bluuebunny/crossref_metadata_2025 huggingface dataset:
HPB SO11 - Dropped Gallstones After Laparoscopic Cholecystectomy: An Umbrella Review
Authors: Abu Abdulrahim , Almoshantaf Mohammad Badr
Published: November 2024

Background

Gallstones (cholelithiasis) are solid formations in the gallbladder or biliary tract due to high cholesterol or bilirubin levels, affecting 10-20% of adults. Over 20% of those affected show symptoms like biliary colic. Gallstones can be cholesterol, black pigment, or brown pigment, with cholesterol stones being the most common. The persistence of gallstones following laparoscopic cholecystectomy (LC) poses a significant clinical challenge, potentially leading to morbidity and diagnostic complexities, often with delayed recognition. These complications can present as various intraabdominal conditions such as abscesses (intraabdominal or abdominal wall), fistula formation, peritonitis, bowel perforation, or ileus.

Method

We performed an extensive search of the academic literature spanning several databases, namely PubMed, Embase, Scopus, Web of Science, and Google Scholar. Inclusion criteria for this research encompassed systematic reviews, with or without meta-analysis, focusing on the examination of spilled gallstones in terms of signs, symptoms, diagnosis, imaging, and management. The assessment of potential bias in the final study selection was undertaken utilizing the R-AMSTAR and Risk of Bias in Systematic Reviews (ROBIS) assessment tools.

Results

The most prevalent sites for lost gallstones were identified as the right subhepatic, perihepatic, retroperitoneal, right flank, and pelvic regions. Multiple stones were found to be more common than single stones. Clinical presentations included the presence of abdominal masses simulating malignancy, intestinal obstruction, and pelvic pain or fistula formation. Surgical intervention emerged as the primary treatment approach. Pain localized to the right upper quadrant was reported by 24% of participants. Computed tomography (CT) was the most frequently employed diagnostic modality for stone identification (70.2%), followed by ultrasonography (US) (63.2%) and X-ray (42.9%).

Conclusion

Our research underscores a significant area that has received limited attention in existing literature. The occurrence of spilled gallstones presents challenges in diagnosis and carries the potential for severe post-laparoscopic cholecystectomy complications. A notable gap exists in the education of both surgeons and patients regarding this complication, emphasizing the need for heightened awareness among surgeons. Given the considerable variability observed between laparoscopic cholecystectomy procedures and the onset of associated symptoms, comprehensive studies with larger cohorts are imperative for elucidating pertinent risk factors and devising effective interventions.
HPB SO14 - Surprise Inside: Gallbladder Herniation in a Parastomal Hernia - A Rare Case Report and Management Insight
Authors: Olusola Siji , Jarman Tobias , Parmar Chetan , Kathirvel Manikandan
Published: November 2024

Background

Parastomal hernias are a common complication of stoma formation, affecting approximately 40% of patients within two years. Gallbladder herniation within a parastomal hernia is a rare phenomenon, with only 18 cases previously reported. Patients are typically elderly females, with the condition attributed to ageing factors such as loss of visceral fat and elastic tissue, liver shrinkage, and the increased length and loss of elasticity of the gallbladder mesentery. These factors contribute to visceroptosis of the gallbladder, increasing its mobility and the risk of herniation.

Method

We present the case of a 68-year-old female with a four-day history of severe parastomal hernia pain and swelling. She had an emergency left hemicolectomy and transverse colostomy in the right upper quadrant 10 years prior for ischaemic colitis and perforation. Her stoma was functioning well. Vital signs and biochemistry results were normal. On examination her hernia was severely tender but partially reducible. CT revealed a right upper abdominal parastomal hernia containing loops of colon and surprisingly the gallbladder with a long stretched cystic duct. There was no evidence of cholecystitis, bowel obstruction, or compromise within the hernial sac.

Results

With analgesia, the patient's pain improved, though her hernia remained irreducible. She was discharged after two days of conservative management and referred back to the hospital where she had the initial operation. On enquiry with that hospital it was reported that an elective parastomal hernia repair with completion right colectomy and end ileostomy was performed. The gallbladder was mobilised and reduced back into the peritoneal cavity, and the hernial defect was closed. The patient made an excellent recovery and was discharged home three days after surgery.

Conclusion

Cholecystic parastomal herniation is a very rare phenomenon and should be considered as a differential in similar cases. Management should be based on clinical presentation, radiological diagnosis, and a multidisciplinary team approach. No standardised classification or approach exists. We propose classifying gallbladder herniations as either being simple (without inflammatory sequelae) or complicated (with cholecystitis, gallbladder torsion, incarceration or perforation). Simple herniations, such as the case presented, can be managed electively with intra-operative reduction of the gallbladder sufficing. Complicated herniations during acute admissions indicate the need for emergency surgical intervention with combined cholecystectomy and parastomal hernia repair.
HPB SO19 - Comparison of perioperative outcomes of open (CUSA) versus laparoscopic (LOTUS) major hepatectomy – revisited. First evaluation of efficacy and safety of AEONTM stapler
Authors: Iqbal Affan , Baltatzis Minas , Stathakis Panagiotis , Siriwardena Ajit , Jamdar Saurabh , Sheen Aali J
Published: November 2024

Background

In 2019, preliminary data matching 40 cases demonstrated improved outcomes of laparoscopic major liver resections using the BOWA-LOTUSTM liver blade (Devon, UK). An updated and expanded comparison between open and laparoscopic major hepatectomies is presented as well as evaluating of an endovascular stapler AEON™ (Lexington Medical, Massachusetts, USA).

