Surgical Strategy for Lumbar Disc Herniation based on the MSU Classification: Percutaneous Endoscopic Lumbar Discectomy versus Transforaminal Lumbar Interbody Fusion: A 5-year Retrospective Study.

OBJECTIVE: Currently, there is no established guideline on whether to opt for percutaneous endoscopic lumbar discectomy (PELD) or traditional transforaminal lumbar interbody fusion (TLIF) surgery based on specific types of lumbar disc herniation (LDH). Based on the Michigan State University (MSU) classification system, this study conducted a medium- to long-term follow-up analysis of two surgical methods over 5 years for the first time, aiming to provide empirical evidence to assist in making more informed decisions before surgery for LDH treatment. METHODS: This was a retrospective study that included 273 patients with single-level LDH who underwent PELD or TLIF treatment at our hospital between January 1, 2016, and December 31, 2018. Detailed metrics included preoperative and postoperative visual analogue scale (VAS) scores and Oswestry disability index (ODI) at 1-day, 1-week, 1-year, and 5-year follow-ups. Complications, recurrences, and 5-year postoperative modified MacNab criteria scores were also recorded. Statistical methods included independent sample t-tests, repeated measures analysis of variance (ANOVA), and χ2 tests. RESULTS: Classified into seven groups according to the MSU classification, it was found that there was an improvement in the VAS and ODI scores at four postoperative follow-ups (p < 0.001). PELD showed better results than TLIF in reducing pain and improving the ODI scores in the classifications of 3B, 2B, and 2C (p < 0.05). TLIF demonstrated consistent superiority over PELD in 2A, 2AB, 3A, and 3AB classifications (p < 0.05). The total recurrence rate in the PELD group (11.05%) within 5 years after surgery was higher (p < 0.05) than that in the TLIF group (3.96%). These were mainly concentrated in the 2A, 2AB, 3A, and 3AB types. Moreover, the rate of excellent and good outcomes in the PELD was higher than in the TLIF but no significant difference (χ2 = 1.0568, p = 0.5895). CONCLUSION: This study suggests that PELD and TLIF may relieve LDH, but have advantages under different MSU classifications. The MSU classification has specific guiding significance and could aid in the surgical selection of PELD or TLIF to achieve optimal treatment outcomes for patients with lumbar disc herniation.

Pediatric Perspectives on Liver Cirrhosis: Unravelling Clinical Patterns and Therapeutic Challenges.

Background: Liver cirrhosis presents significant challenges in the pediatric population due to a complex interplay of etiological factors, clinical manifestations, and limited therapeutic options. The leading contributors to cirrhosis among pediatric patients are chronic cholestasis, metabolic disorders present from birth, and long-term hepatitis. Materials and method: Our narrative review aimed to synthesize literature data on the etiology, clinical picture, diagnostic techniques, optimal management of complications, and timely transplantation. Results: The epidemiology of liver cirrhosis in pediatric patients is evolving. The introduction of a universal vaccination and effective long-term viral suppression in viral hepatitis have significantly decreased complications rates. Liver transplantation programs worldwide have also improved the management of cirrhosis complications. Conclusions: Early diagnosis, comprehensive management strategies, and advancements in treatment modalities are critical for improving outcomes. Understanding these differences is crucial in providing age-appropriate care and support for those affected by cirrhosis.

Contrast enhancing epidural fluid accumulation after percutaneous endoscopic lumbar discectomy: A case report of recurrent disc herniation within pseudocyst secondary to irrigation fluid.

INTRODUCTION: Percutaneous endoscopic lumbar discectomy (PELD) is increasingly being utilized to treat patients with lumbar disc herniation. PELD is unique in that it uses a single working port endoscope with constant irrigation of the surgical field to visualize pathology. The current report is of a case of postoperative epidural irrigation fluid accumulation presenting as peripherally enhancing epidural lesions, masking an underlying re-herniation. PRESENTATION OF CASE: A patient with a Lumbar 5-Sacral 1 level disc herniation presenting with radiculopathy was treated using PELD. Following the operation, the patient experienced recurrent pain, prompting a repeat MRI of the lumbar spine. Multiple ring-enhancing lesions within the epidural space were observed, creating diagnostic dilemmas. The differential diagnoses included epidural abscess, pseudomeningocele from unintended durotomy, epidural hematoma, or trapped epidural fluid collection presenting as a pseudocyst with or without recurrent disc herniation. A repeat endoscopic discectomy was performed to confirm the diagnosis of pseudocyst, revealing a recurrent disc herniation. DISCUSSION: Pseudocysts are not an uncommon complication of PELD, typically believed to be due to an inflammatory response to disc fragments. However, in this case, the epidural fluid collection was likely the result of trapped irrigation fluid from continuous irrigation during the procedure, which masked an underlying re-herniation on imaging. CONCLUSION: With the increasing utilization of PELD, it is important to acknowledge unique complications such as fluid accumulation from irrigation within the epidural space. Fluid accumulation can lead to contrast-enhancing pseudocyst formation, which can theoretically lead to mass effect or increased intracranial and intraspinal pressure and may mask additional underlying pathology.

