Effect of a Hispanic outreach program on referral and liver transplantation volume at a single center.

BACKGROUND: Although Hispanic patients have high rates of end-stage liver disease and liver cancer, for which liver transplantation (LT) offers the best long-term outcomes, they are less likely to receive LT. Studies of end-stage renal disease patients and kidney transplant candidates have shown that targeted, culturally relevant interventions can increase the likelihood of Hispanic patients receiving kidney transplant. However, similar interventions remain largely unstudied in potential LT candidates. METHODS: Referrals to a single center in Texas with a large Hispanic patient population were compared before (01/2018-12/2019) and after (7/2021-6/2023) the implementation of a targeted outreach program. Patient progress toward LT, reasons for ineligibility, and differences in insurance were examined between the two eras. RESULTS: A greater proportion of Hispanic patients were referred for LT after the implementation of the outreach program (23.2% vs 26.2%, p = 0.004). Comparing the pre-outreach era to the post-outreach era, more Hispanic patients achieved waitlisting status (61 vs 78, respectively) and received a LT (971 vs 82, respectively). However, the proportion of Hispanic patients undergoing LT dropped from 30.2% to 20.3%. In the post-outreach era, half of the Hispanic patients were unable to get LT for financial reasons (112, 50.5%). CONCLUSIONS: A targeted outreach program for Hispanic patients with end-stage liver disease effectively increased the total number of Hispanic LT referrals and recipients. However, many of the patients who were referred were ineligible for LT, most frequently for financial reasons. These results highlight the need for additional research into the most effective ways to ameliorate financial barriers to LT in this high-need community.

Single-center Outcomes After Liver Transplantation With SARS-CoV-2-Positive Donors: An Argument for Increased Utilization.

Background: The COVID-19 pandemic has led to an increase in SARS-CoV-2-test positive potential organ donors. The benefits of life-saving liver transplantation (LT) must be balanced against the potential risk of donor-derived viral transmission. Although emerging evidence suggests that the use of COVID-19-positive donor organs may be safe, granular series thoroughly evaluating safety are still needed. Results of 29 consecutive LTs from COVID-19-positive donors at a single center are presented here. Methods: A retrospective cohort study of LT recipients between April 2020 and December 2022 was conducted. Differences between recipients of COVID-19-positive (n = 29 total; 25 index, 4 redo) and COVID-19-negative (n = 472 total; 454 index, 18 redo) deceased donor liver grafts were compared. Results: COVID-19-positive donors were significantly younger (P = 0.04) and had lower kidney donor profile indices (P = 0.04) than COVID-19-negative donors. Recipients of COVID-19-positive donor grafts were older (P = 0.04) but otherwise similar to recipients of negative donors. Donor SARS-CoV-2 infection status was not associated with a overall survival of recipients (hazard ratio, 1.11; 95% confidence interval, 0.24-5.04; P = 0.89). There were 3 deaths among recipients of liver grafts from COVID-19-positive donors. No death seemed virally mediated because there was no qualitative association with peri-LT antispike antibody titers, post-LT prophylaxis, or SARS-CoV-2 variants. Conclusions: The utilization of liver grafts from COVID-19-positive donors was not associated with a decreased overall survival of recipients. There was no suggestion of viral transmission from donor to recipient. The results from this large single-center study suggest that COVID-19-positive donors may be used safely to expand the deceased donor pool.

Surgical techniques for robotic right donor hepatectomy, part 2: robotic parenchymal transection and bile duct division.

Robotic surgery is emerging as a feasible minimally invasive approach for donor hepatectomy at specialized centers. The aim of this article is to systematically describe the surgical techniques for robotic parenchymal transection and bile duct division in right donor hepatectomy. The setup of the robotic arms, methods of parenchymal transection using robotic instruments, and right hepatic duct division with the aid of indocyanine green dye are detailed, along with the pearls and pitfalls of these two parts of the operation.

Surgical techniques for robotic right donor hepatectomy, part 1: robotic hilar dissection and right lobe mobilization.