Method

January 2020 to June 2023 patients were identified from a prospectively maintained database. Propensity score matching analysis used R statistical tool in SPSS (IBM, New York, USA) to isolate matched open and laparoscopic cases. LOTUSTM ultrasonic energy device was used for parenchymal transection in laparoscopic cases and CUSA (Valleylab, Colorado, USA) in open procedures. AEONTM endovascular stapler was used from early 2021.

Results

86 patients constitute the study population after applying propensity score matching analysis in a 1:1 ratio. The median (range) age in the matched sample was 63 (27-83) yrs. Hospital stay (mean 7.8 v 14.7 days; p=0.025) and blood transfusion requirement (0 v 4 units; p=0.035) were all significantly improved when comparing laparoscopic to open. Comparison of the AEONTM stapler with Endo-GIA (Medtronic, MN, USA) showed no significant difference in any outcome measure, although AEONTM demonstrated (non-significantly) a reduced trend in operating time comparing all cases (56 v 69 mins; p=0.300) and laparoscopic (56 v 71 min; p=0.295).

Conclusion

The LOTUS liver blade continues to be associated with acceptable outcomes in laparoscopic liver resections. The AEONTM endovascular stapler was equivalent to other staplers with a trend towards a shorter operating time in liver transectional surgery.
HPB SO21 - Percutaneous Biliary Endoscopy for Managing Disease in Endoscopically Inaccessible Biliary Trees: A Single Unit Experience in the UK
Authors: Brown Oliver D , Jenkins Paul , Gafoor Nelofer , Aroori Somaiah
Published: November 2024

Background

Patients with a history of hepatobiliary surgery often require interventions for complications such as hepatolithiasis, recurrent disease, or anastomotic strictures. Access to the biliary tree in these, and other post-operative patients, is hindered by a diverted alimentary tract or comorbidities that preclude endoscopy or re-operation. While forms of biliary endoscopy have been used for many years in combination with ERCP, recent advances now allow for the combination of percutaneous radiological interventions with cholangioscopy. We share our early experiences and outcomes using percutaneous biliary endoscopy (PBE) to manage a challenging cohort of patients

Method

In our hospital trust, a multidisciplinary team consisting of Interventional Radiologists, endoscopy staff, and a Hepatobiliary Surgeon performed some of the first PBE procedures using the SpyGlass device in the UK. The biliary tree was accessed under ultrasound and fluoroscopic guidance, followed by tract dilation to admit a 12F sheath. This allowed use of the SpyGlass device, along with adjuncts such as electrohydraulic lithotripsy catheters, dilation balloon catheters, biopsy forceps, and biodegradable stents through the working channel. This combined approach enhances the rate of conclusive biopsy and benefits from both visual assessment and radiological navigation.

Results

To date, 9 PBE procedures have been performed on 7 individual patients. Indications have included strictured hepaticojejunostomy, hepatolithiasis, malignant and benign biliary strictures. The first two patients underwent two-stage treatment of their disease following concerns about the burden of their treatment, however procedural intent was achieved in all cases. To date, two patients have experienced complications. The first required ITU admission for inotropic support in the context of a septic shower and the second suffered cholangitis secondary to a post-procedural haemorrhage and intraductal thrombus, requiring traditional internal/external drainage.

Conclusion

PBE, with its adjuncts, offers a minimally invasive alterative to operative treatment, and improved conclusive biopsy rates in patients with endoscopically inaccessible bile ducts due to post-surgical anatomy or impassable strictures. With appropriate multidisciplinary collaboration, PBE could easily be adopted in most hepatobiliary centres where the required equipment is likely to be readily available
HPB SO27 - Reconsidering Routine Histopathological Examination of Gallbladder Specimens in Cholecystectomy: Optimizing Clinical Practice and Resource Management
Authors: Jamal Zohaib , Yu Zirong , Zafar Nowera , Li Damon
Published: November 2024

Background

Cholecystectomy, the removal of the gallbladder, is a common surgery performed globally. Routine histopathological examination (HPE) of gallbladder specimens post-surgery aims to detect pathologies like gallbladder cancer (GBC). GBC incidence varies by region and ethnicity, with higher risks in women and those over 65. Advanced GBC stages often require surgery, while early stages may only need cholecystectomy. Global HPE practices differ based on resources and GBC rates. This study evaluates the necessity of routine HPE by examining the selective processing of specimens suspected of GBC, ensuring patient safety while potentially optimizing resource use.

Method

This retrospective cohort study conducted at Redland Hospital, a district general hospital in Australia, investigated the necessity of routine histopathological examination (HPE) for excised gallbladder specimens. Adhering to routine HPE policy, the study encompassed all elective and emergency cholecystectomies performed from January 2023 to December 2023, excluding pediatric cases, concurrent surgical procedures, and those with suspected malignancy. Demographic data, surgery indications, intraoperative findings, histopathological results, and incidental gallbladder cancer (IGC) outcomes were analyzed. Pathology reports and case documentation were reviewed for cancerous pathology indicators.

