bluuebunny/crossref_metadata_2025 huggingface dataset:
Meta-analysis of randomized controlled trials comparing minimal-invasive versus open pancreatic surgery
Authors: Pfister M , Probst P , Baechtold M , Müller D , Renzulli P , Hauswirth F , Müller M K
Published: June 2022

Objective

To compare perioperative outcomes of minimal-invasive pancreatic surgery (MIPS) to open pancreatic surgery (OPS) using data obtained from randomised controlled trials (RCTs).

Methods

Literature search was done in CENTRAL, Medline and Web of Science; all currently available RCTs comparing MIPS and OPS in adult patients requiring elective distal pancreatectomy (DP) or partial pancreatoduodenectomy (PD) were included in the analysis. Outcomes were mortality, general and pancreatic surgery specific morbidity and length of hospital stay (LOS). Subgroup analysis between PD and DP was performed. A random-effects model for Mantel-Haenzsel and inverse variance analysis was used. Cochrane RoB 2.0 tool and GRADE approach was used for assessment of risk of bias and certainty of evidence.

Results

A total of 166 patients for DP (80 MIPS vs. 86 OPS) in two RCTs and 856 for PD (429 MIPS vs. 427 OPS) in five RCTs were analysed. Meta-analysis showed a reduction of LOS by 1.2 days (-2 to -0.3, p<0.01) and intraoperative blood loss by 143 ml (-186 to -101, p<0.01) in MIPS. In the subgroup analysis reduction of LOS was only present for minimal-invasive DP (-2 days, -2.3 to -1.7, p<0.01). A minimal-invasive approach showed reduction of surgical site infections (odds ratio 0.4, 0.1 to 0.96, p=0.04) and intraoperative blood loss (-141 ml, -181 to -101, p<0.01) only in PD. Duration of surgery was about 96 min longer in minimal-invasive PD (56 to 137 min, p<0.01), but not in DP. Analysis showed no significant difference between MIPS and OPS, as well as between subgroups, in mortality, complications according to Clavien-Dindo >=3 and pancreatic surgery specific complications like postoperative pancreatic fistula and delayed gastric emptying. Certainty of evidence according to the GRADE approach was moderate to low.

Conclusion

This meta-analysis of level 1 evidence shows reduced LOS and intraoperative blood loss in MIPS compared to OPS. Morbidity and mortality did not differ between MIPS and OPS. Longer duration of surgery in minimal-invasive PD hints that minimal-invasive technique in PD is more challenging than in DP. However, patients undergoing minimal-invasive PD seem to benefit from lower surgical site infections and less intraoperative blood loss.
Herlyn-Werner-Wunderlich Syndrome in a young female mimicking acute appendicitis
Authors: Fiechter J , Feki A , Egger B , Chilcott M
Published: June 2022

Objective

Herlyn-Werner-Wunderlich (HWW) Syndrome, also known as Obstructed Hemivagina and Ipsilateral Renal Anomaly (OHVIRA) syndrome, is a very rare congenital urogenital tract anomaly. The incidence of the syndrome is less than 1/1,000,000 females. OHVIRA syndrome radiologically presents as the Wunderlich triad: uterus didelphys, obstructed hemivagina and ipsilateral renal agenesis. Clinical presentation is progressive dysmenorrhea beginning with the menarche. If unilateral renal agenesis is diagnosed in a female newborn, gynecological exams should be performed to exclude corresponding genital anomalies. We present here a case of OHVIRA syndrome mimicking acute appendicitis.

Methods

A 12-year-old recently menarched female presented to our emergency department with lower abdominal pain and nausea without vomiting. The pain started two days earlier and it was the first such episode. The abdomen was tender in the right lower quadrant with no alarming signs. WBC count and CRP were normal. Abdominal ultrasound suggested acute appendicitis (without clear visualization of the appendix) and also revealed left renal agenesis. Performed abdominal MRI confirmed renal agenesis and uterine malformation with 2 uterine bodies, 2 cervical uteri and a closed hemi-vagina with hematocolpos.

Results

With the diagnosis of the rare OHVIRA syndrome and the visualization of a healthy appendix the cause of the pain was identified. The patient was hospitalized for one night to control pain and a treatment with oral contraception was introduced to suppress the hormonal cycle. Since pain was not well controlled the patient returned to the emergency department two days later. Indication for surgical treatment was made and the blood filled hemivagina incised, drained and marsupialised. Oral contraception (Dienogest) was prescribed. Further gynecological follow-up and corrective surgery are planned.

Conclusion

OHVIRA syndrome is very rare and may mislead physicians presuming other pathologies such as acute appendicitis. In young women presenting with abdominal pain, OHVIRA should be taken into account. Ultrasound and MRI are the imagery of choice, especially in fertile young women. Rapid and complete diagnosis is necessary to treat correctly and prevent complications. Moreover, detected genitourinary malformations should always lead to further investigations of concomitants pathologies.
Indocyanine green for leakage control in isolated limb perfusion
Authors: Zucal I , Geis S , Prantl L , Haerteis S , Aung T
Published: June 2022

Objective

Sarcomas are characterized by a high metastatic potential and aggressive growth. Despite surgery, chemotherapy plays an important role in the treatment of these tumors. Optimal anti-cancer therapy with maximized local efficacy and minimized systemic side effects has been the object of many studies for a long time. To improve the local efficacy of anti-tumor therapy, isolated limb perfusion with high-dose cytostatic agents has been introduced in surgical oncology. In order to control the local distribution of substances, radiolabeled cytostatic drugs or perfusion solutions have been applied but often require the presence of specialized personnel and result in a certain exposure to radiation. In this study, we present a novel strategy using indocyanine green to track tumor perfusion with high-dose cytostatic therapy.