Endoscopic double line suture repair technique for repairing Iatrogenic dural tear: a technical case report.

PURPOSE: Introducing a suture repair technology, endoscopic double line suture repair technique, for iatrogenic dural injury during Percutaneous Endoscopic Lumbar Discectomy (PELD) surgery. METHODS: A patient with dural injury and cauda equina herniation during PELD surgery was treated with endoscopic double line suture repair technique. RESULTS: A patient with dural injury and cauda equina nerve herniation during PELD surgery was successfully treated using double-line suture technique. After the repair, no obvious cerebrospinal fluid leakage and cauda equina nerve re-herniation was seen. During the postoperative observation period, the wound healed well and there were no complications related to cerebrospinal leakage. During the follow-up period (1 year), the patient reported significant symptom relief and no complications. CONCLUSION: This novel dural repair technology is safe and effective and can be used to treat dural injuries during PELD surgery.

A Multi-Element Identification System Based on Deep Learning for the Visual Field of Percutaneous Endoscopic Spine Surgery.

Background: Lumbar disc herniation is a common degenerative lumbar disease with an increasing incidence. Percutaneous endoscopic lumbar discectomy can treat lumbar disc herniation safely and effectively with a minimally invasive procedure. However, the learning curve of this technology is steep, which means that initial learners are often not sufficiently proficient in endoscopic operations, which can easily lead to iatrogenic damage. At present, the application of computer deep learning technology to clinical diagnosis, treatment, and surgical navigation has achieved satisfactory results. Purpose: The objective of our team is to develop a multi-element identification system for the visual field of endoscopic spine surgery using deep learning algorithms and to evaluate the feasibility of this system. Method: We established an image database by collecting surgical videos of 48 patients diagnosed with lumbar disc herniation, which was labeled by two spinal surgeons. We selected 6000 images of the visual field of percutaneous endoscopic spine surgery (including various tissue structures and surgical instruments), divided into the training data, validation data, and test data according to 2:1:2. We developed convolutional neural network models based on instance segmentation-Solov2, CondInst, Mask R-CNN and Yolact, and set the four network model backbone as ResNet101 and ResNet50 respectively. Mean average precision (mAP) and frames per second (FPS) were used to measure the performance of each model for classification, localization and recognition in real time, and AP (average) is used to evaluate how easily an element is detected by neural networks based on computer deep learning. Result: Comprehensively comparing mAP and FSP of each model for bounding box test and segmentation task for the test set of images, we found that Solov2 (ResNet101) (mAP = 73.5%, FPS = 28.9), Mask R-CNN (ResNet101) (mAP = 72.8%, FPS = 28.5) models are the most stable, with higher precision and faster image processing speed. Combining the average precision of the elements in the bounding box test and segmentation tasks in each network, the AP(average) was highest for tool 3 (bbox-0.85, segm-0.89) and lowest for tool 5 (bbox-0.63, segm-0.72) in the instrumentation, whereas in the anatomical tissue elements, the fibrosus annulus (bbox-0.68, segm-0.69) and ligamentum flavum (bbox-0.65, segm-0.62) had higher AP(average),while extra-dural fat (bbox-0.42, segm-0.44) was lowest. Conclusion: Our team has developed a multi-element identification system for the visual field of percutaneous endoscopic spine surgery adapted to the interlaminar and foraminal approaches, which can identify and track anatomical tissue (nerve, ligamentum flavum, nucleus pulposus, etc.) and surgical instruments (endoscopic forceps, an high-speed diamond burr, etc.), which can be used in the future as a virtual educational tool or applied to the intraoperative real-time assistance system for spinal endoscopic operation.

Postoperative outcomes of acute-on-chronic liver failure in infants and children with biliary atresia.

