Damage Control Surgery for Liver Trauma

The liver is one of the most commonly injured organs of the abdomen after major trauma and may lead to the extravasation of major amounts of blood. Damage control surgery (DCS) as a concept exists for over one hundred years but has been more widely optimized and implemented over the past few decades. Minimizing the time from the trauma scene to the hospital and recognizing the patterns of injury and the “lethal triad” (acidosis, hypothermia, coagulopathy) is vital to understand which patients will benefit the most from DCS. Immediate patient resuscitation, massive blood transfusion, and taking the patient to the operating room as soon as possible are the critical initial steps that have been associated with improved outcomes. Bleeding and contamination control should be the priority in this first exploratory laparotomy, while the patient should be transferred to the intensive care unit postoperatively with only temporary abdominal wall closure. Once the patient is stabilized, a second operation should be performed where an anatomic liver resection or other more major procedures may take place, along with permanent closure of the abdominal wall

THE EVOLUTION OF CRITERIA FOR LIVER TRANSPLANTATION FOR HEPATOCELLULAR CARCINOMA: FROM MILAN TO SAN FRANCISCO AND ALL AROUND THE WORLD!

Introduction: Hepatocellular carcinoma (HCC) is the fifth most common malignancy and the third most common cancerrelated cause of death in the world. According to the stage of the disease, each patient is allocated to a different treatment option. Liver transplantation, along with surgical resection, is the only totally therapeutic option and is primarily indicated in HCC patients with underlying cirrhosis. However, the restricted number of liver grafts imposes difficulties in selecting the most suitable patients to receive those limited grafts and therefore certain criteria have been proposed. The Milan criteria are currently the most widely accepted and utilized criteria around the world, despite their restrictiveness. In an attempt to assist HCC patients exceeding them, but with a potential to display acceptable survival outcomes, undergo liver transplantation, research teams worldwide suggest expanded criteria based on their findings. Some of the most broadly known are the University of California, San Francisco (UCSF), Kyoto, Tokyo, Hangzhou and up-to-7 criteria. On the other hand, in order to expand the liver donor pool, grafts may be accepted from living, non-heart beating, elderly, steatotic, or even HCV-infected donors, in addition to the use of split livers with both advantages and disadvantages. The aim of this review is to thoroughly present the current situation of liver transplantation for HCC patients, with a focus on the criteria used and emerging challenges presented. Core tip: Hepatocellular carcinoma (HCC) is the third most common malignancy worldwide and liver transplantation represents the treatment of choice, particularly in the setting of cirrhosis. Lack of grafts led to the utilization of certain criteria in order to determine the eligibility of an HCC patient to access the waiting list. The most widely accepted are the Milan criteria, even though they are thought off as too restrictive. Consequently, transplant research groups all over the world published their own criteria, which showed acceptable outcomes. Living donor liver transplantation and other extended-criteria grafts have been proposed as an alternative to reduced donations. Ziogas IA, Tsoulfas G. The evolution of criteria for liver transplantation for hepatocellular carcinoma: from Milan to San Francisco and all around the world! DOI: https://doi.org/10.25176/RFMH.v17.n3.119

Surgical Outcomes in Syndromic Tetralogy of Fallot: A Systematic Review and Evidence Quality Assessment

Tetralogy of Fallot (ToF) is one of the most common cyanotic congenital heart defects. We sought to summarize all available data regarding the epidemiology and perioperative outcomes of syndromic ToF patients. A PRISMA-compliant systematic literature review of PubMed and Cochrane Library was performed. Twelve original studies were included. The incidence of syndromic ToF was 15.3% (n = 549/3597). The most prevalent genetic syndromes were 22q11.2 deletion (47.8%; 95% CI 43.4–52.2) and trisomy 21 (41.9%; 95% CI 37.7–46.3). Complete surgical repair was performed in 75.2% of the patients (n = 161/214; 95% CI 69.0–80.1) and staged repair in 24.8% (n = 53/214; 95 CI 19.4–30.9). Relief of RVOT obstruction was performed with transannular patch in 64.7% (n = 79/122; 95% CI 55.9–72.7) of the patients, pulmonary valve-sparing technique in 17.2% (n = 21/122; 95% CI 11.5–24.9), and RV-PA conduit in 18.0% (n = 22/122; 95% CI 12.1–25.9). Pleural effusions were the most common postoperative complications (n = 28/549; 5.1%; 95% CI 3.5–7.3). Reoperations were performed in 4.4% (n = 24/549; 95% CI 2.9–6.4) of the patients. All-cause mortality rate was 9.8% (n = 51/521; 95% CI 7.5–12.7). Genetic syndromes are seen in approximately 15% of ToF patients. Long-term survival exceeds 90%, suggesting that surgical management should be dictated by anatomy regardless of genetics

Impact of minimal residual disease detection by next-generation flow cytometry in multiple myeloma patients with sustained complete remission after frontline therapy

Minimal residual disease (MRD) was monitored in 52 patients with sustained CR (≥2 years) after frontline therapy using next-generation flow (NGF) cytometry. 25% of patients initially MRD- reversed to MRD+. 56% of patients in sustained CR were MRD+; 45% at the level of 10−5; 17% at 10−6. All patients who relapsed during follow-up were MRD+ at the latest MRD assessment, including those with ultra-low tumor burden. MRD persistence was associated with specific phenotypic profiles: higher erythroblasts’ and tumor-associated monocytes/macrophages’ predominance in the bone marrow niche. NGF emerges as a suitable method for periodic, reproducible, highly-sensitive MRD-detection at the level of 10−6