Methods

In a rat cadaver model, the femoral vessels were cannulated and connected to a peristaltic pump to provide circulation within the selected limb. The perfusion solution contained indocyanine green and high-dose doxorubicin. An infrared camera enabled the visualization of indocyanine green during limb perfusion, and subsequent leakage control was successfully performed.

Results

Histologic analysis of sections derived proximally from the injection site excluded systemic drug dispersion.

Conclusion

In this study, the application of indocyanine green was proven to be a safe and cost- and time-efficient method for precise leakage control in isolated limb perfusion with a high-dose cytostatic agent.
Anatomical analysis of different helical plate designs for distal femoral fracture fixation
Authors: Pastor T , Beeres F J P , Kastner P , Gehweiler D , Miglorini F , Nebelung S , Scaglioni M F , Souleiman F , Link B-C , Babst R , Gueorguiev B , Knobe M
Published: June 2022

Objective

Helical plates potentially avoid the medial neurovascular structures of the thigh. Recently, two plate designs (90°- and 180°-helix) proved similar biomechanically behavior compared to straight plates. The aims of this study were: (1) feasibility of applying 90°- and 180°-helical plates in MIPO-technique to the femur, (2) Assess the distances to adjacent anatomical structures which are at risk, (3) Compare these distances with medial straight plates, and (4) Correlate measurements performed during anatomical dissection with CT-angiography.

Methods

MIPO was performed in ten cadaveric femoral pairs using either a 90°-helical 14-hole-LCP (group1) or a 180°-helical 15-hole-LCP-DF (group2). Using CT-angiography, distances between femoral arteries and plates as well as distances between plates and perforators were evaluated. Following, specimens were dissected, and distances determined again. All plates were removed, and all measurements were repeated with straight medial plates (group3).

Results

Closest overall distances between plates and femoral arteries were 15 mm(11–19 mm) in group1, 22 mm(15–24 mm) in group2 and 6 mm(1–8 mm) in group3 with a significant difference between group1 and group3(p<0.001). Distances to the nearest perforators were 24 mm(15–32 mm) in group1 and 2 mm(1–4 mm) in group2. Measurement techniques (visual after surgery and CT-angiography) showed a strong correlation of 0.972(p<0.01).

Conclusion

MIPO with 90°- and 180°-helical plates is feasible and safe. Attention must be paid to the medial neurovascular structures with 90°-helical implants and to the proximal perforators with 180°-helical implants. Helical implants can avoid medial neurovascular structures compared to straight plates although care must be taken during their distally insertion. Measurements during anatomical dissection correlate with CT-angiography.
Comparison of surgical outcomes in elective sigmoid resection for diverticulitis in different indication-specific strategies: A propensity-score matched cohort study with 636 patients
Authors: Nocera F , Haak F , Ly C , Posabella A , Angehrn F , von Flüe M , Steinemann D C
Published: June 2022

Objective

Comparing different surgical guidelines for recurrent uncomplicated diverticulitis, a careful benefit-risk assessment is recommended although different approaches giving the indication for surgery exists. The purpose of this study was to evaluate the impact of indications-specific strategies on surgical outcomes allowing adequate benefit-risk consulting.

Methods

All patients undergoing elective colonic resection for diverticulitis between January 2011 and March 2020 in our institution were included. They were divided into two groups based on the strategy for surgical indication: relative surgery indication group (RSI; CDD (classification of diverticula disease) Type 2a, 3a and 3b, n = 585) and absolute surgery indication group (ASI; CDD Type 2b and 3c, n = 318). Propensity score-matching (PSM) was applied at a ratio of 1:1 to compare the RSI and the ASI group.

Results

In the univariate analysis, RSI patients were younger (62±10.4 vs. 67.7±11.4, p<0.05), had a higher physical status (ASA score 1 or 2 in 80.7% vs. 60.8%, p<0.05), were less immunosuppressed (3.4% vs. 6.9%, p<0.05) and suffered less from coronary heart disease (3.8% vs. 7.2%, p<0.05). After PSM, 318 vs. 318 patients were selected and baseline characteristics resulted comparable. The proportion of laparoscopic resection was 94.7% in RSI versus 84.6% in ASI (p<0.05) and the conversion rate to open surgery for laparoscopic resection was 5.0% in RSI and 13.8% in ASI (p<0.05). Intraoperative complications were rare in both groups (3.1% vs. 5.3%, p=0.24). Mean operation time was shorter in RSI (211±62 vs. 229±72, p<0.05). Major morbidity (Clavien/Dindo ≥3b) occurred less frequently in RSI (3.8% vs. 10.1%, p<0.05) and the overall comprehensive complications index (CCI) was lower in RSI (9.4±12.2 vs. 12.9±14.9, p<0.05). Anastomotic insufficiency occurred in 0.9% in RSI and in 2.5% in ASI (p=0.22). A defunctioning stoma was received by 0.9% in RSI and 11.0% in ASI (p<0.05).