Robotic surgery is emerging as a feasible minimally invasive approach for donor hepatectomy at specialized centers. The aim of this article is to systematically describe the surgical techniques for robotic hilar dissection and right lobe mobilization in right donor hepatectomy. The setup of the robotic arms, the dissection of inflow vessels and retrohepatic inferior vena cava, and the pearls and pitfalls of these two parts of the operation are detailed.

Transplant Oncology: An Emerging Discipline of Cancer Treatment.

Transplant oncology is an emerging concept of cancer treatment with a promising prospective outcome. The applications of oncology, transplant medicine, and surgery are the core of transplant oncology to improve patients' survival and quality of life. The main concept of transplant oncology is to radically cure cancer by removing the diseased organ and replacing it with a healthy one, aiming to improve the survival outcomes and quality of life of cancer patients. Subsequently, it seeks to expand the treatment options and research for hepatobiliary malignancies, which have seen significantly improved survival outcomes after the implementation of liver transplantation (LT). In the case of colorectal cancer (CRC) in the transplant setting, where the liver is the most common site of metastasis of patients who are considered to have unresectable disease, initial studies have shown improved survival for LT treatment compared to palliative therapy interventions. The indications of LT for hepatobiliary malignancies have been slowly expanded over the years beyond Milan criteria in a stepwise manner. However, the outcome improvements and overall patient survival are limited to the specifics of the setting and systematic intervention options. This review aims to illustrate the representative concepts and history of transplant oncology as an emerging discipline for the management of hepatobiliary malignancies, in addition to other emerging concepts, such as the uses of immunotherapy in a peri-transplant setting as well as the use of circulating tumor DNA (ctDNA) for surveillance post-transplantation.

Validation of a multidisciplinary virtual reality (VR) robotic surgical curriculum.

The objective is to identify whether trainees demonstrate improvement in a standardized knot-tying task as assessed by Global Evaluative Assessment of Robotic Skills (GEARS) score after completion of a virtual reality (VR) robotic curriculum. An IRB-exempt prospective study was conducted with surgical trainees from August 2021 to February 2023. Participants initially performed a baseline robotic suturing task in which they were instructed to tie interrupted square knots in 10 min. Participants then completed a virtual reality simulation curriculum involving 23 exercises until they achieved 90% proficiency on all tasks. Participants then repeated the suturing task. Pre- and post-curriculum suturing tasks were recorded, de-identified, and scored by expert graders using a GEARS score. Trainees from three academic centers were invited to participate. Medical students (MS1-MS3) and surgical residents from gynecology, urology, and general surgery were invited to participate. Twenty-five trainees completed the pre-curriculum suturing task, the VR curriculum, and the post-curriculum suturing task. Trainees demonstrated significant improvement in their post-test GEARS score by 2.43 points (p < 0.05) and were able to tie three additional knots within 10 min after completion of the curriculum (p < 0.05). Trainees also demonstrated a faster time to complete first knot (114 s improvement, p < 0.05) after completion of the curriculum. All participants agreed or strongly agreed that completion of the robotic curriculum helped them feel more comfortable using the robotic console, and improved their robotic surgical skills. Surgical trainees and medical students with limited prior robotic surgical experience demonstrated objective improvement after completion of a standardized VR curriculum.

Developing basic robotic skills using virtual reality simulation and automated assessment tools: a multidisciplinary robotic virtual reality-based curriculum using the Da Vinci Skills Simulator and tracking progress with the Intuitive Learning platform.

This study sought to develop basic robotic surgical skills among surgical trainees across multiple specialties using a VR-based curriculum and provided objective, on-demand, automated assessments using the Intuitive Learning platform. This curriculum was developed using the Da Vinci Skills Simulator and included 24 exercises. A pre-test and post-test were required for completion of the curriculum. Scores > 90 on individual exercises and the post-test were required for successful completion. The Intuitive learning platform provided automated performance metrics and tracked trainee progression. The curriculum was implemented and data collected over a 12-month period. 21 trainees completed the entire curriculum. Post-test scores were significantly higher than pre-test scores and trainees reported improvement in their robotic skills after curriculum completion. A comparison based on training level revealed that junior residents had significantly lower number of attempts per exercise, fewer penalties, and higher completion scores when compared to senior residents and fellows. Individual exercise analysis demonstrated that exercises, such as 'Three-Arm Relay' and 'Ring Rollercoaster', required the longest time and most attempts to achieve a passing score. The 'Energy Pedals' and 'Knot Tying' skills were the least-utilized skills addressed in the curriculum. Virtual reality-based curriculums using the Intuitive Learning platform can be standardized across multiple specialties allowing for the development of basic robotic skills, shared interdisciplinary surgical education, and provides powerful objective and automated performance metrics of trainees.