INTRODUCTION: Acute-on-chronic liver failure (ACLF) is associated with increased mortality and morbidity in patients with biliary atresia (BA). Data on impact of ACLF on postoperative outcomes, however, are sparse. METHOD: We performed a retrospective analysis of patients with BA aged <18 years who underwent LT between 2011 and 2021 at our institution. ACLF was defined using the pediatric ACLF criteria: ≥1 extra-hepatic organ failure in children with decompensated cirrhosis. RESULTS: Of 107 patients (65% female; median age 14 [9-31] months) who received a LT, 13 (12%) had ACLF during the index admission prior to LT. Two (15%) had Grade 1; 4 (30%) had Grade 2; and 7 (55%) had Grade ≥3 ACLF. ACLF cohort was younger at time of listing (5 [4-8] vs. 9 [6-24] months; p < .001) and at LT (8 [8-11] vs. 16 [10-40] months, p < .001) compared to no-ACLF group. Intraoperatively, ACLF patients had higher blood loss (40 [20-53] vs. 10 [6-19] mL/kg; p < .001) and blood transfusion requirements (33 [21-69] vs. 18 [7-25] mL/kg; p = .004). Postoperatively, they needed higher vasopressor support (31% vs. 10.6%; p = .04) and had higher total hospital length of stay (106 [45-151] vs. 13 [7-30] days; p = .023). Rate of return to the operating room, hospital readmission rates, and 1-year post-LT survival rates were comparable between the groups. CONCLUSION: Despite higher perioperative complications, survival outcomes for ACLF in BA after LT are favorable and comparable to those without ACLF. These encouraging data reiterate prioritization during organ allocation of these critically ill children for LT.

Investigating the impact of cartilaginous endplate herniation on recovery from percutaneous endoscopic lumbar discectomy.

OBJECTIVE: This study aimed to evaluate the influence of herniation of cartilaginous endplates on postoperative pain and functional recovery in patients undergoing percutaneous endoscopic lumbar discectomy (PELD) for lumbar disc herniation (LDH). METHODS: A retrospective analysis was conducted on 126 patients with LDH treated with PELD at the Third Hospital of Hebei Medical University from January 2021 to January 2022. Whether cartilaginous endplates had herniated was identified by analyzing these specific findings from MRI scans: posterior marginal nodes, posterior osteophytes, mid endplate irregularities, heterogeneous low signal intensity of extruded material, and Modic changes in posterior corners and mid endplates. Patients were assessed for postoperative pain using the Visual Analogue Scale (VAS) and functional recovery using the Oswestry Disability Index (ODI) and Modified MacNab criteria. Statistical analyses compared outcomes based on the presence of herniation of cartilaginous endplates. RESULTS: Patients with herniation of cartilaginous endplates experienced higher pain scores early postoperatively but showed significant improvement in pain and functional status over the long term. The back pain VAS scores showed significant differences between the groups with and without herniation of cartilaginous endplates on postoperative day 1 and 1 month (P < 0.05). Leg pain VAS scores showed significant differences on postoperative day 1 (P < 0.05). Modic changes were significantly associated with variations in postoperative recovery, highlighting their importance in predicting patient outcomes. In patients with herniation of cartilaginous endplates, there were statistically significant differences in the back pain VAS scores at 1 month postoperatively and the ODI functional scores on postoperative day 1 between the groups with and without Modic changes (P < 0.05). There were no significant differences in the surgical outcomes between patients with and without these conditions regarding the Modified MacNab criteria (P > 0.05). CONCLUSION: Herniation of cartilaginous endplates significantly affect early postoperative pain and functional recovery in LDH patients undergoing PELD. These findings emphasize the need for clinical consideration of these imaging features in the preoperative planning and postoperative management to enhance patient outcomes and satisfaction.

Correlation between Disc Imaging Observations and Clinical Efficacy after Percutaneous Endoscopic Lumbar Discectomy: A 1-Year Follow-up Study.