Results

Over the one-year study period from January 2023 to December 2023, a total of 266 gallbladder specimens were subjected to histopathological examination (HPE) post-cholecystectomy. Of these, 201 were female and 65 were male, yielding a male-to-female ratio of 3:1. Elective cholecystectomy was performed on 56.4% (150) of patients, while 43.6% (116) underwent emergency procedures. Laparoscopic cholecystectomy (LC) was the primary surgical approach, except for one case requiring conversion to an open procedure. None of the patients exhibited gallbladder carcinoma (GBC); however, 3.3% (9) displayed premalignant histopathological features in their specimens.

Conclusion

In conclusion, adopting a selective approach, where only gallbladder specimens with macroscopic abnormalities undergo histopathological examination (HPE), seems prudent, especially in regions with low gallbladder cancer (GBC) incidence. Our study, which revealed no cases of GBC, supports this approach. It not only reduces the risk of missing incidental carcinoma in clinically unsuspected cases but also proves cost-effective and reduces the histopathology department workload without compromising patient outcomes. Therefore, we advocate for routine macroscopic examination of gallbladder specimens for abnormalities before HPE submission, particularly in cholecystectomy patients with gallstone disease.
HPB SO32 - Outcomes Following Surgical Resection for Duodenal Adenocarcinoma – A Single Centre Experience
Authors: Sellappan Hari , Ghahramani Isabella , Fouad Mina , Arora Arvind , Zaitoun Abed , Gomez Dhanny
Published: November 2024

Background

Duodenal adenocarcinomas are rare cancers and their clinico-oncological management pathways tend to follow that of small bowel tumours. The aim of this study was to determine the outcomes of patients undergoing surgical resection for duodenal adenocarcinoma.

Method

Retrospective data of all patients who underwent surgical resection for duodenal adenocarcinoma between January 2008 to December 2023 were included. Collated data included demographics, clinico-pathological features and survival outcomes.

Results

Thirty-one patients were included, with a mean age of 65.7 (± 9.6) years and a greater proportion were male patients (58.1%). The predominant site of the primary tumour was at D2 section of the duodenum (58.1%). The majority of patients required a pancreatico-duodenectomy (80.6%) and 58.1% experienced minor morbidity (Clavien-Dindo I-II) while 22.6% experienced major morbidity (Clavien-Dindo III-V). There were 4 (12.9%) peri-operative mortalities.

Results

The median post-operative follow-up was 29.7 (IQR 61.5) months. Only 37.0% of patients received adjuvant chemotherapy while 13 patients (48.1%) experienced disease recurrence. The 3- and 5-year overall survival was 44.3% and 33.3%, respectively, while the disease-free survival at 3 and 5 years were 37.0% and 29.6%, respectively.

Patients who received adjuvant chemotherapy had a trend towards improved mean overall survival in comparison to patients who did not receive chemotherapy following surgery [80.3 vs 51.2 months; log rank 1.857, p=0.173]. Nevertheless, the median disease-free survival was similar between both groups [24.0 vs 26.0 months, log rank 0.016, p=0.901].

Patients who experienced major morbidity (Clavien-Dindo III-V) were significantly more likely to have a poorer median overall survival compared to patients with minor morbidity (Clavien-Dindo I-II) [72.1 vs 3.4 months; log rank 16.860, p<0.001].

Conclusion

Major morbidity (Clavien-Dindo III-V) following surgery is associated with poorer overall survival. Patients who received adjuvant chemotherapy following surgical resection for duodenal adenocarcinoma may have a trend towards improved overall survival.
HPB SO34 - Inter-fascial/Wound Catheter with Local Anaesthetic Infusion vs Thoracic Epidural Analgesia in Hepato-biliary Surgery (HILA) – A Retrospective Cohort Study
Authors: Sellappan Hari , Charles Nina , Adiamah Alfred , Eastwood Joanne , Sanyal Sudip
Published: November 2024

Background

Thoracic epidural analgesia (TEA) offers effective pain control after open hepato-biliary surgery, however it is associated with several limitations that delay post-operative recovery. This study compared outcomes between inter-fascial/wound catheter with local anaesthetic infusion (IF/WC) and thoracic epidural analgesia (TEA) following open liver and biliary surgery in an enhanced recovery after surgery (ERAS) setting.

Method

Retrospective cohort data of all open liver and biliary surgery between August 2023 to February 2024 that used inter-fascial/wound catheter with local anaesthetic infusion (IF/WC) or thoracic epidural analgesia (TEA). Baseline characteristics were similar in the combined IF (n=17) and WC (n=7) group vs TEA (n=39) group. Technical failure rates were 12.5% in the IF/WC group vs 20.5% in the TEA group, p=0.509.

Results

Vasopressor requirement immediately post-surgery decreased by 32.7% in IF/WC vs TEA group [8.3% vs 41.0%, p=0.005], whereas none in the IF/WC group required vasopressor beyond 24 hours [0 vs 25.6%, p=0.010]. Length of critical care stay reduced by 1.5 days [1.79 vs 3.28 days; 95% CI 0.28-2.70, p=0.016] while length of hospital stay reduced by 2.6 days [5.79 vs 8.41 days; 95% CI 0.72-4.52, p=0.022] in the IF/WC vs TEA group. Admission cost reduced by £3941 per patient in the IF/WC vs TEA group [£10323 vs £14265; 95% CI 661-7222, p=0.019].