Laparoscopic Removal of Intrahepatic Foreign Body: A Novel Technique for Management of an Unusual Cause of Liver Abscess--Fish Bone Migration.

BACKGROUND: Fish bone migration from the gastrointestinal tract into the liver is an unusual cause of liver abscess. MATERIALS AND METHODS: We describe successful laparoscopic removal of intrahepatic fish bones in 2 patients who presented with liver abscesses. Both patients were admitted to our institution with a 2-week history of right upper quadrant pain, fever, chills, and rigors. Radiological imaging revealed the presence of a linear calcified foreign body within a hepatic abscess in the left lateral section of the liver. These findings were suggestive of infection secondary to migration of fish bone from the stomach to the liver. RESULTS: Both patients underwent percutaneous drainage of liver abscesses with control of sepsis, followed by laparoscopic removal of intrahepatic fish bones. Localization of the fish bones was facilitated by intraoperative ultrasonographic examination of the liver. Postoperative recovery was fast and uneventful. CONCLUSIONS: This is the first report of two consecutive cases of liver abscess caused by fish bone migration where our patients were successfully treated by percutaneous drainage of the abscess followed by laparoscopic removal of intrahepatic fish bone.

Strict Selection Criteria During Surgical Training Ensures Good Outcomes in Laparoscopic Omental Patch Repair (LOPR) for Perforated Peptic Ulcer (PPU).

Application of minimal access surgery in acute care surgery is limited due to various reasons. Laparoscopic omental patch repair (LOPR) for perforated peptic ulcer (PPU) surgery is safe and feasible but not widely implemented. We report our early experience of LOPR with emphasis on strict selection criteria. This is a descriptive study of all patients operated on for PPU at academic university-affiliated institutes from December 2010 to February 2012. All the patients who were operated on for LOPR were included as the study population and their records were studied. Perioperative outcomes, Boey score, Mannheim Peritonitis Index (MPI), and physiologic and operative severity scores for enumeration of mortality and morbidity (POSSUM) scores were calculated. All the data were tabulated in a Microsoft Excel spreadsheet and analyzed using Stata Version 8.x. (StataCorp, College Station, TX, USA). Fourteen patients had LOPR out of a total of 45 patients operated for the PPU. Mean age was 46 years (range 22-87 years). Twelve patients (86%) had a Boey score of 0 and all patients had MPI < 21 (mean MPI = 14). The predicted POSSUM morbidity and mortality were 36% and 7%, respectively. Mean ulcer size was 5 mm (range 2-10 mm), mean operating time was 100 minutes (range 70-123 minutes) and mean length of hospital stay was 4 days (range 3-6 days). There was no morbidity or mortality pertaining to LOPR. LOPR should be offered by acute care surgical teams when local expertise is available. This can optimize patient outcomes when strict selection criteria are applied.

Incidence of death and potentially life-threatening near-miss events in living donor hepatic lobectomy: a world-wide survey.