OBJECTIVE: The connection between alterations in the disc structure following percutaneous endoscopic lumbar discectomy (PELD) and symptoms in patients postsurgery has not been reported yet. The purpose of the present study was to discuss the potential correlation between the changes in the morphological characteristics of various reference surfaces of the intervertebral disc after percutaneous endoscopic lumbar discectomy (PELD) and clinical outcomes, to identify the morphological parameters that affect efficacy and provide an evidence-based foundation for assessing postoperative efficacy. METHODS: From October 2019 to October 2021, after percutaneous endoscopic lumbar discectomy (PELD), 98 individuals were enrolled. MRI DICOM data of the lumbar spine were obtained before and after surgery, specifically around 3 months. The morphological parameters of the operated and adjacent segments of the discs were measured using T2-weighted images from three reference planes. Outcomes were assessed using the Oswestry disability index (ODI), visual analogue pain scores for the back and leg (VAS-back/VAS-leg), Japanese Orthopaedic Association (JOA) scores, and recovery rates. Postoperative changes in disc parameters and outcomes were compared between patients with different severity and types of LDH based on the MSU staging. Patients completed the questionnaire during outpatient follow-up appointments 3, 6, and 12 months after the surgery. The follow-up period was 14.69 ± 4.21 months, ranging from 12 to 24 months. RESULTS: Parameters such as area and circumference of intervertebral discs in the cross-section were not associated with the change in the efficacy index. Postoperatively, a negative correlation between the variation of the disc height, disc height index, and protrusion distance and the difference in VAS scores for low back pain at 3 and 6 months was observed among the two sagittal change parameters. Differences between changes in disc imaging parameters and postoperative efficacy were not statistically significant between various types of lumbar disc herniation. CONCLUSION: For the patients after percutaneous endoscopic lumbar discectomy, the changes in parameters such as disc area and circumference in the cross-sectional plane are not associated with efficacy, and the changes in disc height and herniation distance in the sagittal plane provide a morphologic basis for the assessment of short-term postoperative efficacy. In addition, the changes in disc morphologic parameters and postoperative efficacy do not differ between various types of lumbar disc herniation.

Radiographic characteristics-based classification system for percutaneous endoscopic lumbar discectomy surgical approach selection in patients with L5-S1 disc herniation: a hierarchical clustering analysis.

Background: No classification system exists for aiding the selection of surgical approaches in L5-S1 disc herniation when undergoing percutaneous endoscopic lumbar discectomy (PELD). We aimed to identify radiographic subtypes to aid the selection of percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID) in patients with L5-S1 disc herniation via unsupervised hierarchical clustering analysis. Methods: In this retrospective case-control study, we gathered 296 anteroposterior and lateral lumbar spine radiographs (dataset 1) from Tianjin Hospital between January 2016 and October 2021 for clustering analyses. Additionally, we analyzed 111 patients who underwent PEID or PETD for L5-S1 disc herniation at Tianjin Hospital from January 2016 to August 2022. We included patients with radicular leg pain or back pain associated with intra-canal disc herniation who failed in conservative treatments over 6 weeks. First, pair-wise Spearman correlation coefficients were calculated among plain radiographic metrics in dataset 1 to reveal the association among these radiographic metrics. Second, hierarchical clustering analysis was conducted to unsupervised cluster the plain films into several subtypes. Last, for each radiographic subtype, the intraoperative blood loss (IBL), operation time (OT), total operating room time (TORT) along with visual analogue scale (VAS) and Oswestry Disability Index (ODI) were compared between patients underwent PETD or PEID with age as covariates. Results: This study yielded 3 main findings: (I) iliac height (IH) was negatively correlated with intervertebral foramen width (IFW), intervertebral foramen height (IFH), and intertransverse height (ITH) (R=-0.50, -0.42, and -0.46, all P<0.001), ITH was positively correlated with IFW and IFH (R=0.40 and 0.53, all P<0.001); (II) 2 lumbosacral radiographic subtypes were identified via hierarchical clustering analysis; (III) relative to subtype 1, the patients identified as subtype 2 exhibited lesser IBL, shorter OT, and shorter TORT following PETD (t=2.92, P=0.006; t=2.65, P=0.012; t=3.17, P=0.003). Conclusions: The morphology pattern of the lumbosacral region affect the ease of different PELD procedures when performing percutaneous discectomy at the segment of L5-S1. Without considering the type of disc herniation, this classification system might aid spine surgeons in the selection of an appropriate surgical approach.

Prevalence, Risk Factors and Clinical Outcomes of Acute Kidney Injury after Paediatric Liver Transplantation.