Conclusion

Inter-fascial/wound catheter with local anaesthetic infusion (IF/WC) is an effective, safe and cost-saving alternative to thoracic epidural analgesia (TEA) with significant decrease in post-operative vasopressor requirements, and length of critical care and hospital stay.
HPB SO39 - Incidence for the need of blood transfusion for Laparoscopic Cholecystectomy :Is a group and save always needed ?
Authors: Jeelani Sarah Masroor , BintulHuda Yusma , Ip Ignatius , Shrivastava Abishek , Malik Izzah , Broder Ephraim , Owera Anas , Moussa Osama , Arhi Chanpreet
Published: November 2024

Background

Major bleeding is rare but among the most serious complications of laparoscopic surgery. As low as 1.3% of patient undergoing laparoscopic cholecystectomy may require a blood transfusion. We propose that not all patients undergoing laparoscopic cholecystectomy require a valid group and save sample, as the risk of bleeding is minimal.

Method

Health records of 458 patients who underwent cholecystectomy at our two hospital sites were reviewed for blood transfusion up to 30 days post-operatively. This review included elective and emergency procedures from January 2023 till March 2024. Demographics and surgical outcomes, including preoperative Haemoglobin (Hb) levels, need for transfusion, reason for transfusion and amount of units transfused were recorded. We analysed nominal values in proportions and percentages.

Results

Average pre-operative Hb levels were 13.38 g/dl. 7 patients required peri-operative blood transfusion. Three patients requiring transfusion had conversion to open cholecystectomy. Three patients requiring transfusion underwent emergency procedures. Time to transfusion ranged from 2 hours-5 days. All patients requiring transfusion were at our main hospital site (Watford General Hospital). Our yearly cost of ordering routine group and save sample throughout the audit period was £12,824

Conclusion

Routine group and save is not required prior to Laparoscopic Cholecystectomy. In case transfusion is required sufficient time to process a group and save samples is present. High risk patients i.e those with known haematological malignancies, coagulopathy, concurrent use of blood thinner, higher ASA grades can be identified and selective blood grouping performed.
HPB SO44 - From Electives to Career-Changing: A Cross-Sectional Survey exploring the impact of International Medical Electives in Hepato-Pancreatic-Biliary Surgery Unit
Authors: Al-Rubaye Rawan , Al saoudi Tareq , Issa Eyad , Isherwood John , Garcea Giuseppe , Dennison Ashley , Bhardwaj Neil
Published: November 2024

Background

International medical graduates (IMGs) are crucial in addressing NHS workforce shortages, representing one-third of staff. Reliance on IMGs is likely to continue. Electives offer IMGs a valuable opportunity to overcome work culture and clinical skills challenges, difficult to address through PLAB tests alone. These experiences can aid in passing the exam. Entering a new culture and service can be daunting; electives help build confidence by increasing familiarity with the NHS and UK medical traditions. This survey was designed to gain insight into IME experiences, the educational value perceived by participants, and their influence on personal growth and career direction.

Method

A cross-sectional survey was sent to 26 IMGs who completed an IME rotation in the HPB department at University Hospitals of Leicester NHS Trust since 2019. The survey included quantitative and qualitative questions to gather demographic details, insights into experiences, educational values gained, and career impact. Medical education and HPB surgery experts evaluated the survey for content validity and alignment with learning outcomes.Conducted via Google Forms®,recruitment emails were sent anonymously with weekly reminders for four weeks to ensure high response rates. Quantitative data were analysed using descriptive statistics, and qualitative data underwent thematic analysis.

Results

18 out of 26 participants (62.2%) responded. Ages ranged from 23-30, with 61.11% between 23-25 years. The gender split was 61.11% male and 38.89% female. Most (66.67%) were medical students during their elective, while 33.33% were Foundation Doctors. 72% of respondents are preparing for or have taken GMC registration exams, with 44% are already fully registered. The survey revealed overall positive responses, highlighting the welcoming and educational environment. However, participants suggested improving the induction program and providing a more defined daily schedule for elective students. These insights offer opportunities to enhance an already valuable program.

Conclusion

The study revealed a successful international medical elective program in the HPB department. Most respondents found the experience met their expectations, achieved learning objectives, and positively influenced their careers. All participants were satisfied and would recommend the elective, with 94% considering NHS careers. The program provided effective teaching, mentorship, and hands-on clinical experience for most participants. Many have begun or completed GMC registration, indicating lasting impact. This initiative is valuable in attracting and preparing IMGs for the NHS and should be replicated across the UK, with a structured program and ensuring necessary exposure and guidance.
HPB SO60 - A Re-Audit: Radiological Investigations In Patients Diagnosed With Gallstone Disease
Authors: Anis Iman , Sousseing Makeda Kingue , Gondavakuru Lesleen , Rai Anil , Al-Fagih Othman , Munasinghe Aruna
Published: November 2024

Background

Gallstones disease is very commonly encountered in general surgery and often detected by different modes of imaging.

NICE guidance advises offering liver function tests and ultrasound where gallstones are suspected. MRCP and EUS are then considered if gallstones have not been detected. However, ultrasound is not always offered first line in patient cases, for varying reasons.

This retrospective audit aims to assess the different radiological investigations used in gallstones against NICE guidance and the reasons behind this.

Method

Data was collected from a cohort of 108 patients over a 2 month period, all diagnosed with gallstones. The data collected included information regarding their demographics and imaging used to diagnose gallstones, as well as the reasoning when the first line investigation was not used. These results were then presented at the local general surgery CGM, findings were also communicated to doctors within the hospital. The audit was then repeated a year later with a similar cohort of patients, to compare findings.

