Rates of hepatic artery thrombosis in liver transplantation with the use of a microscope: A systematic review.

OBJECTIVE: Hepatic artery anastomosis in liver transplantations requires a meticulous technique to minimize the risk of hepatic artery thrombosis (HAT). The microscope helped improve anastomosis techniques in pediatric patients with small caliber vessels. The aim of this review was to compare microsurgical and non-microsurgical techniques on the incidence of HAT in liver transplantations. The secondary objective was to compare HAT incidence between pediatric and adult cohorts and between plastic and transplant surgeons. METHODS: A systematic review of the literature using Medline, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) was conducted on studies involving HAT in liver transplantations with microsurgery. Three reviewers performed a full article review and data extraction for studies meeting the eligibility criteria of the study. RESULTS: Forty-five studies were incorporated in the final analysis. A total of 7346 patients and 7506 liver transplants were included. The mean age was 17 years old with an equivalent distribution between pediatric (51%, n = 3218) and adult patients (49%, n = 3145). A total of 6351 of these transplantations underwent microsurgical repair, against 1157 with non-microsurgical techniques. The overall HAT rate was 4.9%, including 4.2% in the microsurgical group (n = 268) and 8.5% in the non-microsurgical group (n = 98), a statistically significant increase of 4.3%. The occurrence of HAT was 2.6% with a plastic surgeon versus 4.6% with other types of surgeons. When using microsurgical techniques, the HAT rate was 4.2% with living donors versus 7.7% with deceased donors. CONCLUSIONS: HAT and subsequent liver transplant failure are lower when microsurgical techniques, living donors, and plastic surgeons with a microsurgical training are involved in the operation.

A Road Less Traveled: Endoscopic Retrograde Cholangiopancreatography in a Patient with Long-standing Achalasia and Sigmoid Esophagus.

Endoscopic retrograde cholangiopancreatography in a patient with achalasia and sigmoid esophagus poses a unique technical challenge, as one must safely guide the side viewing duodenoscope across a severely distorted distal esophagus and non-relaxing lower esophageal sphincter. In such patients, the use of an overtube is a simple solution that allows the safe passage of a duodenoscope and the removal of common bile duct stones.

Staged Mastopexy Before Nipple-Sparing Mastectomy: Improving Safety and Appearance in Implant-Based and Autologous Breast Reconstruction.

BACKGROUND: Breast reconstruction following nipple sparing mastectomy in patients with large or ptotic breasts remains challenging because of the risk of ischemic complications and the difficulty in managing the redundant skin envelope. Staged mastopexy or breast reduction before the mastectomy/reconstruction has been shown to decrease the risk of complications and improve clinical outcomes. METHODS: A retrospective analysis was conducted of patients with a genetic predisposition to breast cancer who underwent staged breast reduction/mastopexy before nipple sparing mastectomy and reconstruction in our institution. In patients with in situ disease or invasive cancer, the first stage consisted of lumpectomy and oncoplastic reduction/mastopexy. Breast reconstruction at the second stage was performed with free abdominal flaps or breast implants and acellular dermal matrix. Data regarding the ischemic complications were recorded. RESULTS: In total, 47 patients (84 breasts) underwent this staged approach. All patients had a genetic predisposition to breast cancer. The time interval between the two stages was 11.5 months (range, 1.3 to 23.6 months). Twelve breasts (14.3 percent) were reconstructed with free abdominal flaps, 6 (7.1 percent) with tissue expanders and 66 (78.6 percent) with permanent subpectoral implants and acellular dermal matrix. There was one postoperative superficial nipple areolar complex epidermolysis (1.2 percent), and two partial mastectomy skin flap necrosis (2.4 percent). The mean follow-up time after completion of reconstruction was 8.3 months. CONCLUSION: Mastopexy or breast reduction before nipple sparing mastectomy and reconstruction is a safe procedure with a low risk of ischemic complications.

Expanding the Classic Facial Canons: Quantifying Intercanthal Distance in a Diverse Patient Population.

