninvasive tools in the organ allocation process mandates confirmatory studies.

Parvovirus B19 Infection due to over Immunosuppression in Kidney Transplant Recipients: Case Reports and Literature Review.

Parvovirus B19 (PB19) is a single-stranded DNA virus that belongs to the Erythrovirus genus within the Parvoviridae family. Clinical presentations associated with PB19 infection vary greatly, depending on the infected individual's age and hematologic and immunologic status. The limited data available regarding consensus on screening algorithms and indications in donors and recipients prior to kidney transplantation makes diagnosis and management challenging. We presented 3 cases of pure red cell aplasia due to parvovirus B19 after kidney transplant. These patients were diagnosed with severe normocytic, normochromic anemia (hemoglobin below 60 g/L) in the 1st 6 months posttransplant. A complete anemia work-up revealed low reticulocyte count and was otherwise inconclusive. All patients were diagnosed with pure red cell aplasia due to parvovirus B19. Two patients improved after receiving intravenous immunoglobulin 2 gm/kg given over 4 doses. Unfortunately, they relapse after few weeks and required additional doses of intravenous immunoglobulin in conjugation with reduction of their immunosuppressive medication. The third patient improved after holding mycophenolate mofetil (MMF) and did not require intravenous immunoglobulin. Whereas PB19 infection is typically self-limiting and associated with positive IgM serology in immunocompetent hosts, these cases highlight the importance of considering PB19 infection in the differential diagnosis of persistent anemia in immunocompromised patients and the challenges in confirming the diagnosis. Intravenous immunoglobulin (IVIG) can be an effective treatment in immunocompromised patients with primary or relapsed PB19 infection in conjunction with minimizing immunosuppressive medication. Further research and consideration are required to determine appropriate and targeted screening in donors and recipients in the peritransplantation period.

Urinary Tract Infections in the First 6 Months after Renal Transplantation.

PURPOSE: Urinary tract infections (UTIs) are common in the first 6 months after renal transplantation, and there are only limited data about UTIs after transplantation in Saudi Arabia in general. METHODS: A retrospective study from January 2017 to May 2020 with 6-month follow-up. RESULTS: 279 renal transplant recipients were included. Mean age was 43.4 ± 16.0 years, and114 (40.9%) were women. Urinary stents were inserted routinely during transplantation and were removed 35.3 ± 28 days postoperatively. Ninety-seven patients (35%) developed urinary tract infections (UTIs) in the first six months after renal transplantation. Of those who developed the first episode of UTI, the recurrence rates were 57%, 27%, and 14% for having one, two, or three recurrences, respectively. Late urinary stent removals, defined as more than 21 days postoperatively, tended to have more UTIs (OR: 1.43, P: 0.259, CI: 0.76-2.66). Age >40, female gender, history of neurogenic bladder, and transplantation abroad were statistically significant factors associated with UTIs and recurrence. Diabetes, level of immunosuppression, deceased donor renal transplantation, pretransplant residual urine volume, or history of vesicoureteral reflux (VUR) was not associated with a higher incidence of UTIs. UTIs were asymptomatic in 60% but complicated with bacteremia in 6% of the cases. Multidrug resistant organisms (MDROs) were the causative organisms in 42% of cases, and in-hospital treatment was required in about 50% of cases. Norfloxacin + Bactrim DD (160/800 mg) every other day was not associated with the lower risk of developing UTIs compared to the standard prophylaxis daily Bactrim SS (80/400 mg). CONCLUSION: UTIs and recurrence are common in the first 6 months after renal transplantation. Age >40, female gender, neurogenic bladder, and transplantation abroad are associated with the increased risk of UTIs and recurrence. MDROs are common causative organisms, and hospitalization is frequently required. Dual prophylactic antibiotics did not seem to be advantageous over the standard daily Bactrim.

The Impact of Timing of Stent Removal on the Incidence of UTI, Recurrence, Symptomatology, Resistance, and Hospitalization in Renal Transplant Recipients.