Results

Mean age of patients decreased from initial audit to reaudit periodFemale preponderance in both audit and re-audit cyclePatients more likely to have imaging when abdominal pain present AND deranged LFTs as opposed to just one of the twoComparing total number of scans: less patients are undergoing CT scans (44 in audit period vs 31 in re-audit period)- 30% decreaseDecrease in number of patients having CTAP as first mode of scan (38 in audit period vs 21 in re-audit period). Total of 45 % drop.

Conclusion

While ultrasound scan is the first line radiological investigation where gallstones are suspected, it is not always the first to be used. This is for a plethora of reasons, including:Differing clinical judgment/ diagnostic uncertaintyDifferent clinicians/ specialities booking investigationsUnawareness of NICE guidanceLogistical delay in ultrasounds

However, it does appear there has been improvement in adherence to NICE guidance between first and second cycle. Other modes of awareness will be implemented to further improve this, including publishing further guidance about NICE protocol within the trust so this is more easily accessible to doctors.
HPB SO74 - Autologous Islet Transplantation combined with Pancreatic resection in Adults and Children
Authors: Chikkala Bhargava , Longhorn Chelsey , Neito Angelos Maillo , Pandanaboyana Sanjay , Wilson Colin , White Steven
Published: November 2024

Background

After extended pancreatic resections there is a risk of developing difficult to manage diabetes. The current NHS commissioning criteria only allows autologous islet isolation and transplantation in adult patients having total pancreatectomy for chronic pancreatitis. We present our experience of pancreatic resection combined with autologous islet transplantation (AIT) in both adults and children.

Method

Patients were assessed for AIT electively or as an emergency if an extended resection was required for trauma. Patients with chronic pancreatitis were assessed for Total Pancreatectomy (TP) by a multi-disciplinary team which included gastroenterologists, diabetes physicians, pain specialists, surgeons and psychiatrists. A similar approach was used in children. Patients were evaluated pre-operatively with a MMT to assess any borderline diabetes.

Results

22 (20 adults and 2 children, age range 9-64 yrs) patients underwent pancreas resection with AIT. Two patients had islet isolated remotely (Edinburgh and Kings College). Five received AIT for trauma (one total and four subtotal). Other indications included Chronic Pancreatitis (n=17) one of which had Familial Hyocalciuric Hypercalcaemia. Ten had gene mutations PRSS1 (n=6) or SPINK1 (n=4). Mean number of islets transplanted were 1534 IEQ/kg ranging in total from <5000- 443,000 IEQ. Patients with mutations received lower numbers of islets. Five remained insulin independent, overall 78% had measurable C peptide. 4/17 Chronic pancreatitis still have abdominal pain.

Conclusion

Pancreas resection combined with AIT is a viable treatment for both adults and children, even in those presenting with severe pancreatic trauma. Achieving good islet yields in patients with gene mutation remains a problem and is related to the extent of disease and duration of symptoms. Timing of TPIAT in these patients is critical if good outcomes are to be achieved.
HPB SO78 - A Novel Application of ISGPS Guidelines for Calculating Pancreatic Fistula Rates Post-Distal Pancreatectomy
Authors: Amin Golboo Abbasian , Allum Freddie , Talukder Shibojit
Published: November 2024

Background

Post-operative pancreatic fistula (POPF) remains a major cause of morbidity and mortality following distal pancreatectomy and there is continual debate regarding the optimal peri-operative practice. The impact of drain displacement on outcome is poorly understood and limited information is documented on how the ISGPS guidelines are used to determine a clinically significant POPF. This study aims to assess the POPF and drain displacement rate at our institution and identify factors predicting a clinically significant POPF. We have proposed an algorithm to standardise the interpretation of the ISGPS guidelines.

Method

Case records of patients undergoing left sided pancreatectomy at our institution from January 2019 to January 2024 were analysed to assess the incidence of biochemical and clinically significant POPF using ISGPS criteria. Post operative CT scans were reviewed to record drain displacement with respect to the pancreatic stump. Continuous data was represented as mean +/- SD or median(IQR) depending on normality. Appropriate statistical tests were used for comparison of continuous and categorical variables (alfa error of 5%). Receiver operating characteristic curves were performed to assess the suitability of drain fluid amylase level as a predictor of clinically significant POPF.

Results

A total of 56 patients qualified for analysis. There was no difference between the clinically insignificant and significant groups with respect to age, gender, BMI, pathology and surgical technique (open/laparoscopic, splenic preservation, stump reinforcement). The clinically significant group had higher day three and peak drain amylase levels. The day of peak drain amylase was significantly later in this group. The drain displacement rate was 41% and did not differ significantly between the two groups. A day 3 drain fluid amylase level of 1120(U/L) had a 74% sensitivity of predicting a clinically significant POPF.

Conclusion

The ISGPS guidelines do not provide explicit criteria for stratifying the grade of POPF. We propose an algorithm to standardise the interpretation of these guidelines. Drain displacement did not impact POPF rate allowing for small sample size. Day 3 fluid amylase level is a useful predictor of clinically significant POPF.