BACKGROUND: Knowledge about acute kidney injury (AKI) in paediatric patients after liver transplantation is limited. This study focused on the prevalence and contributing factors of AKI and its impact on the postoperative outcomes of paediatric recipients. METHODS: The data of 211 paediatric patients (<12 years old) who, from December 2018 to November 2020, received first-time liver transplantation for end-stage liver disease or advanced hepatic failure in our hospital were processed for retrospective analysis. According to the criteria of the Kidney Disease Improving Global Outcomes, all patients were dichotomised into AKI and non-AKI groups. The preoperative characteristics of the patients, laboratory test results, donor type and intraoperative parameters between the two groups were compared. The effects of AKI on the postoperative outcomes of paediatric recipients were analysed. The risk factors for AKI after liver transplantation were analysed by multivariate logistic regression. RESULTS: The incidence of AKI within the first seven days after paediatric liver transplantation was 34.1%. AKI at stages I, II and III accounted for 69.4%, 22.2% and 8.3%, respectively. Compared with non-AKI patients, AKI patients had a higher proportion of hepatic cirrhosis (p = 0.039) and ascites (p = 0.003); Worse hepatic function (prolonged prothrombin time, activated partial thromboplastin time, decreased level of serum albumin and increased international normalised ratio and total bilirubin level); Higher paediatric end-stage liver disease (PELD) score (p = 0.008); And larger amount of intraoperative blood loss (p < 0.001), fluid positive balance (p = 0.035), red blood cells (RBCs) (p < 0.001) and fresh frozen plasma transfusion (p < 0.001). The multivariate logistic regression analysis demonstrated that ascites (odds ratio (OR): 2.273, p = 0.040), PELD (OR: 1.027, p = 0.013) and RBCs transfusion (OR: 1.033, p < 0.001) were independent contributing factors to AKI in paediatric patients who received liver transplantation. AKI contributed to prolonged hospital stays but did not increase hospital mortality. CONCLUSIONS: The onset of AKI can markedly prolong the hospital stay, and is common in paediatric patients undergoing liver transplantation. Poor hepatic function and large RBC transfusion contribute to AKI after liver transplantation.

Prevalence, Risk Factors and Clinical Outcomes of Acute Kidney Injury after Paediatric Liver Transplantation

Background: Knowledge about acute kidney injury (AKI) in paediatric patients after liver transplantation is limited. This study focused on the prevalence and contributing factors of AKI and its impact on the postoperative outcomes of paediatric recipients. Methods: The data of 211 paediatric patients (<12 years old) who, from December 2018 to November 2020, received first-time liver transplantation for end-stage liver disease or advanced hepatic failure in our hospital were processed for retrospective analysis. According to the criteria of the Kidney Disease Improving Global Outcomes, all patients were dichotomised into AKI and non-AKI groups. The preoperative characteristics of the patients, laboratory test results, donor type and intraoperative parameters between the two groups were compared. The effects of AKI on the postoperative outcomes of paediatric recipients were analysed. The risk factors for AKI after liver transplantation were analysed by multivariate logistic regression. Results: The incidence of AKI within the first seven days after paediatric liver transplantation was 34.1%. AKI at stages I, II and III accounted for 69.4%, 22.2% and 8.3%, respectively. Compared with non-AKI patients, AKI patients had a higher proportion of hepatic cirrhosis (p = 0.039) and ascites (p = 0.003); Worse hepatic function (prolonged prothrombin time, activated partial thromboplastin time, decreased level of serum albumin and increased international normalised ratio and total bilirubin level); Higher paediatric end-stage liver disease (PELD) score (p = 0.008); And larger amount of intraoperative blood loss (p < 0.001), fluid positive balance (p = 0.035), red blood cells (RBCs) (p < 0.001) and fresh frozen plasma transfusion (p < 0.001) (AU)

A murine model of BSCL2-associated Celia's encephalopathy.

Celia's encephalopathy or progressive encephalopathy with/without lipodystrophy is a neurodegenerative disease with a fatal prognosis in childhood. It is generally caused by the c.985C > T variant in the BSCL2 gene, leading to the skipping of exon 7 and resulting in an aberrant seipin protein (Celia-seipin). To precisely define the temporal evolution and the mechanisms involved in neurodegeneration, lipodystrophy and fatty liver in Celia's encephalopathy, our group has generated the first global knock-in murine model for the aberrant human transcript of BSCL2 (Bscl2Celia/Celia) using a strategy based on the Cre/loxP recombination system. In order to carry out a characterization at the neurological, adipose tissue and hepatic level, behavioral studies, brain PET, metabolic, histological and molecular studies were performed. Around 12% of homozygous and 5.4% of heterozygous knock-in mice showed severe neurological symptoms early in life, and their life expectancy was dramatically reduced. Severe generalized lipodystrophy and mild hepatic steatosis were present in these affected animals, while serum triglycerides and glucose metabolism were normal, with no insulin resistance. Furthermore, the study revealed a reduction in brain glucose uptake, along with patchy loss of Purkinje cells and the presence of intranuclear inclusions in cerebellar cortex cells. Homozygous, non-severely-affected knock-in mice showed a decrease in locomotor activity and greater anxiety compared with their wild type littermates. Bscl2Celia/Celia is the first murine model of Celia's encephalopathy which partially recapitulates the phenotype and severe neurodegenerative picture suffered by these patients. This model will provide a helpful tool to investigate both the progressive encephalopathy with/without lipodystrophy and congenital generalized lipodystrophy.

