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The role of angioembolization in managing hemodynamically stable patients with liver injury has obviated the need for surgery. Although mortality and morbidity rates after the adoption of this technique have decreased, this procedure is not devoid of complications. This study assesses the impact of this procedure and its associated complications. We performed a case series analysis of patients with hepatic trauma in a level one trauma center over 10 years (2008–2017). Data were collected from hospital records of patients with liver injury and analyzed according to demographics, injury type, management strategy, procedure time, efficacy, complications of embolization, and outcome. We included all patients who underwent angioembolization. Patients who underwent surgery only or had incomplete records were excluded. Of 366 patients with liver trauma, eighteen were managed with angioembolization. Of which, thirteen had grade IV injury or higher, while five had grade II or III. Twelve patients had blunt liver trauma. Six patients were initially managed by laparotomy followed by angioembolization. The most common embolized artery was the right hepatic artery (eleven patients). Nine patients had at least one complication after the procedure. The liver collection was the most common complication (seven patients). There was one hepatic complication-related death. Morbidity was more common in patients who underwent exploratory laparotomy before angioembolization compared to angioembolization alone. Those who had a laparotomy before the angioembolization may have a higher complication rate.

Kidney transplantation at the time of a global viral pandemic has become challenging in many aspects. Firstly, we must reassess deceased donor safety (for the recipient) especially in communities with a relatively high incidence of coronavirus disease 19 (COVID-19). With respect to elective live donors, if one decides to do them at all, similar considerations must be made that may impose undue hardship on the donor. Recipient selection is also problematic since there is clear evidence of a much higher morbidity and mortality from COVID-19 for patients older than 60 and those with comorbidities such as hypertension, diabetes, obesity and lung disease. Unfortunately, many, if not most of dialysis patients fit that mold. We may and indeed must reassess our allocation policies, but this must be done based on data rather than conjecture. Follow-up routines must be re-engineered to minimize patient travel and exposure. Reliance on technology and telemedicine is paramount. Making this technology available to patients is extremely important. Modifying or changing immunosuppression protocols is controversial and not based on clinical studies. Nevertheless, we should reassess the need for induction therapy across the board for ordinary patients and the more liberal use of mammalian target of rapamycin inhibitors in transplant patients with proven infection.

Many obstacles may complicate renal transplant, the preferred treatment for end-stage renal disease. Anatomic anomalies are of special importance during surgery. Double inferior vena cava is a rare anomaly reported in 0.2% to 3% of the population and may complicate renal transplant in certain cases. We present a case of a 29-year-old man with end-stage renal disease who was scheduled for repeat kidney renal transplant from a living related donor. His transplant posed many challenges to the transplant team. These included (1) difficult access for dialysis, which required transhepatic insertion of a dialysis catheter, (2) anomalous inferior vena cava anatomy with a double inferior vena cava, (3) a blocked right inferior vena cava, and (4) a small blocked bridging vein connecting the right inferior vena cava to an additional left inferior vena cava. A stent was inserted into the bridging vein to allow venous drainage from the graft. During the transplant procedure, the donated kidney was transplanted into the left iliac fossa and anastomosed to the left external iliac vein. The surgery was successful, without major operative or postoperative complications. The patient was discharged with normal renal function and enjoys normal renal function 6 months after surgery. This case emphasizes the importance of pretransplant evaluation and preparation and the need for high index of suspicion for anatomic variants in donors and recipients.

As a result of increased life expectancy and a growing incidence of liver disease in the older population, demand for liver transplantation during later stages of life will continue to increase. Older patients (aged >70 years) can benefit from deceased donor liver transplantation (DDLT) with similar graft and patient survival as younger DDLT recipients [1].

Liver transplantation during the COVID-19 pandemic is challenging. Both donor and recipient issues can be influenced by the risks attributed to the pandemic. Allocation policy may need to be modified and criteria may be influenced by local infection rates and availability of medical facilities. Modifying immunosuppression (IS) protocols is controversial and is not evidence-based. In this study, we review the published literature on liver transplant recipients who were infected with COVID-19. A literature review was performed using PubMed, ScienceDirect, and WHO databases to identify relevant English-language articles published up to May 20, 2020. Fifteen articles reported 120 liver transplant recipients who were infected with COVID-19. Only 10 papers with 22 patients reported full encounter characteristics. Four papers reported 23, 17, 13, and 6 patients, respectively, but with minimal data. One paper reported the authors' own 39 patients' characteristics and demographics. The mean age was 58.2 years with 66% males. The most commonly reported presentations in descending order were fever (91%), cough (36.7%), shortness of breath (SOB) (31.8%), and diarrhea (31.8%). Liver transplant patients infected with COVID-19 were maintained on Tac (79%), mycophenolate (MMF) (48.4%), and Prednisone (29.6%) and were managed by reducing MMF in 14.3% of patients and reducing Tac in 14.3% of patients; 28.6% of patients needed ICU admission, 13.6% of patients had died, and the reported general population COVID-19 mortality rate was 3.4%. The clinical presentation of COVID-19 in liver transplant recipients may be different from the general population, with higher rates of severe disease, complications, and mortality.

