Acute-on-Chronic Liver Failure (ACLF): The ‘Kyoto Consensus’-Steps From Asia

Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the APASL ACLF Research Consortium (AARC) was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia-Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the \u27Golden Therapeutic Window\u27, the \u27transplant window\u27, and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The \u27Kyoto APASL Consensus\u27 presented below carries the final recommendations along with the relevant background information and areas requiring future studies

A comparative study of excision with primary closure versus Limberg flap in pilonidal sinus

Background: The term ‘pilonidal sinus’ describes a condition found in the natal cleft overlying the coccyx which is treated by excision.Methods: This study is a prospective study held in Department of general surgery, Safdarjung Hospital, New Delhi from October 2014 to April 2016 on 60 patients out of which 30 were controls (excision with primary closure) and 30 were taken as case (Limberg flap). Post-operative follow up was done till 6 months and complications were noted. The data was tabulated and SPSS version 17 was used for statistics.Results: Pilonidal sinus disease is common in age group 20 years and above and twice more common in males than females. Although operating time in Limberg flap is little more as compared to primary closure but insignificant. The post-operative pain in the long term follow up is less in the Limberg flap procedure, although in the initial post-operative period it is slightly higher as compared to primary closure. In Limberg flap procedure, post-operative complications like stitch line infection, seroma formation, wound dehiscence are low as compared to primary closure. Limberg flap require 2.27±0.52 days hospital stay as compared to 3.57±1.43 days in primary closure due to less post-operative complications. Recurrence rate is 3.33% in Limberg flap as compared to 26.67% in primary closure group.Conclusions: We recommend the Limberg flap method for primary pilonidal disease with low morbidity rates over primary closure.</jats:p