Innate Immune Training of Granulopoiesis Promotes Anti-tumor Activity

Trained innate immunity, induced via modulation of mature myeloid cells or their bone marrow progenitors, mediates sustained increased responsiveness to secondary challenges. Here, we investigated whether anti-tumor immunity can be enhanced through induction of trained immunity. Pre-treatment of mice with beta-glucan, a fungal-derived prototypical agonist of trained immunity, resulted in diminished tumor growth. The anti-tumor effect of beta-glucan-induced trained immunity was associated with transcriptomic and epigenetic rewiring of granulopoiesis and neutrophil reprogramming toward an anti-tumor phenotype; this process required type I interferon signaling irrespective of adaptive immunity in the host. Adoptive transfer of neutrophils from beta-glucan-trained mice to naive recipients suppressed tumor growth in the latter in a ROS-dependent manner. Moreover, the anti-tumor effect of beta-glucan-induced trained granulopoiesis was transmissible by bone marrow transplantation to recipient naive mice. Our findings identify a novel and therapeutically relevant anti-tumor facet of trained immunity involving appropriate rewiring of granulopoiesis

Diagnostic value of anti-cyclic citrullinated peptide antibodies in Greek patients with rheumatoid arthritis

Background: Anti-cyclic citrullinated peptide (anti-CCP) antibodies have been of diagnostic value in Northern European Caucasian patients with rheumatoid arthritis ( RA). In these populations, anti-CCP antibodies are associated with the HLA-DRB1 shared epitope. We assessed the diagnostic value of anti-CCP antibodies in Greek patients with RA where the HLA shared epitope was reported in a minority of patients. Methods: Using an enzyme-linked immunosorbent assay ( ELISA) (CCP2) kit, we tested anti-CCP antibodies in serum samples from 155 Greek patients with RA, 178 patients with other rheumatic diseases, and 100 blood donors. We also determined rheumatoid factor (RF) and compared it to anti-CCP antibodies for area under the curve (AUC), sensitivity, specificity and likelihood ratios. Results: Sensitivity of anti-CCP2 antibodies and RF for RA was 63.2% and 59.1%, and specificity was 95.0% and 91.2%, respectively. When considered simultaneously, the AUC for anti-CCP antibodies was 0.90 with 95% CI of 0.87 to 0.93 and the AUC for RF was 0.71 with 95% CI of 0.64 to 0.77. The presence of both antibodies increased specificity to 98.2%. Anti-CCP antibodies were positive in 34.9% of RF-negative RA patients. Anti-CCP antibodies showed a correlation with the radiographic joint damage. Anti-CCP-positive RA patients had increased the swollen joint count and serum CRP concentration compared to anti-CCP-negative RA patients (Mann-Whitney U test, p = 0.01, and p < 0.001, respectively). However, no correlation was found between anti-CCP antibodies and DAS28 score ( r = 0.13, p = 0.12). Conclusion: In Greek patients with RA, anti-CCP2 antibodies exhibit a better diagnostic value than RF and a correlation with radiological joint damage and therefore are useful in everyday rheumatology practice

Robotic vs. laparoscopic major hepatectomy

The introduction of laparoscopic technology and surgical robots in hepatobiliary surgery in the 1990s and 2000s, respectively, has dramatically revolutionized the field. Even though laparoscopic and robotic major hepatectomy was slower to adopt compared to minimally-invasive minor hepatectomy, the number of major hepatectomies performed with both approaches worldwide has significantly increased and is still rising. Despite the few comparative studies between laparoscopic and robotic major hepatectomy, most studies are focused on describing the procedures or reporting the outcomes of each method, either separately, or mixed with minor hepatectomies. Based on the available data, the direct comparison between the two techniques has shown that when robotic major hepatectomy is performed by experienced hepatobiliary surgeons in high-volume centers, it can lead to similar operating times, estimated blood loss, hospital length of stay, complication and mortality rates compared to its laparoscopic counterpart. The likelihood of achieving a margin-negative resection in cancer patients, as well as long-term disease-free and overall-survival are comparable between the groups. However, broader adoption of the robotic approach might be a hurdle in low-volume centers due to the high fixed capital and annual maintenance cost of the surgical robot

Frailty and Liver resection: where do we stand?

As the world population is continuously aging, the number of older patients requiring liver surgery is also on the rise. Data have shown that age should not be a limiting factor for liver resection, as it cannot accurately predict postoperative outcomes. Instead, frailty can serve as a more reliable measure of the patient’s overall health and functional reserves. Several frailty assessment tools have been implemented for preoperative risk stratification before liver surgery, and higher scores have commonly been associated with postoperative morbidity, mortality, and length of hospital stay. However, no consensus has been reached on the most useful screening tool. Future studies should focus on comparing the currently available assessment tools, constructing a liver resection-specific tool, and assessing the role of frailty assessment tools in preoperative patient optimization

Liver transplantation for hepatoblastoma

Liver transplantation is the only potentially curative option for unresectable hepatoblastoma. The introduction of platinum-based chemotherapy drastically improved the survival outcomes of patients with hepatoblastoma. However, the use of neoadjuvant chemotherapy and the optimal number of cycles required in patients listed for liver transplantation, as well as the potential use of adjuvant chemotherapy, remain unclear. Additionally, the shortage of donor liver grafts, along with the lack of clear consensus on the management of metastatic hepatoblastoma, makes the decision on whether to proceed to liver transplantation even more complex and challenging. Technological advances may optimize intraoperative imaging of both the primary tumor and metastatic sites, thus facilitating complete resection. Such improvements, along with the wider use of social media platforms to increase public awareness, could potentially pave the way for more optimal implementation of liver transplantation for the treatment of patients with unresectable hepatoblastoma