Conclusion

Our study demonstrates that even after PSM analysis patients with RSI in contrast to patients with more advanced diverticular disease have a lower risk of suffering from postoperative overall morbidity and major morbidities as well as the risk of receiving a temporary stoma. These observations should be considered when counselling patients with an equivocal indication for surgery for diverticular disease.
Coffee is more than just caffeine – a single-center, randomized, double-blinded, placebo-controlled superiority trial (CaCo trial)
Authors: Abbassi F , Müller S A , Steffen T , Schmied B M , Warschkow R , Beutner U , Tarantino I
Published: June 2022

Objective

Avoidance of prolonged postoperative bowel paralysis after colorectal surgery is of major importance due to its significant clinical implications. Postoperative caffeine consumption appears to be a promising strategy. The aim of this study was to assess whether postoperative oral caffeine intake shortens bowel hypomotility after elective laparoscopic colorectal surgery.

Methods

This was a single-center, randomized, double-blinded, placebo-controlled superiority trial conducted from October 1st, 2015 to August 10th, 2020. Patients aged >=18 years with malignant or benign disease undergoing elective laparoscopic colectomy were included and assigned randomly before surgery to receive 3x daily either 100 mg caffeine or 200 mg caffeine or 250 mg corn starch (placebo) after the procedure. Substances were served in indistinguishable capsules three times daily before the meals. The primary endpoint was time to first bowel movement, measured from the time of wound closure to the patient's first defecation. Secondary endpoints included colonic transit time, time to tolerance of solid food, length of hospital stay and perioperative morbidity.

Results

A total of 60 patients were randomized, 20 to each group. Twenty-seven patients followed the protocol and were included in the per-protocol (PP) analysis. Baseline characteristics were similarly distributed among the groups. In intention-to-treat analysis, the time to first bowel movement in the caffeine 200 mg group was 67.9 h (standard deviation [SD] 19.2), in the caffeine 100 mg group 68.2 h (SD 32.2) and in the placebo group 67.3 h (SD 22.7) (p=0.887). PP analysis and measurement of colonic transit time (41.8 h [SD 21.7] in the caffeine 200 mg group, 34.2 h [SD 22.9] in the caffeine 100 mg group and 46.3 h [SD 20.6] in the placebo group, p=0.317) confirmed non-significant differences. The time to tolerance of solid food, length of hospital stay and postoperative morbidity were comparable among the three groups and no deaths or related serious adverse events were observed during the study.

Conclusion

Although caffeine intake after laparoscopic colorectal surgery is safe, its administration was not associated with a shortened time to first bowel movement in contrast to previous studies. Thus, other ingredients of coffee might be responsible for the intestinal stimulatory effect previously described.
Swiss consensus on the management of acute diverticulitis
Authors: Girardin T , Martin D , Clerc D , Lázaro-Fontanet E , Hübner M , Hahnloser D
Published: June 2022

Objective

Acute diverticulitis is a frequent clinical conditions encountered in emergency settings. Despite recent international guidelines, management of acute diverticulitis (AD) varies and is not standardized. The aim of the study was to achieve a Swiss nationwide consensus on clinical management of acute diverticulitis.

Methods

A three-staged consensus meeting according to the Delphi method was performed in 2020 involving 78 Swiss surgeons from 40 hospitals. A steering-group drafted the questionnaires, gathered best available evidence which was presented and discussed in meetings prior answering the questions. Consensus was defined as ≥70% of agreement.

Results

57 surgeons answered all the 3 rounds and 28 (53%) performed > 50 colorectal resections per year. On initial workup in the emergency setting, performing leucocytes count (87%), CRP (98%) and CT imaging (98%) reached consensus for the diagnosis, but no uniform classification system of AD was retained. Signs of generalized peritonitis (100%), requiring intravenous pain medication (98%), inability to tolerate oral intake (95%), lack of adequate social support (86%), immunosuppression (96%), and complicated AD on CT (84%) were criteria for hospitalization. Persisting symptoms (95%) and immunosuppression (89%) were criteria for elective colonic resection, while the number of AD episodes were not (27%). In case of abscess, a size ≥ 4 cm reached consensus for percutaneous drainage (88%). No consensus were reached for surgical approach and techniques in the emergency settings, apart from damage control surgery for instable patients (70%). In the follow-up, recommendation for dietary restrictions or lifestyle habits did not reach reach consensus.

Conclusion

Swiss colorectal surgeons reached consensus for several diagnostics, hospitalization, and elective surgery criterias. However, emergency surgical management and follow-up are less standardized. These variations should be further assessed, and particularly in the context the latest published recommendations.
Software-based perfusion assessment of the ileal J-pouch – a standardized and objective approach of interpreting intraoperative indocyanine green near-infrared fluorescence
Authors: Lobbes L , Berns S , Beyer K , Weixler B
Published: June 2022

Objective

For ileal J-pouch after restorative proctocolectomy, intraoperative perfusion assessment is vital to prevent complications such as anastomotic leak (AL) of the pouch. Indocyanine green derived near-infrared fluorescence (ICG-NIRF) is gaining popularity for intraoperative visualization, while its interpretation and relevance remain subjective. Standardized NIRF protocols with objective and quantifiable data are not yet established. This study aimed to evaluate a standardized approach of intraoperative ICG-NIRF imaging combined with a novel, software-based perfusion assessment for the detection of AL of the pouch. We hypothesized that an analysis of fluorescence intensity over time would result in novel, quantifiable and objective indicators of perfusion.

