Successful Transplantation of a Split Crossed Fused Ectopic Kidney into a Patient with End-Stage Renal Disease

Potential donors with congenital renal anomalies but normal renal function are often overlooked because of a possible increase in technical difficulty and complications associated with the surgery. However, as the waiting list for a deceased donor kidney transplant continues to grow, it is important to consider these kidneys for potential transplant. This paper describes the procurement of a crossed fused ectopic kidney, and subsequent parenchymal transection prior to transplantation as part of a combined simultaneous kidney pancreas transplant. The transplant was uncomplicated, and the graft had immediate function. The patient is now two years from transplant with excellent function

Early patient and liver allograft outcomes from donation after circulatory death donors using thoracoabdominal normothermic regional: a multi-center observational experience

BackgroundDonation after circulatory death (DCD) liver allografts are associated with higher rates of primary non-function (PNF) and ischemic cholangiopathy (IC). Advanced recovery techniques, including thoracoabdominal normothermic regional perfusion (TA-NRP), may improve organ utilization and patient and allograft outcomes. Given the increasing US experience with TA-NRP DCD recovery, we evaluated outcomes of DCD liver allografts transplanted after TA-NRP.MethodsLiver allografts transplanted from DCD donors after TA-NRP were identified from 5/1/2021 to 1/31/2022 across 8 centers. Donor data included demographics, functional warm ischemic time (fWIT), total warm ischemia time (tWIT) and total time on TA-NRP. Recipient data included demographics, model of end stage liver disease (MELD) score, etiology of liver disease, PNF, cold ischemic time (CIT), liver function tests, intensive care unit (ICU) and hospital length of stay (LOS), post-operative transplant related complications.ResultsThe donors' median age was 32 years old and median BMI was 27.4. Median fWIT was 20.5 min; fWIT exceeded 30 min in two donors. Median time to initiation of TA-NRP was 4 min and median time on bypass was 66 min. The median recipient listed MELD and MELD at transplant were 22 and 21, respectively. Median allograft CIT was 292 min. The median length of follow up was 257 days. Median ICU and hospital LOS were 2 and 7 days, respectively. Three recipients required management of anastomotic biliary strictures. No patients demonstrated IC, PNF or required re-transplantation.ConclusionLiver allografts from TA-NRP DCD donors demonstrated good early allograft and recipient outcomes

Evolving role of vascular resection and reconstruction in hepatic surgery for malignancy

Primary and secondary hepatic malignancies, including hepatocellular cancer, cholangiocarcinoma and metastatic disease from colorectal cancer continue to increase in incidence worldwide, and remain diseases with a high mortality. Liver resection, with negative margins, is associated with improved survival and better quality of life over nonoperative treatment. As liver resection continues to evolve, aggressive centers are increasingly using vascular resection and reconstruction to achieve negative margins and improve outcomes. As these resections become more common, the morbidity and mortality associated with these complex surgical procedures is decreasing. Currently, resections of the portal vein are becoming routine in major liver and pancreatic resections, and experience with hepatic artery, hepatic vein and inferior vena cava resections is increasing. This review paper looks at the current indications, techniques and outcomes for major vascular resection in hepatic malignancy

Clinical effectiveness of COVID-19 vaccination in solid organ transplant recipients.

GoalWe aimed to assess the incidence rate of coronavirus disease 2019 (COVID-19) in vaccinated versus unvaccinated solid organ transplant recipients (SOTR) at our center.MethodsWe abstracted the following clinical data from our transplant registry from 1/1/2021 to 6/2/2021: demographics, details of COVID-19 vaccination, incidence of COVID-19, and related mortality. We calculated incidence of symptomatic COVID-19 per 1000/person days at risk and incidence rate ratio (IRR).ResultsAmong 2151 SOTRs, 912 were fully vaccinated, and 1239 were controls (1151 unvaccinated, 88 partially vaccinated). Almost 70% of vaccinated subjects received the mRNA-1273 vaccine. There were 65 cases of COVID-19 that occurred during the study period - four occurred among fully vaccinated individuals and 61 among controls (including two in partially vaccinated individuals). Incidence rate for COVID-19 was 0.065 (95% CI 0.024-0.17) per 1000 person days in vaccinated versus 0.34 (95% CI 0.26-0.44) per 1000/person days in the control group; IRR was 0.19 (95% CI 0.049 -0.503, p < 0.005). There were no COVID-19 related deaths in the four breakthrough infections and two of 61 (3.3%) among controls.ConclusionWe demonstrate real world clinical effectiveness of COVID-19 vaccination in SOTRs with an almost 80% reduction in the incidence of symptomatic COVID-19 versus unvaccinated SOTRs during the same time

Acute Fulminant Hepatic Failure in 23-Year-Old Female Taking Homeopathic Remedy.