The Value of 18F-FDG PET/MRI in Detecting Lumbar Radiculopathy for Selective Percutaneous Endoscopic Discectomy: a Case Report.

Magnetic resonance imaging (MRI) is the most popular imaging modality for investigating intervertebral disc herniation. However, it has a high chance for identifying incidental findings that are morphologically or structurally abnormal but not responsible for patients' symptoms. Although a previous study suggested that 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/magnetic resonance imaging (PET/MRI) may help identify neuroinflammation in lumbar radiculopathy, there is currently no direct evidence obtained from surgery. Here, we describe the case of a 32-year-old man with low back pain and right leg paresthesia for 7 months. MRI demonstrated disc herniation at the L3-L4, L4-L5 and L5-S1 levels, causing bilateral L5 and left S1 root compression. 18F-FDG PET/MRI demonstrated increased 18F-FDG uptake at the right L5 root, which was compatible with the patient's symptoms. Transforaminal percutaneous endoscopic lumbar discectomy (PELD) was performed. Intraoperative images revealed a swollen nerve root at the right L5 after removal of the herniated disc. After surgery, the patient experienced immediate pain relief and had no recurrence at the 6-month follow-up. When performing PELD in patients with multilevel radiculopathy identified on MRI, the use of 18F-FDG PET/MRI can help in accurate localization of the symptomatic roots and minimize surgical incision and soft-tissue injury.

Risk factors for lumbar disc herniation recurrence after percutaneous endoscopic lumbar discectomy: a meta-analysis of 58 cohort studies.

Recurrent lumbar disc herniation (rLDH) is one of the most serious complications and major causes of surgical failure and paralysis following percutaneous endoscopic lumbar discectomy (PELD). There are reports in the literature on the identification of risk factors associated with rLDH; however, the results are controversial. Therefore, we conducted a meta-analysis to identify risk factors for rLDH among patients following spinal surgery. PubMed, EMBASE, and the Cochrane Library were searched without language restrictions from inception to April 2018 for studies reporting risk factors for LDH recurrence after PELD. MOOSE guidelines were followed in this meta-analysis. We used a random effects model to aggregate odds ratios (ORs) with 95% confidence intervals (CIs). The evidence of observational studies was classified into high quality (class I), medium quality (class II/III), and low quality (class IV) based on the P value of the total sample size and heterogeneity between studies. Fifty-eight studies were identified with a mean follow-up of 38.8 months. Studies with high-quality (class I) evidence showed that postoperative LDH recurrence after PELD was significantly correlated with diabetes (OR, 1.64; 95% CI, 1.14 to 2.31), the protrusion type LDH (OR, 1.62; 95% CI, 1.02 to 2.61), and less experienced surgeons (OR, 1.54; 95% CI, 1.10 to 2.16). Studies with medium-quality (class II or III) evidence showed that postoperative LDH recurrence was significantly correlated with advanced age (OR, 1.11; 95% CI, 1.05 to 1.19), Modic changes (OR, 2.23; 95% CI, 1.53 to 2.29), smoking (OR, 1.31; 95% CI, 1.00 to 1.71), no college education (OR, 1.56; 95% CI, 1.05 to 2.31), obesity (BMI ≥ 25 kg/m2) (OR, 1.66; 95% CI, 1.11 to 2.47), and inappropriate manual labor (OR, 2.18; 95% CI, 1.33 to 3.59). Based on the current literature, eight patient-related and one surgery-related risk factor are predictors of postoperative LDH recurrence after PELD. These findings may help clinicians raise awareness of early intervention for patients at high risk of LDH recurrence after PELD.

Full endoscopic spine surgery.