PURPOSE: To evaluate the impact of early (<3 weeks) versus late (>3 weeks) urinary stent removal on urinary tract infections (UTIs) post renal transplantation. METHODS: A retrospective study was performed including all adult renal transplants who were transplanted between January 2017 and May 2020 with a minimum of 6-month follow-up at King Abdulaziz Medical City, Riyadh, Saudi Arabia. RESULTS: A total of 279 kidney recipients included in the study were stratified into 114 in the early stent removal group (ESR) and 165 in the late stent removal group (LSR). Mean age was 43.4 ± 15.8; women: n: 114, 40.90%; and deceased donor transplant: n: 55, 19.70%. Mean stent removal time was 35.3 ± 28.0 days posttransplant (14.1 ± 4.6 days in the ESR versus 49.9 ± 28.1 days in LSR, p < 0.001). Seventy-four UTIs were diagnosed while the stents were in vivo or up to two weeks after the stent removal "UTIs related to the stent" (n = 20, 17.5% in ESR versus n = 54, 32.7% in LSR; p=0.006). By six months after transplantation, there were 97 UTIs (n = 36, 31.6% UTIs in ESR versus n = 61, 37% in LSR; p=0.373). Compared with UTIs diagnosed after stent removal, UTIs diagnosed while the stent was still in vivo tended to be complicated (17.9% versus 4.9%, p: 0.019), recurrent (66.1% versus 46.3%; p: 0.063), associated with bacteremia (10.7% versus 0%; p: 0.019), and requiring hospitalization (61% versus 24%, p: 0.024). Early stent removal decreased the need for expedited stent removal due to UTI reasons (rate of UTIs before stent removal) (n = 11, 9% in the early group versus n = 45, 27% in the late group; p=0.001). The effect on the rate of multidrug-resistant organisms (MDRO) was less clear (33% versus 47%, p: 0.205). Early stent removal was associated with a statistically significant reduction in the incidence of UTIs related to the stent (HR = 0.505, 95% CI: 0.302-0.844, p=0.009) without increasing the incidence of urological complications. Removing the stent before 21 days posttransplantation decreased UTIs related to stent (aOR: 0.403, CI: 0.218-0.744). Removing the stent before 14 days may even further decrease the risk of UTIs (aOR: 0.311, CI: 0.035- 2.726). CONCLUSION: Early ureteric stent removal defined as less than 21 days post renal transplantation reduced the incidence of UTIs related to stent without increasing the incidence of urological complications. UTIs occurring while the ureteric stent still in vivo were notably associated with bacteremia and hospitalization. A randomized trial will be required to further determine the best timing for stent removal.

The Effect of Bariatric Surgery on Metabolic Syndrome: A Three-center Experience in Saudi Arabia.

PURPOSE: The prevalence of metabolic syndrome (MetS) increases in parallel with the increasing incidence of obesity. Hence, bariatric surgery is potentially curative in obese patients with MetS. We aim to measure the effect of bariatric surgery as well as the potential factors leading to MetS resolution in the Saudi population. METHODS: A retrospective review of three tertiary care centers in Saudi Arabia was done. We identified 386 patients who have MetS and underwent bariatric surgery during the period between January 2016 and December 2018. After exclusion of patients with insufficient follow-up, data from 275 patients was analyzed. MetS diagnosis, persistence, and resolution were determined using the International Diabetes Federation consensus worldwide definition. RESULTS: MetS resolution was achieved in 78%, 79%, 73%, and 82% at 1, 2, 3, and 4 years after bariatric surgery, respectively. Accumulatively, 80% achieved MetS resolution with an average follow-up period of two and a half years. Patients who experienced resolution had younger age, lower BMI, lower systolic blood pressure, lower triglycerides, lower fasting plasma glucose, and lower HbA1c preoperatively in addition to a higher percentage of excess weight loss after bariatric surgery when compared to those who had persistence of MetS. CONCLUSION: More than three fourths of patients with MetS achieved resolution after bariatric surgery. Certain patient characteristics, such as young age and higher excess weight loss postoperatively, were associated with a higher chance of MetS resolution.

Ways to Overcome Organ Shortage: Increasing Donor Pool by Accepting Suboptimal Kidney Donors.

Many factors affect organ donations worldwide, including religious factors, legislative decisions, economic factors, presence of organ procurement organizations, cultural issues, the presence of commercial transplant, and other unknown factors. The number of patients with end-stage renal disease has increased by 6% worldwide. Even with more transplant procedures, these numbers have not combated the dramatically increased number of patients on wait lists. With regard to potential living donors, around 50% are either blood group or HLA incompatible with the recipient, which then requires patient desensitization or paired kidney donation or a combination of both. Survival rates of kidney donors and the general population are almost the same 35 to 40 years after donation. Although the renal consequences of diabetes after kidney donation are almost the same as that shown in the general population, other risk factors should be considered, such as hypertension, proteinuria, and low glomerular filtration rate, before donation. It is so far unknown whether donors with impaired glucose tolerance can safely donate. With diabetes, what was considered normal blood sugar in 1960 to 1990 is now considered frank diabetes. What was considered normal blood pressure is now considered hypertension. Because individuals with these parameters were accepted as organ donors in the past and have been shown to maintain good health, it is worth considering the safe use of organs from donors with early diabetes and hypertension. Whereas young donors may have not reached the age at which hypertension, diabetes, and other kidney diseases develop, older donors have the lowest likelihood of developing end-stage renal disease after donation. As a general approach, young donors can be accepted if they have high glomerular filtration rate, but young donors from certain ethnic minorities and/or extensive family history of chronic kidney disease and those less than 18 years old should not be considered.

Author Correction: Sustained perfusion of revascularized bioengineered livers heterotopically transplanted into immunosuppressed pigs.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Sustained perfusion of revascularized bioengineered livers heterotopically transplanted into immunosuppressed pigs.