The incidence of morbidity and mortality after living donor liver transplantation (LDLT) is not well understood because reporting is not standardized and relies on single-center reports. Aborted hepatectomies (AHs) and potentially life-threatening near-miss events (during which a donor's life may be in danger but after which there are no long-term sequelae) are rarely reported. We conducted a worldwide survey of programs performing LDLT to determine the incidence of these events. A survey instrument was sent to 148 programs performing LDLT. The programs were asked to provide donor demographics, case volumes, and information about graft types, operative morbidity and mortality, near-miss events, and AHs. Seventy-one programs (48%), which performed donor hepatectomy 11,553 times and represented 21 countries, completed the survey. The average donor morbidity rate was 24%, with 5 donors (0.04%) requiring transplantation. The donor mortality rate was 0.2% (23/11,553), with the majority of deaths occurring within 60 days, and all but 4 deaths were related to the donation surgery. The incidences of near-miss events and AH were 1.1% and 1.2%, respectively. Program experience did not affect the incidence of donor morbidity or mortality, but near-miss events and AH were more likely in low-volume programs (≤50 LDLT procedures). In conclusion, it appears that independently of program experience, there is a consistent donor mortality rate of 0.2% associated with LDLT donor procedures, yet increased experience is associated with lower rates of AH and near-miss events. Potentially life-threatening near-miss events and AH are underappreciated complications that must be discussed as part of the informed consent process with any potential living liver donor.

Successful nutritional therapy for superior mesenteric artery syndrome.

Superior mesenteric artery (SMA) syndrome is an uncommon cause of duodenal outlet obstruction. Symptoms and signs suggestive of this condition are nonspecific, and a high index of suspicion coupled with appropriate imaging studies are necessary for diagnosis. We present the case of a 70-year-old man who developed SMA syndrome following prolonged hospitalisation for a surgically treated bleeding duodenal ulcer. His SMA syndrome resolved after successful nonoperative management based on accepted guidelines for nutritional therapy, thus avoiding the need for reoperation and its attendant risks in a malnourished patient.

Video-assisted Thoracoscopic Surgery (VATS) drainage of salmonella enteritidis empyema and needle-localization for retrieval of a dropped gallstone.

INTRODUCTION: Spillage of gallstones into the peritoneal cavity (dropped gallstones) is more common in laparoscopic compared with open cholecystectomy. Subsequent infectious complications are often delayed, occurring in 0.1% to 2.9% of cases. We present the first reported case of Salmonella enterica subphrenic abscess and empyema complicating dropped gallstones, treated with video-assisted thoracoscopic surgery (VATS), and surgical retrieval. CASE REPORT: A 67-year-old male with symptomatic cholelithiasis underwent an uncomplicated laparoscopic cholecystectomy. Four years later, he presented with a mass in his right flank, and an abdominal computed tomography (CT) revealed a right flank intramuscular abscess containing gallstones. The abscess was drained surgically with removal of gallstones. He was readmitted 15 months later with right upper quadrant pain, fever, and dyspnea. Chest and abdominal computer tomography (CT) showed a right pleural effusion and a right subphrenic abscess containing a dropped gallstone. The gallstone was localized with a needle using CT guidance. He subsequently underwent a right VATS for decortication. A separate flank incision was made at the site of the needle to drain the subphrenic abscess and retrieve the gallstone. Cultures from his empyema grew S enteritidis. The patient made an uneventful recovery. DISCUSSION: During laparoscopic cholecystectomy, efforts should be made to retrieve dropped gallstones as they can cause abscess and empyema, which might necessitate furthermore surgical intervention. The use of VATS has been established as a safe and effective alternative to thoracotomy, including the treatment of empyema. Needle-localization resulted in a successful retrieval of the gallstone in our patient. Culture of the abscess is important, as unusual organisms such as Salmonella could be present. S. enteritidis has not been implicated as a cause of cholecystitis and is rarely associated with abdominal abscesses. We postulate that the organism reached the gallbladder through the bile or bloodstream after gastrointestinal colonization and that its persistence in the gallbladder may have been facilitated by gallstones.

Eliminating the effects of paradoxic imaging during laparoscopic surgery.