Homeopathic remedies made primarily from eggshells, and therefore calcium, can be marketed for treatment of back pain and vaginal discharge. We present a case of a 23-year-old otherwise healthy woman who presented with acute liver failure (ALF) ultimately requiring liver transplantation as a result of taking increased doses of a homeopathic product with the primary ingredient of eggshells. Although relatively uncommon compared with medications such as acetaminophen, herbal supplements have been reported to cause drug-induced liver injury (DILI), thought to be primarily due to contaminants. This is the first known report of DILI resulting from a homeopathic product with the primary ingredient of eggshells, and it demonstrates the importance of early ALF recognition and treatment, as well as the importance of practicing caution when using homeopathic supplements

Scalpels and Solutions: The Cutting-Edge Surgeon Feedback Platform Streamlining Operational Efficiency

Issues Addressed/Background: The quality and efficiency of surgical operations are crucial for both patient outcomes and healthcare institutions. Despite advancements in surgical techniques and technology, operational issues persist, leading to suboptimal performance, increased costs, and patient dissatisfaction. Surgeons in the UCSDH operating rooms (ORs) under-report adverse events and process improvement concerns through the existing iReport system, hampering the ability of the system to provide safe and efficient patient care. Traditional surgeon feedback methods are often too broad given inclusion of patient safety issues (e.g. iReport), have a high access barrier, and/or limited in effectiveness, necessitating an innovative approach to address these challenges.Description of Project: This project aims to design and implement a specialized surgeon feedback platform tailored to address operational issues in the perioperative environment. The platform was developed using a multidisciplinary approach, integrating insights from surgeons, healthcare administrators, and information technology experts. Features included secure submission of feedback, automated input of relevant case information where applicable, and the ability to promote closed-loop communication as well as identify trends and patterns in operational issues. Additionally, the platform enabled the sharing of best practices and the development of targeted solutions. A survey was sent to surgeons before and after implementation of this platform to gauge trends in reporting and impact of the platform.Lessons Learned/Expected Outcomes: The implementation of the surgeon feedback platform has demonstrated several key benefits. First, the streamlined submission process encouraged more frequent and detailed feedback from surgeons, leading to increased engagement and a heightened sense of ownership in resolving operational issues. Second, the real-time analysis and visualization tools enabled faster identification of trends and patterns, and decrease in average days to close, which allowed surgical teams to proactively address recurring problems. Third, the facilitated communication among surgical teams fostered a culture of collaboration, promoting the exchange of innovative ideas and solutions.Preliminary survey data from the pre-implementation phase are demonstrate that surgeons used a diverse array of venues to escalate operational issues, and the most common specific complaint was the lack of knowing if and when a solution to the report was made. Post-implementation survey data is forthcoming, and we hypothesize that the new platform will be utilized forreporting operational issues appropriately, and increase satisfaction with closed-loop communication.Recommendations: Based on the success of the specialized surgeon feedback platform, we recommend the following: (1) Encourage healthcare institutions to adopt similar feedback platforms for a more targeted approach in addressing operational issues in the perioperative environment. (2) Prioritize a multidisciplinary approach when designing feedback platforms to ensure they cater to the unique needs of the perioperative community. (3) Promote a culture of continuous learning and collaboration among perioperative teams, enabling them to share best practices and innovative solutions. (4) Conduct further research and survey continue to gauge impact and refine the platform, and the exploration of applications in other medical specialties.By embracing such innovative approaches, healthcare institutions can further enhance the quality and efficiency of perioperative care, ultimately benefiting patients and healthcare providers alike.Figure 1. Surgeon Feedback Platform a. QR code for access, b. computer reporting screen, c. mobile reporting screen.Figure 2. Pre-Implementation Survey Results – “If any, what platform or method do you currently use to report OR operational issues, such as with surgical equipment, sterilization, or operating room staffing?