Implanted bioengineered livers have not exceeded three days of continuous perfusion. Here we show that decellularized whole porcine livers revascularized with human umbilical vein endothelial cells and implanted heterotopically into immunosuppressed pigs whose spleens had been removed can sustain perfusion for up to 15 days. We identified peak glucose consumption rate as a main predictor of the patency of the revascularized bioengineered livers (rBELs). Heterotopic implantation of rBELs into pigs in the absence of anticoagulation therapy led to sustained perfusion for three days, followed by a pronounced immune responses directed against the human endothelial cells. A 10 day steroid-based immunosuppression protocol and a splenectomy at the time of rBEL implantation reduced the immune responses and resulted in continuous perfusion of the rBELs for over two weeks. We also show that the human endothelial cells in the perfused rBELs colonize the liver sinusoids and express sinusoidal endothelial markers similar to those in normal liver tissue. Revascularized liver scaffolds that can maintain blood perfusion at physiological pressures might eventually help to overcome the chronic shortage of transplantable human livers.

Use of Eculizumab for Active Antibody-mediated Rejection That Occurs Early Post-kidney Transplantation: A Consecutive Series of 15 Cases.

BACKGROUND: Active antibody-mediated rejection (AMR) that occurs during the amnestic response within the first month posttransplant is a rare but devastating cause of early allograft loss after kidney transplant. Prior reports of eculizumab treatment for AMR have been in heterogeneous patient groups needing salvage therapy or presenting at varied time points. We investigated the role of eculizumab as primary therapy for active AMR early posttransplant. METHODS: We performed a retrospective observational study of a consecutive cohort of solitary kidney transplant recipients who were transplanted between January 1, 2014, and January 31, 2018, and had AMR within the first 30 days posttransplant and treated with eculizumab ± plasmapheresis. RESULTS: Fifteen patients had early active AMR at a median (interquartile range [IQR]) of 10 (7-11) days posttransplant and were treated with eculizumab ± plasmapheresis. Thirteen cases were biopsy proven, and 2 cases were presumed on the basis of donor-specific antibody trends and allograft function. Within 1 week of treatment, the median estimated glomerular filtration rate increased from 21 to 34 mL/min (P = 0.001); and persistent active AMR was only found in 16.7% (2/12) of biopsied patients within 4-6 months. No graft losses occurred, and at last follow-up (median [IQR] of 13 [12-19] mo), the median IQR estimated glomerular filtration rate increased to 52 (46-60) mL/min. CONCLUSIONS: Prompt eculizumab treatment as primary therapy is safe and effective for early active AMR after kidney transplant or abrupt increases in donor-specific antibodies when biopsy cannot be performed for diagnosis confirmation.

Successful endoscopic management of gastric perforation caused by ingesting a sharp chicken bone.

INTRODUCTION: Gastrointestinal perforation related to foreign body ingestion is uncommon. Surgical interventions aiming at removal of the offending agent and restoration of bowel continuity are sought when perforations occur. Presentation of case A 68 year old male presented with epigastric abdominal pain and anorexia for 2 days. On examination, he was febrile and had localized epigastric tenderness. Laboratory investigations revealed marked leucocytosis with no other abnormalities. Computed tomography revealed the presence of a foreign body penetrating through the full thickness of the gastric wall with its tip lying adjacent to the pancreatic head. Endoscopic trial to extract the foreign body was successfully carried out. The gastric defect was sealed by applying an endoscopic metallic clip. DISCUSSION: Gastric perforations secondary to foreign body ingestion usually follow an elusive clinical course and are rarely diagnosed early in its course. Early diagnosis allows for the utilization of minimally invasive management. Unfortunately, Most reported cases were diagnosed after intra-abdominal processes, such as abscesses, have ensued. CONCLUSION: This case illustrates the importance of early diagnosis of foreign body related gastrointestinal perforations and emphasizes the role of therapeutic endoscopy.

Outcome of duct-to-duct vs. Roux-en-Y hepaticojejunostomy biliary anastomoses in below 15-kg pediatric liver transplant recipients.

The best type of biliary anastomosis to use in lower weight pediatric liver transplant recipients is debatable. In this study, we share a single center's experience comparing the rate of anastomotic biliary complications based on the type of biliary anastomosis performed in this population of patients. A retrospective review of pediatric liver transplants for recipients weighing <15 kg from 11/2003 till 12/2011 was performed. Patients were grouped based on the type of biliary anastomosis into two groups: duct-to-duct (d-d) and Roux-en-Y hepaticojejunostomy (h-j) anastomoses. A total of 24 patients (12 males, 12 females) with a mean age of 26 ± 20 months and a mean weight of 9.27 ± 2.63 kg (range = 5.3-13.9 kg) were studied. All anastomotic complications occurred in patients who received left lateral segments. No statistical differences were found in the post-operative biliary (p = 0.86) or vascular (p = 0.99) complications between the two groups. Acknowledging the limited sample size, our data suggest that duct-to-duct anastomosis can be performed safely in pediatric liver transplantation recipients weighing below 15 kg.