Methods

In this prospective single centre study patients undergoing restorative proctocolectomy with ileal J-pouch formation were included. Intraoperatively, ICG-NIRF visualization was performed at three time points in a strictly standardized setting and video recorded. Postoperatively, a special software was used to depict fluorescence intensity over time, generating perfusion graphs for each recorded pouch visualization. The characteristics of these perfusion graphs were correlated with postoperative outcome, including AL of the pouch within 30 days precisely defined and screened for by pouchoscopy.

Results

18 patients were included, of which 4 developed AL of the ileal pouch-anal anastomosis (IPAA). Distinctive perfusion curves were generated for regions of interest (ROIs) across each pouch. Novel characteristics of perfusion were identified (ingress, maximum slope, egress and maximum egress). Differences in the shape of the perfusion graphs became evident when comparing pouches with a normal to those with an AL. In cases of AL, the pouch apex displayed lower ingress, maximum slope and egress values, indicating impaired perfusion. This was confirmed by comparing the maximum slope of the perfusion curve versus the egress on the pouch apex.

Conclusion

We present a novel methodology to assess anastomotic perfusion in pouch surgery with ICG-NIRF in real-time. By dynamically analyzing fluorescence intensity over time in the form of perfusion graphs and correlation with outcome, novel parameters of perfusion were identified. These have the potential to improve the objectivity and quantifiability of intraoperative perfusion assessment.
Prospective data analysis of 1307 ventral hernia patients: Emergency hernia repair and smoking predict recurrence
Authors: Soppe S , Wirsching A , Slieker J , Keerl A , Nocito A
Published: June 2022

Objective

Ventral hernias are frequent and hernia repair is regularly performed by general surgeons. Emergency repair is less frequent and can be challenging. Long-term outcomes comparing emergency and elective ventral hernia repair are scarce.

Methods

Consecutive patients undergoing emergency and elective ventral hernia repair at our institution were prospectively entered in our HerniaMed database between August 2013 and February 2020. Ventral herniation included umbilical, epigastric and incisional hernias. Demographic-, perioperative- and outcome data were reviewed. Patients were contacted after one-, five- and ten years to assess long-term complications like hernia recurrence. Risk factors for emergency repair and hernia recurrence were assessed by univariate and multivariate analysis.

Results

We included 1307 patients in our analysis. Emergency and elective hernia repair was performed in 11% and 89% of patients with one-year follow-op rates of 94% and 92%, respectively. Female gender, BMI >40 kg/m2, ASA class 3 and 4, large size umbilical herniation (>4 cm) and epigastric herniation were more frequent in emergency compared to elective hernia repair. Furthermore, emergency repair led to increased length of hospital stay and increased overall complications (median 4 vs. 2 days, p<0.001 and 20% vs. 13%, p<0.021). Binary logistic regression analysis identified female gender (Odds ratio: 2.12 and 95% confidence interval: 1.13–3.99, p=0.019) and ASA class 3 and 4 (Odds ratio: 3.96 and 95% confidence interval: 1.96–7.99, p<0.001) to be independent predictors of emergency repair. After one year of follow up, hernia recurrence was found in 6% after emergency and in 2% of patients after elective repair (p=0.019). Emergency repair and smoking predicted hernia recurrence (Odds ratio: 4.48 and 95% confidence interval: 1.55–12.92, p=0.006; Odds ratio: 3.60 and 95% confidence interval: 1.39–9.32, p=0.008).

Conclusion

Female gender and high ASA class were found to be independent predictors of emergency repair. Therefore, early elective ventral hernia repair should be considered for female and comorbid patients. In addition, since emergency repair and smoking were risk factors for recurrence, smokers should be counseled accordingly.
Photodynamique therapy relieves tumor vascular anergy and promotes immune cell trafficking in an orthotopic mouse model of malignant pleural mesothelioma
Authors: Chriqui L E , Hao Y , Ortolini M E , Gattlen C , Gonzalez M , Krueger T , Perentes J-Y , Cavin S
Published: June 2022

Objective

Malignant pleural mesothelioma (MPM) is a deadly disease with limited treatment options. Recently, dual immune checkpoint inhibition therapy (ICI) showed improved patient survival. However, only a fraction of patients were responsive to immunotherapy. One potential mechanism of MPM resistance to ICIs could be their endothelial anergy that hampers leukocyte trafficking to the tumor bulk. Here, we hypothesized that vascular-targeted low dose photodynamic therapy (L-PDT), treatment of MPM could relieve tumor endothelial anergy and improve immunotherapy efficacy.

Methods

Using an orthotopic syngeneic MPM murine model (AB12 cells injected in the pleura of BALB/c mice), we determined the impact of L-PDT on the endothelial expression of E-Selectin, a key molecule involved in leukocyte diapedesis by immunohistochemistry. Furthermore, to confirm the role of E-selectin, we determined the extravasation of effector T cells (CD8+/CD4+) by immunostaining in L-PDT treated tumors in the presence or absence of an E-selectin blocking antibody. Finally, we assessed tumor growth/survival of our MPM murine model treated with L-PDT alone or combined to ICIs.

Results

L-PDT pre-treatment enhanced MPM endothelial E-Selectin expression in vivo. The latter was associated with increased CD4+ and CD8+ lymphocyte infiltration of MPM following L-PDT which did not occur after E-Selectin blockade. Also, L-PDT pre-treatment of MPM influenced favorably tumor control, mouse survival and the impact of ICIs compared to controls.