Post‐transplant survey to assess patient experiences with donor‐derived HCV infection

BackgroundDespite increased utilization of hepatitis C virus-infected (HCV+) organs for transplantation into HCV-uninfected recipients, there is lack of standardization in HCV-related patient education/consent and limited data on financial and social impact on patients.MethodsWe conducted a survey on patients with donor-derived HCV infection at our center transplanted between 4/1/2017 and 11/1/2019 to assess: why patients chose to accept HCV+ organ(s), the adequacy of their pre-transplant HCV education and informed consent process, financial issues related to copays after discharge, and social challenges they faced.ResultsAmong 49 patients surveyed, transplanted organs included heart (n&nbsp;=&nbsp;19), lung (n&nbsp;=&nbsp;9), kidney (n&nbsp;=&nbsp;11), liver (n&nbsp;=&nbsp;4), heart/kidney (n&nbsp;=&nbsp;4), and liver/kidney (n&nbsp;=&nbsp;2). Many recipients accepted an HCV-viremic (HCV-V) organ due to perceived reduction in waitlist time (n&nbsp;=&nbsp;33) and/or trust in their physician's recommendation (n&nbsp;=&nbsp;29). Almost all (n&nbsp;=&nbsp;47) felt that pre-transplant education and consent was appropriate. Thirty patients had no copay for direct-acting antivirals (DAA) for HCV, including 21 with household income &lt;20 000; seven had copays of <100 and one had a copay &gt;$1000. Two patients reported feeling isolated due to HCV infection and eight reported higher than anticipated medication costs. Patients' biggest concern was potential HCV transmission to partners (n&nbsp;=&nbsp;18) and family/friends (n&nbsp;=&nbsp;15). Overall almost all (n&nbsp;=&nbsp;47) patients reported a positive experience with HCV-V organ transplantation.ConclusionWe demonstrate that real-world patient experiences surrounding HCV-V organ transplantation have been favorable. Almost all patients report comprehensive HCV-related pre-transplant consent and education. Additionally, medication costs and social isolation/exclusion were not barriers to the use of these organs

Liver transplantation for hepatocellular carcinoma following checkpoint inhibitor therapy with nivolumab

Limited case series describe conflicting results regarding the safety of checkpoint inhibitors (CPI) prior to liver transplantation (LT). We reviewed single-center data on all consecutive patients who underwent LT for hepatocellular carcinoma treated with CPI between January 1, 2018, and January 30, 2021. Time from CPI to LT, immunosuppression, biopsy-proven acute cellular rejection (BPACR), graft loss and death were evaluated. Five patients with a mean age 65 (range 61-71) years underwent LT after CPI with nivolumab. Time from last CPI to LT ranged from 0.3 to 11&nbsp;months. Two patients with &lt;3&nbsp;months from the last dose of CPI to LT developed BPACR and severe hepatic necrosis, one of whom required retransplantation with recurrent BPACR but without recurrent graft loss over 38&nbsp;months of follow up. None of the patients who underwent LT &gt;3&nbsp;months from the last dose of CPI had BPACR. In conclusion, pretransplant use of CPIs, particularly within 90&nbsp;days of LT, was associated with BPACR and immune-mediated hepatic necrosis. Future multicenter studies should consider a sufficient interval from the last dose of CPI to LT to mitigate the risk for adverse immune-mediated outcomes and graft loss

Call me Ishmael: addressing the white whale of team communication in the operating room with labelled surgical caps at an academic medical centre.

INTRODUCTION: Effective communication in the operating room (OR) is crucial. Addressing a colleague by their name is respectful, humanising, entrusting and associated with improved clinical outcomes. We aimed to enhance team communication in the perioperative environment by offering personalised surgical caps labelled with name and provider role to all OR team members at a large academic medical centre. MATERIALS AND METHODS: This was a quasi-experimental, uncontrolled, before-and-after quality improvement study. A survey regarding perceptions of team communication, knowledge of names and roles, communication barriers, and culture was administered before and after cap delivery. Survey results were measured on a 5-point Likert Scale; descriptive statistics and mean scores were compared. All cause National Surgical Quality Improvement Project (NSQIP) morbidity and mortality outcomes for surgical specialties were examined. RESULTS: 1420 caps were delivered across the institution. Mean survey scores increased for knowing the names and roles of providers around the OR, feeling that people know my name and feeling comfortable communicating without barriers across disciplines. The mean score for team communication around the OR is excellent was unchanged. The highest score both before and after was knowing the name of an interdisciplinary team member is important for patient care. A total of 383 and 212 providers participated in the study before and after cap delivery, respectively. Participants agreed or strongly agreed that labelled surgical caps made it easier to talk to colleagues (64.9%) while improving communication (66.0%), team culture (60.5%) and patient care (56.8%). No significant differences were noted in NSQIP outcomes. CONCLUSIONS: Personalised labelled surgical caps are a simple, inexpensive tool that demonstrates promise in improving perioperative team communication. Creating highly reliable surgical teams with optimal communication channels requires a multifaceted approach with engaged leadership, empowered front-line providers and an institutional commitment to continuous process improvement