Background: With a dramatic increase in elderly population worldwide, the prevalence of degenerative spine disease is steadily rising. Even though the entire spinal column is affected the problem is more commonly seen in the lumbar, cervical spine and to some extent the thoracic spine. The treatment of symptomatic lumbar disc or stenosis is primarily conservative with analgesics, epidural steroids and physiotherapy. Surgery is advised only if conservative treatment is ineffective. Conventional open microscopic procedures even though are still a gold standard, have the disadvantages of excessive muscle damage and bone resection, epidural scarring along with prolonged hospital stay and increased need of postoperative analgesics. Minimal access spine surgeries minimize surgical access related injury by minimizing soft tissue and muscle damage and also bony resection thus preventing iatrogenic instability and unnecessary fusions. This leads to good functional preservation of the spine and enhances early postoperative recovery and early return to work. Full endoscopic spine surgeries are one of the more sophisticated and advanced form of MIS surgeries. Purpose: Full endoscopy has definitive benefits over conventional microsurgical techniques. These include better and clear vision of the pathology due to presence of irrigation fluid channel, minimal soft tissue and bone trauma, better and relatively easy approach to deep seated pathologies like thoracic disc herniations and a possibility to avoid fusion surgeries. The purpose of this article is to describe these benefits, give an overview of the two main approaches - transforaminal and interlaminar, their indications, contraindications and their limitations. The article also describes about the challenges in overcoming the learning curve and its future prospectives. Conclusion: Full endoscopic spine surgery is one of the fastest growing technique in the field of modern spine surgery. Better intraoperative visualization of the pathology, lesser incidence of complications, faster recovery time, less postoperative pain, better relief of symptoms and early return to activity are the main reasons behind this rapid growth. With better patient outcomes and reduced medical costs, the procedure is going to be more accepted, relevant and popular procedure in future.

National Liver Allocation Policy-Consensus Document by the Liver Transplantation Society of India for a Nationally Uniform System of Allocation of Deceased Donor Liver Grafts.

Background: Deceased donor liver transplantation (DDLT) is increasing in India and now constitutes nearly one-third of all liver transplantation procedures performed in the country. There is currently no uniform national system of allocation of deceased donor livers. Methods: A national task force consisting of 19 clinicians involved in liver transplantation from across the country was constituted under the aegis of the Liver Transplantation Society of India to develop a consensus document addressing the above issues using a modified Delphi process of consensus development. Results: The National Liver Allocation Policy consensus document includes 46 statements covering all aspects of DDLT, including minimum listing criteria, listing for acute liver failure, DDLT wait-list management, system of prioritisation based on clinical urgency for adults and children, guidelines for allocation of paediatric organs and allocation priorities for liver grafts recovered from public sector hospitals. Conclusion: This document is the first step in the setting up of a nationally consistent policy of deceased donor liver allocation.

Home Parenteral Nutrition for Children: What Are the Factors Indicating Dependence and Mortality?

Parenteral nutrition (PN) in children with short bowel syndrome is crucial and lifesaving. Taking care of such patients requires interprofessional practice and multiple team resource management. Home PN (HPN) usage allows patients and families to live regular lives outside hospitals. We share our experiences for the last two decades and identify the risk factors for complications and mortality. A retrospective study of HPN patients was conducted between January 2000 and February 2022. Medical records of age, body weight, diagnosis, length of residual intestines, HPN period, central line attempts, complications, weaning, and survival were collected and analyzed. The patients were classified as HPN free, HPN dependent, and mortality groups. A total of 25 patients received HPN at our outpatient clinic, and one was excluded for the adult age of disease onset. There were 13 patients (54.1%) who were successfully weaned from HPN until the record-enroled date. The overall mortality rate was 20.8% (five patients). All mortality cases had prolonged cholestasis, Child Class B or C, and a positive Pediatric End-Stage Liver Disease (PELD) score. For HPN dependence, extended resection and multiple central line placement were two significant independent factors. Cholestasis, Child Class B or C, and positive PELD score were the most important risk factors for mortality. The central line-related complication rate was not different in all patient groups. The overall central line infection rate was 1.58 per 1000 catheter days. Caution should be addressed to prevent cholestasis and intestinal failure-associated liver disease during the HPN period, to prevent mortality. By understanding the risks of HPN dependence and mortality, preventive procedures could be addressed earlier.

Long-term follow-up and liver outcomes in children with cystic fibrosis and nodular liver on ultrasound in a multi-center study.