Program permission

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Regional government institutions and the capacity for women to reconcile career and motherhood
Authors: Giannantoni Costanza , Rodríguez-Pose Andrés
Published: November 2024

Declining fertility and the persistent underrepresentation of women in the labour market are key concerns of our time. The fact that they overlap is not fortuitous. Traditionally, women everywhere have faced a conflict in balancing their career ambitions with family responsibilities. Yet, the pressures arising from this conflict vary enormously from one place to another. Existing research has tended to overlook the geographical features of this dilemma, which could result in an inadequate understanding of the issue and lead to ineffective policy responses. This article examines how variations in the quality of regional institutions affect women’s capacity to reconcile career and motherhood and, consequently, gender equality within Europe. Using panel data from 216 regions across 18 European countries, we uncover a positive effect of regional institutional quality on fertility rates, taking into account variations in female employment. Moreover, we show that European regions with better government quality provide a more reliable environment for managing the career/motherhood dilemma often faced by women. In contrast, women living in regions with weaker government institutions are more constrained in both their career and childbearing options.
A case of asymptomatic giant renal angiomyolipoma with extrusion of fat content with literature review
Authors: Ahmad Manzoor , Varshney Kartik , Qadri Shagufta , Ali Wasif Mohammad , Ali Imad
Published: November 2024

Angiomyolipoma is a benign mesenchymal tumour of kidney that consists of adipose tissue, muscle cells and blood vessels. Renal angiomyolipomas represent almost one percent of all renal tumours. We reported a case of a 50-year-old woman complaining of mild abdominal discomfort with no other symptoms and no remarkable medical history. Clinical examination was inconclusive and no lump was palpable in abdomen. Ultrasonography raised the suspicion of existence of a large, homogeneous, hyperechoic tissue mass arising from right kidney. Abdominal computed tomography scan suggested the presence of giant angiomyolipoma of right kidney. The histopathological examination confirmed the diagnosis of renal angiomyolipoma. The patient underwent open simple nephrectomy to remove the tumour without any complications. We documented a rare case of retroperitoneal angiomyolipoma with extrusion of fat content from the renal hilum breaching the cortex as peculiarity which presented just as mild abdominal discomfort.
Date palm diverts organic solutes for root osmotic adjustment and protects leaves from oxidative damage in early drought acclimation
Authors: Franzisky Bastian L , Mueller Heike M , Du Baoguo , Lux Thomas , White Philip J , Carpentier Sebastien Christian , Winkler Jana Barbro , Schnitzler Joerg-Peter , Kudla Jörg , Kangasjärvi Jaakko , Reichelt Michael , Mithöfer Axel , Mayer Klaus F X , Rennenberg Heinz , Ache Peter , Hedrich Rainer , Messerer Maxim , Geilfus Christoph-Martin
Published: November 2024

Date palm (Phoenix dactylifera L.) is an important crop in arid regions and it is well adapted to desert ecosystems. To understand its remarkable ability to grow and yield in water-limited environments, we conducted experiments in which water was withheld for up to 4 weeks. In response to drought, root, rather than leaf, osmotic strength increased, with organic solutes such as sugars and amino acids contributing more to the osmolyte increase than minerals. Consistently, carbon and amino acid metabolism was acclimated toward biosynthesis at both the transcriptional and translational levels. In leaves, a remodeling of membrane systems was observed, suggesting changes in thylakoid lipid composition which, together with the restructuring of the photosynthetic apparatus, indicated an acclimation preventing oxidative damage. Thus, xerophilic date palm avoids oxidative damage under drought by combined prevention and rapid detoxification of oxygen radicals. Although minerals were expected to serve as cheap key osmotics, date palm also relies on organic osmolytes for osmotic adjustment in the roots during early drought acclimation. The diversion of these resources away from growth is consistent with the date palm strategy of generally slow growth in harsh environments and clearly indicates a trade-off between growth and stress-related physiological responses.
Two sides of the same coin? Cross-linguistic sentiment comparison and thematic discovery of reader’s reception of Wolf Totem
Authors: Chen Ruina , Zhong Zhuojun , Yuan Xinyu , Liu Haitao
Published: November 2024

Despite growing attention to the global dissemination of cross-cultural literature, rigorous research on cross-linguistic sentiment analysis remains limited, especially for works like Wolf Totem, which hold both worldwide reach and cultural depth. This study conducted a cross-language sentiment and thematic analysis of online book reviews by Chinese and English readers, utilizing advanced linguistic techniques such as BERT, MAXQDA, and ProtAnt. The analysis reveals that Chinese readers are more critical of the themes “Ethnicity and Culture”, “Society and Politics”, and “Wolf and Wolf Nature”, while English readers respond more positively to “Historical Context and Background”, “Plot and Theme”, and “Emotional Response and Reading Experience”. This study not only highlights these emotional variations but also provides robust methodological insights for cross-linguistic sentiment analysis, showcasing the integration of quantitative and qualitative approaches and enhancing understanding of how cultural identity shapes reader engagement.
JADES: primaeval Lyman α emitting galaxies reveal early sites of reionization out to redshift z ~ 9
Authors: Witstok Joris , Maiolino Roberto , Smit Renske , Jones Gareth C , Bunker Andrew J , Helton Jakob M , Johnson Benjamin D , Tacchella Sandro , Saxena Aayush , Arribas Santiago , Bhatawdekar Rachana , Boyett Kristan , Cameron Alex J , Cargile Phillip A , Carniani Stefano , Charlot Stéphane , Chevallard Jacopo , Curti Mirko , Curtis-Lake Emma , D’Eugenio Francesco , Eisenstein Daniel J , Hainline Kevin , Hausen Ryan , Kumari Nimisha , Laseter Isaac , Maseda Michael V , Rieke Marcia , Robertson Brant , Scholtz Jan , Shivaei Irene , Williams Christina C , Willmer Christopher N A , Willott Chris
Published: November 2024