Conclusion

L-PDT pre-treatment relieves endothelial anergy in MPM which improves antitumor immunity and response to ICI. This approach could constitute a promising pre-treatment option, in combination with ICIs, for the management of this deadly disease.
CT-based sarcopenia and outcomes in patients undergoing VATS anatomical resection for NSCLC
Authors: Hasenauer A , Hungerbühler J , Perentes J , Abdelnour E , Koerfer J , Forster C , Krueger T , Becce F , Gonzalez M
Published: June 2022

Objective

Sarcopenia is defined by a progressive loss of skeletal muscle mass and strength, combined with muscle fatty infiltration. Lung cancer patients frequently suffer from sarcopenia which may be associated with poorer post-operative outcomes. The aim of this study is to evaluate whether preoperative CT-based sarcopenia was associated with postoperative outcomes and survival after VATS resections in patients with early-stage non-small cell lung cancer (NSCLC).

Methods

We retrospectively reviewed all consecutive patients that underwent anatomical resection for NSCLC between 2012 and 2019. The skeletal muscle index (SMI) and muscle quality (SMRA and IMAT) were measured at the L3 vertebral level on preoperative CT or PET/CT scans. We used the following SMI cut-off values for sarcopenia: 52.4 cm2 /m2 for men and 38.5 cm2 /m2 for women.

Results

In total, 401 patients (sex ratio F/M: 173/228, mean age: 67 +/- 9.3 years) underwent VATS lobectomies (n=304) and segmentectomies (n=97) for NSCLC. Overall morbidity and mortality were 42.4% and 0.2%, respectively. The median length of stay was 7 days (IQR: 4–10). Sarcopenia was identified in 92 patients (23%). Patients with sarcopenia were predominantly males (75% vs 25%, p<0.001) and had lower BMI (21.4 vs 26.5, p<0.001). Patients with sarcopenia presented significantly increased morbidity (53.2% vs 39.2%, p=0.017) and had longer lengths of stay (6 vs 8 days, p=0.032). However, only lower BMI and ASA score >2 remained associated with increased morbidity on multivariate analysis. The median overall survival was comparable between patients with sarcopenia and those without sarcopenia (41 vs. 46 months, p=0.240).

Conclusion

Based on CT assessment alone, preoperative sarcopenia appeared to have little impact on postoperative clinical outcomes or overall survival in patients undergoing VATS pulmonary resection. Further studies should also consider muscle strength and physical performance, in addition to CT imaging, for preoperative risk assessment.
Analysis of DCD porcine kidney graft viability during sub-normothermic perfusion using magnetic resonance imaging and spectroscopy
Authors: Agius T , Songeon J , Klauser A , Longchamp G , Allagnat F , Nastasi A , Ruttiman R , Meier R P H , Toso C , Bühler L , Corpataux J-M , Lazeyras F , Longchamp A
Published: June 2022

Objective

Better preservation strategies for the storage of donation after circulatory death grafts could increase the number of kidneys available and improve patient survival. Warm (22°C and 37°C) ex-vivo perfusion has emerged as an alternative to hypothermia and a feasible strategy to recover/repair organs, but the underlying mechanism remains elusive. Here, using magnetic resonance imaging spectroscopy (MRIs), we evaluated kidney viability, and adenosine triphosphate (ATP) production during sub-normothermic ex-vivo kidney perfusion (22°C + O2) versus hypothermic machine perfusion (4°C and 4°C + O2) in a porcine kidney autotransplantation model.

Methods

To mimic donation after circulatory death (DCD), kidneys from 8-month-old pigs underwent 60 minutes of warm ischemia, prior to procurement. Kidneys were then perfused ex-vivo at 4°C with (4°C + O2), and without oxygen (4°C) or at 22°C (22°C + O2) before autotransplantation. During the ex-vivo perfusion, and after transplantation we assessed energy metabolites using MRIs. In addition, we performed Gadolinum (Gd) perfusion sequences. Each sample underwent histopathological analyzing and scoring. mRNA expression was analyzed on renal biopsies at various time points.

Results

Using MRI, we found that in pig kidney, total ATP content was 4 times higher during ex-vivo perfusion at sub-normothermic temperature compared to cold perfusion, with or without oxygen. At 22°C, ATP levels gradually increased up to 10 hrs of perfusion, then progressively declined. Similarly, AMP content was increased in SNOP perfused organs, then slowly consumed. over time. In addition, 22°C + O2 improved cortical and medullary perfusion (Gd elimination). Finally, sub-normothermic ex-vivo perfused graft had lower grade of histological damages 1 hour after transplantation compared to cold perfused organs (injury score 22°C + O2 : 8.8–12.2, 4°C : 13.5–18.8, 4°C + O2 : 17.5–18.5).

Conclusion

In kidneys, sub-normothermic perfusion improved graft viability when compared with hypothermic perfusions. These results suggest that sub-normothermic ex-vivo kidney perfusion might dampen the negative effect of warm ischemia and promote kidney metabolism such as ATP production. Future clinical studies will define the benefits of sub-normothermic ex-vivo kidney perfusion in improving kidney graft function, and patient's survival.
Treatment and outcome in combined scapula and rib fractures
Authors: Hoepelman R , Beeres F , van Veelen N , Houwert M , Babst R , Link B-C , van de Wall B
Published: June 2022

Objective

The primary aim was to describe the population characteristics of patients with combined scapula and rib fractures and outcomes associated with different treatment strategies. Secondarily, a systematic literature review was conducted to provide an overview of the available literature on this population.