BACKGROUND: Nodular liver (NOD) in cystic fibrosis (CF) suggests advanced CF liver disease (aCFLD); little is known about progression of liver disease (LD) after detection of sonographic NOD. METHODS: Clinical, laboratory, and ultrasound (US) data from Prediction by Ultrasound of the Risk of Hepatic Cirrhosis in CFLD Study participants with NOD at screening or follow-up were compared with normal (NL). Linear mixed effects models were used for risk factors for LD progression and Kaplan-Meier estimator for time-to-event. RESULTS: 54 children with NOD (22 screening, 32 follow-up) and 112 NL were evaluated. Baseline (BL) and trajectory of forced expiratory volume, forced vital capacity, height/BMI z-scores were similar in NOD vs NL. Platelets were lower in NOD at BL (250 vs 331×103/microL; p < 0.001) and decreased by 8600/year vs 2500 in NL. Mean AST to Platelet Ratio Index (1.1 vs 0.4; p < 0.001), Fibrosis-4 Index (0.4 vs 0.2, p < 0.001), and spleen size z-score (SSZ) [1.5 vs 0.02; p < 0.001] were higher in NOD at BL; SSZ increased by 0.5 unit/year in NOD vs 0.1 unit/year in NL. Median liver stiffness (LSM) by transient elastography was higher in NOD (8.2 kPa, IQR 6-11.8) vs NL (5.3, 4.2-7, p < 0.0001). Over 6.3 years follow-up (1.3-10.3), 6 NOD had esophageal varices (cumulative incidence in 10 years: 20%; 95% CI: 0.0%, 40.0%), 2 had variceal bleeding, and 2 underwent liver transplantation; none had ascites or hepatic encephalopathy. No NL experienced liver-related events. CONCLUSIONS: NOD developed clinically evident portal hypertension faster than NL without worse growth or lung disease.

Transforaminal Versus Interlaminar Endoscopic Lumbar Discectomy for Lumbar Disc Herniation: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Meta-analysis and systematic review. OBJECTIVE: This study aims to investigate and compare patient-reported outcomes, perioperative data, and complications between 2 common endoscopic approaches for lumbar disc herniation: transforaminal and interlaminar endoscopic lumbar discectomy, by published high-quality evidence. METHODS: Electronic databases were searched for reported outcomes following TELD and IELD. Oswestry Disability Index (ODI), visual analog scale of back (VASB) and leg pain (VASL), and MacNab criteria were evaluated. Operative time, hospital stays, blood loss, radiation exposure, and complications were investigated. Odds ratio (OR) and mean differences (MD) with 95% confidence intervals (CI) were calculated using random and fixed-effect models. RESULTS: Total of 1948 patients from 18 studies were included, consisting of 1006 patients (51.6%) in TELD group and 942 (48.4%) patients in IELD group. TELD had better improvement of postoperative ODI (MD = 1.26; 95% CI: .07-2.16; P = .04), postoperative VASB (MD = -.23; 95% CI: -.40 to -.05; P = .01) and last follow-up VASB (MD = -.25; 95% CI: -.41 to -.09; P = .002), but with longer operative time (MD = 10.1 min; 95% CI: 1.925-18.77; P < .00001) and more fluoroscopic time (SMD = 4.12; 95% CI: 3.22-5.03; P < .00001), especially in L5-S1 operation. Bed rest time was significantly longer following IELD, with no difference in VASL, hospital stays, or complication. CONCLUSION: We found comparable clinical outcomes in terms of ODI, VAS, patient satisfaction, hospital stays, and complication between both techniques. TELD required more radiation exposure and longer operative time at L5-S1 level than IELD. Our study provided results to help consider appropriate approaches for selected patients and informed consent of benefits from each approach.

Percutaneous endoscopic drainage for acute long segment epidural abscess following endoscopic lumbar discectomy: A case report.

Introduction: Acute epidural abscess after percutaneous endoscopic lumbar discectomy is a rare but grievous complication. When faced with a long-segment epidural abscess, open surgery has traditionally been performed which can lead to huge surgical trauma and unpredictable complications. For this reason, surgeons around the world are constantly looking for more minimally invasive and effective surgical methods. Patient Concerns: Our patient was a 32-year-old woman who had been receiving percutaneous endoscopic interlaminar discectomy for L5/S1 lumbar disc herniation one week ago. She returned to our institution with a fever and lower back pain. Diagnoses: Magnetic resonance imaging revealed a long segment epidural abscess accompanied by a paravertebral abscess, and staphylococcus aureus was detected in a bacterial culture of pyogenic fluids extracted from the paravertebral abscess. Treatments: We performed percutaneous endoscopic drainage (PED) for the epidural abscess. Long-term sensitive antibiotic treatment after surgery. Outcomes: Immediate pain relief was achieved and the inflammatory reaction subsided after 4 weeks of antibiotic therapy. Re-examination of the lumbar spine MRI after 1 month showed that the epidural abscess disappeared completely. Conclusion: Percutaneous endoscopy allowed us to approach the epidural abscess directly, enabling the immediate drainage of the abscess with minimal trauma to the patient. The good results obtained show that percutaneous endoscopic drainage is a reliable way to treat a long-segment epidural abscess.