BACKGROUND: Complex laparoscopic tasks are nearly impossible to complete when the telescope is pointed toward the operator (i.e., paradoxic image). Attempts at image manipulation have been reported, but altered monitor displays may introduce even more confusion. The availability of high-quality, lightweight, head-mounted displays (HMDs) now allows individualization of the laparoscopic image. We studied the effect of manipulation of the paradoxic image on task performance. STUDY DESIGN: Fifteen surgical residents (PGY levels 1-5) were timed while performing the standard "bead pass" skill from the Fundamentals of Laparoscopic Surgery (FLS) course. Conventional diamond-shaped configuration, with telescope and camera in line with the operator and overhead image projection at the opposite end, served as control. A paradoxic image was created by placing the telescope at the opposite side of the box trainer (180 degrees from operator), and the task was repeated with different image corrections: (1) paradoxic image as-is; (2) left-right reversed image (mirror); and (3) left-right reversed and upside-down image (i.e., inverted mirror). Times were recorded and analyzed for intra- and interoperator variance and compared with control. RESULTS: Time-per-bead was 7.5 +/- 1.5 seconds (standard error of the mean) in controls. With the as-is paradoxic image, time-per-bead was 164.1 +/- 80.8 seconds/bead. All but 2 residents failed to complete the task. Times were 120.0 +/- 55.9 seconds/bead for the mirror image and 46.7 +/- 26.0 seconds/bead for the inverted mirror image (P < 0.01; ANOVA and Kruskal-Wallis). CONCLUSIONS: The difficulty of performing a relatively simple laparoscopic task with paradoxic image display was almost insurmountable. Left-right image inversion was not sufficient to correct the handicap. Inverted mirror-image projection significantly improved performance, which almost reached control levels. The availability of personal image-display devices may, in the future, allow image customization for task performance in suboptimal conditions during endoscopic surgery.

Living donor liver transplantation for hepatocellular carcinoma: Increased recurrence but improved survival.

In regions with a limited deceased donor pool, living donor adult liver transplantation (LDALT) has become an important treatment modality for patients with hepatocellular carcinoma (HCC) and cirrhosis. Studies have shown higher recurrence rates of HCC after LDALT in comparison with deceased donor liver transplantation (DDLT). The aim of our study was to examine the outcome results and recurrence rates for patients with HCC who underwent LDALT at our center. During an 8-year period, 139 patients underwent LDALT, of whom 28 (20.1%) had HCC in their explanted livers. The median follow-up was 40.8 months. The mean explant tumor size was 3.3 +/- 1.2, and the mean number of tumors was 1.5 +/- 0.8. Twenty-one patients (75%) had tumors within the Milan criteria, 5 patients had tumors outside the Milan criteria but within the University of California San Francisco (UCSF) criteria, and 2 patients were beyond the UCSF criteria. The overall 1- and 5-year patient and graft survival rates were 96% and 81%, respectively. Survival following LDALT was significantly better than survival following DDLT for HCC during the same time period (P = 0.02). Eight patients (28.6%) developed tumor recurrence. Poor differentiation of tumor cells was the most significant determinant of recurrence. Despite high recurrence rates of HCC following LDALT, overall 5-year survival appears to be excellent.

Intention to treat survival following liver transplantation for hepatocellular carcinoma within a donor service area.

BACKGROUND: This study aimed to assess the impact of wait times on patient survival following liver transplantation for hepatocellular carcinoma (HCC) in a single donor service area. PATIENTS AND METHODS: Patients listed in the New England Organ Bank (NEOB) from 1996 to 2005 for liver transplantation with a diagnosis of HCC were identified from the United Network for Organ Sharing database. The following data were extracted: date of listing, date removed from the wait list, indication for wait list removal, patient death and date of last known follow-up. Kaplan-Meier survival estimates were calculated from the time of listing for transplant (intention to treat liver transplant survival, ITT OLT) and compared to those calculated from the date of transplant (liver transplant, OLT). RESULTS: There were 63 new registrations to the transplant list during the study period. Sixty-one patients were removed from the waiting list: transplanted 41 (65%), death seven (11%), candidate condition deteriorated/too sick to transplant eight (13%), medically unsuitable one (2%), other one (2%), transferred to another center two (3%), and transplanted at another center one (2%). Three-year survival following liver transplantation for primary liver cancer was 85%. When the results were analyzed using an intention to treat analysis there was a 10-20% decrease in survival rate at every time point due to wait list drop-out. CONCLUSION: Wait list drop-out adversely affects liver transplant survival in transplant centers served by the NEOB. These data should be considered when recommending transplant versus resection as first line therapy for stage I or II HCC in our region.