Methods

All adult (≥18 years) patients with concurrent ipsilateral scapula and rib fractures admitted to the study hospital between 1st January 2010 and 31st June 2021 were retrospectively reviewed. Secondarily, the Pubmed, EMBASE and CENRTAL databases were searched to identify studies reporting on this patient population.

Results

A total of 243 patients were admitted with concurrent ipsilateral rib and scapula fractures. 160 patients (72%) were treated conservatively, 63 patients (28%) operatively. Among operatively treated patients, 32 (51%) underwent rib fixation (RF) only, 24 (38%) underwent scapula fixation (SF) only and 7 patients (11%) underwent combined fixation of scapula and ribs (SRF). In general, more severely injured patients were treated with more extensive surgery. RF patients had a median hospital length of stay of 16 days, the SF patients 11 days and SRF patients 18 days. There were no significant differences in complications (pneumonia, recurrent pneumothorax, and revision surgery) between groups. The systematic review included 9 studies of which none reported on outcomes or treatment strategy for this combined injury.

Conclusion

Injury severity resulted in different treatment modalities. As a result different patient characteristics between treatment groups were observed, which makes direct comparison between treatment modalities impossible. All treatment modalities seem feasible, however the additional value of both rib and scapula fixation has yet to be proven in large multicentre studies.
Impact of positive resection margins (R1) on long-term survival of patients with advanced diffuse type gastric cancer
Authors: Gaspar-Figueiredo S , Joliat G-R , Borgstein A B J , Van Berge Henegouwen M I , Brunel C , Demartines N , Allemann P , Schäfer M
Published: June 2022

Objective

Gastric cancer (GC) is a leading cause of cancer-related mortality worldwide. Diffuse type GC have a much worse prognosis compared to intestinal type GC. There is an ongoing debate whether microscopic involvement of the proximal margin (R1 resection) influences overall survival (OS) in advanced gastric cancer.

The aim of this study was to assess OS in patients with diffuse gastric cancers and positive lymph node involvement who underwent oncological gastrectomy with R0 and R1 resections.

Methods

All consecutive patients from two tertiary centers operated with curative intent for diffuse gastric cancer between January 2005 and December 2018 were analyzed. Patients with R2 resections or missing data were excluded. Extracted data included demographics, major comorbidities, ASA score, neo-adjuvant treatment, pre- and postoperative staging (TNM 8th edition), postoperative complication with grading according to Clavien classification, survival data and pattern of recurrence. Lymph node involvement was based on pathology.

Kaplan-Meier curves with log-rank test for comparison were used to evaluate survival between groups.

Results

A total of 94 patients with diffuse gastric cancer were included. Two patients were excluded because of R2 resection and missing data regarding pathology, leaving a cohort of 92 patients (48 male, 44 female, median age 62 years). Sixty-four patients were lymph node positive (pN+); 48 patients (75%) with R0 resection and 16 patients (25%) with R1 resection. No difference in terms of preoperative data and intraoperative characteristics was found between R0 and R1 groups. Median OS was better in the R0 group (27 months, 95% CI 17–37) compared to R1 group (7 months, 95% CI 3–11, p<0.001). Similar results were found with disease-free survival (DSF) (25 vs. 6 months, p=0.002).

On multivariable analysis, T stage and resection margin (R status) were independent factors predicting OS (T stage: HR 4.5, p<0.001, R status: HR 4.2, p<0.001) and DFS (T stage: HR 2.9, p=0.004, R status: HR 3.5, p=0.001) in the cohort of patients with lymph node involvement.

Conclusion

The present series confirmed that patients with negative surgical margins have better OS compared to patients with positive margins in case of locally advanced diffuse GC. Therefore, R0 resections should be the goal of oncological gastrectomies.
Temporal validation of a prognostic model for mortality of patients with AAA treated with EVAR
Authors: Meuli L , Stefanikova S , Menges A-L , Reutersberg B , Zimmermann A , Makaloski V
Published: June 2022

Objective

The role of EVAR in patients with asymptomatic AAA not suitable for open surgical repair has been questioned. The aim of this study was to temporally validate a previously published predictive model for survival after EVAR in asymptomatic AAA.

Methods

This retrospective observational cohort study included all consecutive patients treated with standard EVAR for asymptomatic AAA at a tertiary center between 2001 and 2020.

A predictive Cox model for survival after EVAR in patients treated between 2001 and 2012 (Cohort A) has been published but not yet implemented. Older age, lower eGFR, and COPD were found to be independent predictors for worse survival after EVAR. This Cox model was temporally validated using patients treated at the same institution between 2013 and 2020 (Cohort B) and then updated using the overall cohort. A risk score with four different risk groups was built to predict the 5-year survival and internally validated with resampling methods.

Results

A total of 558 patients (91.2% males, mean age 74.9 years) were treated for asymptomatic AAA with EVAR. At 5 years, mortality was 35.9% in Cohort A, and 36.2% in Cohort B, p=.102 (log-rank). The original model based on Cohort A was tested on Cohort B and showed moderate to good discrimination ability (Harrell's C: 0.68, 95%-CI: 0.62–0.75). Older age, lower eGFR, and COPD were confirmed as independent predictors for worse survival after EVAR. The updated model showed good discrimination ability (C=0.70, 95%-CI: 0.66–0.75) and was robust in bootstrap validation. The risk score was built using the three variables and split into four risk groups. Patients in the “high risk” groups are expected to have a 5-year survival probability of only 40% (95%-CI: 32–50%), whereas patients in the “low risk” group and have an excellent 5-year survival probability of 89% (95%-CI: 84–95%). Patients in the “low-to-moderate” and “moderate-to-high” risk group have 5-year survival probabilities of 83% (95%-CI: 76–90%) and 68% (95%-CI: 60–79%), respectively.