Given the sensitivity of the resonant Lyman $\alpha$ (Ly $\alpha $) transition to absorption by neutral hydrogen, observations of Ly $\alpha$ emitting galaxies (LAEs) have been widely used to probe the ionizing capabilities of reionization-era galaxies and their impact on the intergalactic medium (IGM). However, prior to JWST our understanding of the contribution of fainter sources and of ionized ‘bubbles’ at earlier stages of reionization remained uncertain. Here, we present the characterization of three exceptionally distant LAEs at $z \gt 8$, newly discovered by JWST/Near-Infrared Spectrograph in the JADES survey. These three similarly bright ($M_\text{UV} \approx -20 \, \mathrm{mag}$) LAEs exhibit small Ly $\alpha$ velocity offsets from the systemic redshift, $\Delta v_\rm{{Ly\alpha }} \lesssim 200 \, \mathrm{km \, s^{-1}}$, yet span a range of Ly $\alpha$ equivalent widths (15, 31, and $132 \, \mathring{\rm A}$). The former two show moderate Ly $\alpha$ escape fractions ($f_\rm{esc, {Ly\alpha }} \approx 10~{{\rm per\,cent}}$), whereas Ly $\alpha$ escapes remarkably efficiently from the third ($f_\rm{esc, {Ly\alpha }} \approx 72~{{\rm per\,cent}}$), which moreover is very compact (half-light radius of $90 \pm 10 \, \mathrm{pc}$). We find these LAEs are low-mass galaxies dominated by very recent, vigorous bursts of star formation accompanied by strong nebular emission from metal-poor gas. We infer the two LAEs with modest $f_\rm{esc, {Ly\alpha }}$, one of which reveals evidence for ionization by an active galactic nucleus, may have reasonably produced small ionized bubbles preventing complete IGM absorption of Ly $\alpha$. The third, however, requires a $\sim \!3 \, \text{physical Mpc}$ bubble, indicating faint galaxies have contributed significantly. The most distant LAEs thus continue to be powerful observational probes into the earlier stages of reionization.
Simultaneous optical and X-ray detection of a thermonuclear burst in the 2024 outburst of EXO 0748−676
Authors: Knight Amy H , Rhodes Lauren , Buisson Douglas J K , Matthews James H , Castro Segura Noel , Ingram Adam , Middleton Matthew , Roberts Timothy P
Published: November 2024

The neutron star low-mass X-ray binary, EXO 0748−676, recently returned to outburst after a $\sim\!\! 16$ yr-long quiescence. Since its return, there has been a global effort to capture the previously unseen rise of the source and to understand its somewhat early return to outburst, as it is typical for a source to spend longer in quiescence than in outburst. Here, we report on the simultaneous optical and X-ray detection of a type I X-ray burst, captured by XMM–Newton during a director’s discretionary time observation on 2024 June 30. The data show three X-ray eclipses consistent with the known ephemeris and one type I X-ray burst at 60492.309 MJD. The X-ray burst is reprocessed into the optical band and captured by XMM–Newton’s Optical Monitor during a 4399 s exposure with the B filter in image $+$ fast mode. We determine that the optical peak lags the X-ray peak by $4.46 \pm 1.71$ s. The optical and X-ray rise times are similar, but the optical decay time-scale is shorter than the X-ray decay time-scale. The reprocessing site is likely within a few light-seconds of the X-ray emitting region, so the companion star, accretion disc, and ablated material are all plausible.
Unraveling demographic patterns in tropical birds across an elevational gradient
Authors: Neate-Clegg Montague H C , Saracco James F , Rodríguez-Vásquez Fabiola , Jones Samuel E I
Published: November 2024

An increasing body of evidence has displayed upslope shifts in the high-diversity avian communities of tropical mountains. Such shifts have largely been attributed to warming climates, although their actual mechanisms remain poorly understood. One likely possibility is that changes in species-specific demographic rates underlie elevational range shifts. Fine-scale population monitoring and capture–mark–recapture (CMR) analysis could shed light on these mechanisms, but, until recently, analytical constraints have limited our ability to model multiple demographic rates across bird communities while accounting for transient individuals. Here, we used Bayesian hierarchical multi-species CMR models to estimate the apparent survival, recruitment, and realized population growth rates of 17 bird species along an elevational gradient in the cloud forests of Honduras. For 6 species, we also modeled demographic rates across elevation and time. Although demographic rates varied among species, population growth rates tended to be higher in lower elevation species. Moreover, some species showed higher population growth rates at higher elevations, and elevational differences in growth rates were positively associated with previous estimates of upslope shifts at the study site. We also found that demographic rates showed contrasting trends across the duration of the study, with recruitment decreasing and apparent survival increasing, and stronger effects at lower elevations. Collectively, we provide the methodological tools to encourage more multi-species demographic analyses in other systems, while highlighting the potential for the demographic impacts of global change. We provide a Spanish translation in the Supplementary Materials.
Property not required for its trust purpose—and the concept of ‘general charitable intent’
Authors: Wilde David
Published: November 2024