Background: The intercanthal distance (ICD) is central to our perception of facial proportions, and it varies according to gender and ethnicity. Current standardized reference values do not reflect the diversity among patients. Therefore, the authors sought to provide an evidence-based and gender/ethnicity-specific reference when evaluating patients' ICD. Methods: As per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search of PubMed, Medline, and Embase was carried out for studies reporting on the ICD. Demographics, study characteristics, and ICDs were extracted from included studies. ICD values were then pooled for each ethnicity and stratified by gender. The difference between men and women, and that across ethnicities and measurement types were compared by means of independent sample t-test and one-way ANOVA (SPSS v.24). Results: A total of 67 studies accounting for 22,638 patients and 118 ethnic cohorts were included in this pooled analysis. The most reported ethnicities were Middle Eastern (n = 6629) and Asian (n = 5473). ICD values (mm) in decreasing order were: African 38.5 ± 3.2, Asian 36.4 ± 1.6, Southeast Asian 32.8 ± 2.0, Hispanic 32.3 ± 2.0, White 31.4 ± 2.5, and Middle Eastern 31.2 ± 1.5. A statistically significant difference (P < 0.05) existed between all ethnic cohorts, between genders among most cohorts, and between most values stratified by measurement type. Conclusions: Our standards of craniofacial anthropometry must evolve from the neoclassical canons using White values as references. The values provided in this review can aid surgeons in appreciating the gender- and ethnic-specific differences in the ICD of their patients.

Groundwater levels time series sensitivity to pluviometry and air temperature: a geostatistical approach to Sfax region, Tunisia.

In this paper, the pattern of groundwater level fluctuations is investigated by statistical techniques for 24 monitoring wells located in an unconfined coastal aquifer in Sfax (Tunisia) for a time period from 1997 to 2006. Firstly, a geostatistical study is performed to characterize the temporal behaviors of data sets in terms of variograms and to make predictions about the value of the groundwater level at unsampled times. Secondly, multivariate statistical methods, i.e., principal component analysis (PCA) and cluster analysis (CA) of time series of groundwater levels are used to classify groundwater hydrographs regard to identical fluctuation pattern. Three groundwater groups (A, B, and C) were identified. In group "A," water level decreases continuously throughout the study periods with rapid annual cyclic variation, whereas in group "B," the water level contains much less high-frequency variation. The wells of group "C" represents a steady and gradual increase of groundwater levels caused by the aquifer artificial recharge. Furthermore, a cross-correlation analysis is used to investigate the aquifer response to local rainfall and temperature records. The result revealed that the temperature is more affecting the variation of the groundwater level of group A wells than the rainfall. However, the second and the third groups are less affected by rainfall or temperature.

Structural evidence for the inhibition of grape dihydroflavonol 4-reductase by flavonols.

Dihydroflavonol 4-reductase (DFR) is a key enzyme of the flavonoid biosynthesis pathway which catalyses the NADPH-dependent reduction of 2R,3R-trans-dihydroflavonols to leucoanthocyanidins. The latter are the precursors of anthocyans and condensed tannins, two major classes of phenolic compounds that strongly influence the organoleptic properties of wine. DFR has been investigated in many plant species, but little was known about its structural properties until the three-dimensional structure of the Vitis vinifera enzyme complexed with NADP(+) and its natural substrate dihydroquercetin (DHQ) was described. In the course of the study of substrate specificity, crystals of DFR-NADP(+)-flavonol (myricetin and quercetin) complexes were obtained. Their structures exhibit major changes with respect to that of the abortive DFR-NADP(+)-DHQ complex. Two flavonol molecules bind to the catalytic site in a stacking arrangement and alter its geometry, which becomes incompatible with enzymatic activity. The X-ray structures of both DFR-NADP(+)-myricetin and DFR-NADP(+)-quercetin are reported together with preliminary spectroscopic data. The results suggest that flavonols could be inhibitors of the activity of DFR towards dihydroflavonols.