Conclusion

Age, eGFR and COPD are independent predictors of survival after EVAR. This predictive model could identify low-risk patients with a favourable life expectancy who would likely benefit from EVAR and high-risk patients with a short life expectancy who may not benefit from EVAR at the current diameter threshold.
Long-term outcome of patients treated by TEVAR for type B aortic dissection or intramural hematoma depending on a healthy vs non-healthy proximal landing zone
Authors: Reutersberg B , Meuli L , Menges A , Stoklasa K , Zimmermann A , Düppers P
Published: June 2022

Objective

Thoracic endovascular aortic repair (TEVAR) is the first-line therapy for complicated type B aortic dissection (TBAD) or intramural hematoma (IMH). However, depending on the location of the primary entry tear, there is paucity of data as to whether the proximal landing zone (PLZ) of the stent prosthesis must be in a non-dissected healthy part (healthy landing zone = HLZ) or in the dissected aorta (non-healthy landing zone= non-HLZ).

Methods

Retrospective analysis of patients who underwent TEVAR for acute (<14 days) or subacute (<3 months) TBAD or IMH from 2003–2020 at a single center. A HLZ was defined as a non-dissected aortic segment (length ≥2 cm). Primary endpoints were freedom from aortic reintervention and -growth (≥5 mm). Secondary endpoints involved stroke, retrograde type A aortic dissection, proximal stent graft induced new entry (pSINE), debranching failure, 30-day and overall mortality.

Results

94 patients (age 70 years (interquartile-range (IQR): 59 to 78) were included. 84 (89%) presented with a TBAD and only ten (11%) with an IMH. CTA analysis revealed a HLZ in 62 (66%) patients. Debranching of the left subclavian artery was performed in 21 (22%) patients to extend the PLZ.

The median follow-up time was 20 (IQR: 4.6 to 72.9) months. The overall aortic reintervention rate was 22%. Estimated re-intervention rate at 12 months was 13.1% for HLZ vs. 16.1% for non-HLZ and at 5 years 16.8% for HLZ 29.9% vs. for non-HLZ (P=0.187).

Aortic growth was observed in 12 patients after 2.2 years (IQR: 0.8 to 5.9), with no significant difference in patients with HLZ vs. non-HLZ (11% vs 16%,P=0.535).

No significant differences were observed for the secondary endpoints. 30-day mortality was 10% in both groups, P=1.0. Overall survival was 47% in the HLZ group vs. 41% in the non-HLZ group, P=0.663.

A Cox proportional hazard model for reintervention with mortality as a competing risk showed a trend towards better long-term outcome for patients with a HLZ, hazard ratio 0.451 (95%-CI: 0.186–1.09, P=0.078).

Conclusion

In the majority of patients, it was possible to land in a HLZ. Consistently, reintervention rates, aortic growth, and mortality were higher in patients with non-HLZ compared with HLZ over the mid- and long-term. However, these differences were not statistically significant. Therefore, larger studies are urgently needed.
What Does it Mean to be Contrary to Nature?
Authors: Bradshaw David
Published: June 2022

St. Paul says that same-sex sexual acts are “contrary to nature.” Plainly this is intended as a condemnation, but beyond that its meaning is obscure. In particular, we are given no general account of what it means to be contrary to nature, including what other acts might fit this description. This article attempts to provide such an account. It relies for this purpose on the biblical and classical sources of this idiom as well as its subsequent use within the Greek patristic tradition. It argues that the core meaning of “contrary to nature” is that of violating the integrity of structure and function of the human body. The article further contrasts this biblical and Greek patristic understanding with that of the “sin against nature” developed in the West during the Middle Ages. It argues that they are different in important ways and that a recovery of the biblical and Greek patristic view can help restore the concept of the unnatural to its proper place within Christian ethics.
Emergency computed tomography evaluation of caustic ingestion
Authors: Assalino Michela , Resche-Rigon Matthieu , Corte Helene , Maggiori Leon , Zagdanski Anne Marie , Goere Diane , Sarfati Emile , Cattan Pierre , Chirica Mircea
Published: June 2022

Computed tomography (CT) is used increasingly for the emergency assessment of caustic injuries and the need for emergency endoscopy has been challenged. The study evaluates outcomes of caustic ingestion in the modern era and the feasibility of abandoning emergency endoscopy. Between 2013 and 2019, 414 patients (197 men, median age 42 years) were admitted for caustic ingestion. Emergency and long-term outcomes of patients managed by CT and endoscopy (n = 120) and by CT alone (n = 294) were compared. Propensity score-based analysis was performed to limit bias of between-group comparison. A standard mortality ratio (SMR) was used to compare the observed mortality with the expected mortality in the general French population. Complications occurred in 97 (23%) patients and 17 (4.1%) patients died within 90 days of ingestion. Among 359 patients who underwent nonoperative management, 51 (14%) experienced complications and 7 (2%) died. Of 55 patients who underwent emergency surgery, 46 (84%) experienced complications and 10 (18%) died. The SMR was 8.4 for whole cohort, 5.5 after nonoperative management, and 19.3 after emergency surgery. On multivariate analysis, intentional ingestion (P < 0.016), age (P < 0.0001) and the CT grade of esophageal injuries (P < 0.0001) were independent predictors of survival. The CT grade of esophageal injuries was the only independent predictor of success (P < 0.0001). Crude and propensity match analysis showed similar survival in patients managed with and without endoscopy. CT evaluation alone can be safely used for the emergency management of caustic ingestion.
Source parameter estimation of acoustic emissions induced by hydraulic fracturing in the laboratory
Authors: Naoi Makoto , Imakita Keiichi , Chen Youqing , Yamamoto Kazune , Tanaka Rui , Kawakata Hironori , Ishida Tsuyoshi , Fukuyama Eiichi , Arima Yutaro
Published: June 2022