This article compares the treatment of various types of trust where the settlor stipulates that trust property is to be used to pursue a particular purpose, but that purpose proves abortive, leaving the relevant property not now needed for the purpose and not otherwise disposed of. It argues that charitable trusts, and in particular the doctrine of ‘general charitable intent’ leading to cy-près application, could perhaps draw a lesson from beneficiary trusts.
The Whirlpool Sign in Pediatric Body Imaging: Diagnostic Value and Clinical Implications
Authors: Aboughalia Hassan , Alp Oztek Murat , Shet Narendra , Noda Sakura
Published: November 2024

The whirlpool sign denotes twisting of the vascular pedicle of a nearby organ, suggesting an emergency that needs urgent attention and prompt treatment. Although the whirlpool sign does not determine the underlying cause of torsion, it is most often specific for torsion, which is the driving force for management in most scenarios. A mesenteric whirlpool indicates midgut malrotation and volvulus, while in the adnexa it denotes ovarian torsion, and finally a scrotal whirlpool indicates testicular torsion. Thus, it is important to recognize such signs, mostly on ultrasound, to avoid the downsides of delayed recognition and improper treatment.
Dosing, Toxicity and Drug Concentrations for Ganciclovir/Valganciclovir in Preterm and Low Birthweight Infants Treated for Cytomegalovirus
Authors: Abu Bakar Asrar , Payne Helen , Tickner Neil , Muhd Helmi Muhd Alwi , Jacobs Tom G. , Lyall Hermione
Published: November 2024

Background:

There is a lack of data regarding suitable dosage when administering intravenous ganciclovir (GCV) or oral valganciclovir (valGCV) to preterm and low birthweight infants with cytomegalovirus (CMV) disease.

Methods:

Data were collected for infants born before 32 weeks gestation and/or weighing less than 1.8 kg treated for CMV disease with GCV or valGCV between 2016 and 2023.

Results:

Twenty-four infants (58% males and 48% Asian ethnicity) with a median gestation of 31 weeks [interquartile range (IQR): 26.6–36.1], median weight of 950 g (IQR: 470–1692) and median age of 45 days (IQR: 6–84) at initiation of treatment were included. Seventeen infants were treated for symptomatic postnatal CMV and 7 for symptomatic congenital CMV. Most infants receiving GCV had 6 mg/kg twice daily dosing and most receiving valGCV had 16 mg/kg twice daily dosing. Fourteen infants had drug concentrations measured with combined geometric mean minimum blood plasma concentration (Cmin) of 2.44 mg/L and maximum blood plasma concentration of 7.98 mg/L for doses of 6 mg/kg GCV and 16 mg/kg valGCV, which is higher compared with term infants. The estimated area under the curve at 12 hours (AUC0–12h) was 54.34 mg × h/L, which doubled the value for term infants in a previous study. Notably, AUC0–12h had an inverse relationship with gestational age and weight. Infants with lower gestation and higher Cmin showed a higher tendency for more than 1 adverse effect.

Conclusions:

GCV and valGCV use among preterm and very low birthweight infants with CMV disease resulted in a higher incidence of adverse events, increased AUC0–12h and elevated Cmin compared with term infants. Further pharmacokinetic studies are necessary to determine the ideal dosage in this population.
Unforeseen challenge: bilateral, spontaneous, symmetrical displacement of toric implantable collamer lens: case report
Authors: Gupta Sonal , Chaudhary Sanjay , Mehra Hema , Pandey Alka
Published: November 2024

Introduction:

The phakic intraocular lenses represent a significant advancement in refractive correction particularly in patients for whom conventional procedures such as laser in situ keratomileusis (LASIK) are contraindicated. To our knowledge, although studies have extensively documented the occurrence and management of implantable collamer lens (ICL) rotation, spontaneous displacement of the ICL has not yet been documented. In this article, we present an interesting case of bilateral ICL displacement.

Patient and Clinical Findings:

After undergoing bilateral ICL surgery, the patient presented with blurring of vision the next day. On examination, there was symmetrical bilateral displacement of the ICL despite having implanted the maximum size of this lens.

Diagnosis, Intervention, and Outcomes:

After discussion and analysis, a bilateral explantation of the ICL was performed.

Conclusions:

Despite taking into consideration all the essential anterior segment parameters for ICL size calculation, there can still be a possibility of ICL displacement.
Ciliary processes and ciliary sulcus hypoplasia in Marfan syndrome
Authors: Sugiura Takeshi , Sakimoto Toru
Published: November 2024

Introduction:

Lens dislocation is a major ophthalmological complication of Marfan syndrome. However, to our knowledge, no previous study has reported direct observation of the ciliary sulcus in living eyes of patients with Marfan syndrome. Therefore, in this study, we report hypoplasia of the ciliary process and sulcus observed using intraocular endoscopy in patients with Marfan syndrome and lens dislocation.

Patient and Clinical Findings:

We performed the ciliary sulcus suture fixation of intraocular lens in both eyes of 3 cases with Marfan syndrome and lens dislocation. The ciliary sulcus observed using an intraocular endoscope revealed hypoplasia of the ciliary process in all 3 cases. Therefore, no ciliary sulcus was formed.

Diagnosis, Intervention, and Outcomes:

Lens luxation was caused by rupture of the zonules of Zinn, most likely caused by hypoplasia of the ciliary process. Hypoplasia of the ciliary processes has been suggested to cause hypoplasia or excessive elongation of the zonules of Zinn, leading to their rupture.

Conclusions:

Anatomical hypoplasia of the ciliary process was recognized in Marfan syndrome, possibly leading to zonal rupture and lens dislocation. Ciliary process hypoplasia may be associated with Marfan syndrome.