The hydraulic fracturing technique is used for resource production, such as in shale gas/oil extraction and enhanced geothermal systems. The effects of fracturing are often monitored via induced earthquakes, and obtaining as much information as possible from those earthquakes is desirable. The stress drop—calculated from the seismic moment Mo and corner frequency fc—is an earthquake-related parameter that can help identify additional characteristics of the seismicity. To investigate the relationship between stress drops and hydraulically induced seismic events, we estimated the Mo and fc of acoustic emission (AE) events during hydraulic fracturing experiments performed in the laboratory in previous studies using 2 Eagle Ford shale and 10 Kurokami-jima granite samples. We estimated Mo by fitting the theoretical spectra to the observed spectra after correcting for the following effects: (1) frequency response of AE transducers under the installation method used in the fracturing experiment, including differences in sensitivity across every transducer used in each experiment; and (2) the difference in radiation pattern coefficients, which depends on the focal mechanisms of each AE event. This analysis used 46 857 focal mechanisms obtained from moment tensor solutions estimated using a deep learning technique. The range of the resultant Mo was found to be 2.8 × 10–5 ≤ Mo ≤ 4.5 × 10–1 [N·m], corresponding to −9.1 ≤ Mw ≤ −6.3, where Mw is the moment magnitude. We also estimated fc using the multiple-empirical Green's function method, reducing the influence of modelling errors in the AE sensor response and transfer function of the medium. Out of the 1053 events whose Mo and fc were estimated, 465 events (44.2 per cent)—regardless of their focal mechanisms—were found to have Mo and fc values consistent with the constant stress drop scaling of shear failure (i.e. shear failures have 0.1–100 MPa stress drops independent of their magnitude) that has been repeatedly confirmed in many previous studies. The remaining events showed lower fc values than those expected from the scaling law. This indicates that high pore pressure in a source region induced by fluid stimulation contributes to the occurrence of low-frequency earthquakes. Overall, we demonstrated that source parameter estimation was possible for laboratory AEs induced by hydraulic fracturing, which can improve our understanding of the characteristics of fluid-induced earthquakes.
The Invasion of the Land in Deep Time: Integrating Paleozoic Records of Paleobiology, Ichnology, Sedimentology, and Geomorphology
Authors: Buatois Luis A , Davies Neil S , Gibling Martin R , Krapovickas Verónica , Labandeira Conrad C , MacNaughton Robert B , Mángano M Gabriela , Minter Nicholas J , Shillito Anthony P
Published: June 2022

The invasion of the land was a complex, protracted process, punctuated by mass extinctions, that involved multiple routes from marine environments. We integrate paleobiology, ichnology, sedimentology, and geomorphology to reconstruct Paleozoic terrestrialization. Cambrian landscapes were dominated by laterally mobile rivers with unstable banks in the absence of significant vegetation. Temporary incursions by arthropods and worm-like organisms into coastal environments apparently did not result in establishment of continental communities. Contemporaneous lacustrine faunas may have been inhibited by limited nutrient delivery and high sediment loads. The Ordovician appearance of early land plants triggered a shift in the primary locus of the global clay mineral factory, increasing the amount of mudrock on the continents. The Silurian–Devonian rise of vascular land plants, including the first forests and extensive root systems, was instrumental in further retaining fine sediment on alluvial plains. These innovations led to increased architectural complexity of braided and meandering rivers. Landscape changes were synchronous with establishment of freshwater and terrestrial arthropod faunas in overbank areas, abandoned fluvial channels, lake margins, ephemeral lakes, and inland deserts. Silurian–Devonian lakes experienced improved nutrient availability, due to increased phosphate weathering and terrestrial humic matter. All these changes favoured frequent invasions to permament establishment of jawless and jawed fishes in freshwater habitats and the subsequent tetrapod colonization of the land. The Carboniferous saw rapid diversification of tetrapods, mostly linked to aquatic reproduction, and land plants, including gymnosperms. Deeper root systems promoted further riverbank stabilization, contributing to the rise of anabranching rivers and braided systems with vegetated islands. New lineages of aquatic insects developed and expanded novel feeding modes, including herbivory. Late Paleozoic soils commonly contain pervasive root and millipede traces. Lacustrine animal communities diversified, accompanied by increased food-web complexity and improved food delivery which may have favored permanent colonization of offshore and deep-water lake environments. These trends continued in the Permian, but progressive aridification favored formation of hypersaline lakes, which were stressful for colonization. The Capitanian and end-Permian extinctions affected lacustrine and fluvial biotas, particularly the invertebrate infauna, although burrowing may have allowed some tetrapods to survive associated global warming and increased aridification.