This article reviews the Adult-to-Adult Living Donor Liver Transplant Cohort Study (A2ALL). The findings show that the number of adult-to-adult living donor liver transplants is consistently increasing. Living donor liver transplantation has an important benefit for patients with acute liver failure, does not compromise donor safety, and has lower rates of acute cellular rejection in biologically related donor and recipient. The conclusions from the A2ALL consortium have been critical in transplant advancement, supporting increased use to help decrease waitlist death and improve long-term survival of transplant recipients.

BACKGROUND Liver transplantation (LT) is the treatment of choice for most end-stage liver diseases. This treatment increases survival rates and improves quality of life. Because of the shortage of organ donors, as opposed to waiting patients, the need to optimize the matching of donors to recipients for maximum utility is crucial. AIM The aim of this study was to examine a predictive model based on the combination of donor and recipient risk factors using the liver Donor Risk Index (DRI) and recipient Model of End-stage Liver Disease (MELD) to predict patients' survival following LT. PATIENTS AND METHODS The charts of 289 adult primary LT patients, who had undergone transplantation in Israel between 2010 and 2015, were studied retrospectively using prospectively gathered data. RESULTS Two variables, DRI and MELD, were found to significantly affect post-transplant patient survival. DRI negatively affected survival in a continuous fashion, whereas MELD had a significantly negative effect only at MELD more than 30. Both female sex and the presence of hepatocellular carcinoma were associated with increased patient survival. CONCLUSION According to our findings, the model described here is a novel prediction tool for the success of orthotopic LT and can thus be considered in liver allocation.

Erythropoietic protoporphyria (EPP) is a rare inherited disorder of the heme biosynthesis pathway resulting in the accumulation of protoporphyrins in the blood, erythrocytes, and other tissues. Because of a gene mutation in the FECH gene, ferrochelatase, the enzyme involved in the final step of heme synthesis, is deficient in these patients. Although the major symptom of this disorder is photosensitivity, rarely, it can cause progressive liver disease requiring liver transplantation (LT). However, LT is not curative and only bone marrow transplantation (BMT) can correct the underlying enzymatic defect. Because liver disease results from accumulation of protoporphyrin in the liver, LT without hematopoietic stem cell transplantation leaves the new liver at risk for similar EPP-related damage. A handful of pediatric patients undergoing sequential LT and stem cell transplantation have been described in the literature; however, to date none has been described in detail in adults. We report a case of an adult male with EPP and liver failure who successfully underwent a sequential liver and hematopoietic stem cell transplantation (HSCT).

Bariatric surgery dramatically improves glycemic control, yet the underlying molecular mechanisms remain controversial because of confounding weight loss. We performed sleeve gastrectomy (SG) on obese and diabetic leptin receptor–deficient mice (db/db). One week postsurgery, mice weighed 5% less and displayed improved glycemia compared with sham-operated controls, and islets from SG mice displayed reduced expression of diabetes markers. One month postsurgery SG mice weighed more than preoperatively but remained near-euglycemic and displayed reduced hepatic lipid droplets. Pair feeding of SG and sham db/db mice showed that surgery rather than weight loss was responsible for reduced glycemia after SG. Although insulin secretion profiles from islets of sham and SG mice were indistinguishable, clamp studies revealed that SG causes a dramatic improvement in muscle and hepatic insulin sensitivity accompanied by hepatic regulation of hepatocyte nuclear factor-α and peroxisome proliferator–activated receptor-α targets. We conclude that long-term weight loss after SG requires leptin signaling. Nevertheless, SG elicits a remarkable improvement in glycemia through insulin sensitization independent of reduced feeding and weight loss.

Natural orifice translumenal endoscopic surgery (NOTES) and single-port surgery (SPS) have maximized the enhanced aesthetic profile of laparoscopic surgery. Nevertheless, these modalities also accentuate the inherent limitations of subvisibility and decreased instrument dexterity of motion. The goal of this study was to evaluate the utility of a miniature laparoscopic camera to alleviate these obstacles.A miniature laparoscopic camera was inserted via an endoscopic working channel or embedded into laparoscopic tools. Following laparoscopic trainer studies, operations were conducted on pigs using standard laparoscopic, SPS, and NOTES approaches. Additionally, the camera was used to perform colonoscopies on mice, rats, and pigs.The camera enabled visualizing the dissection area behind the renal vessels during laparoscopic nephrectomy and in the Triangle of Calot in laparoscopic cholecystectomy while providing accurate and detailed visualization of the operative field. The camera was successfully passed through the working channel of a standard gastroscope and used during NOTES procedures. It was used during colonoscopy to evaluate the distal colon in pigs and allowed the diagnosis of small colonic polyps with good image quality. Additionally, it could be easily passed beyond colonic strictures created in a porcine model. Finally, its miniature size enabled performance of colonoscopies on rats serving as animal models for colonic polyps.The miniature laparoscopic camera provides adequate images with enhanced visibility in conventional laparoscopic, SPS, and NOTES procedures. We believe that this device or similar miniature cameras may greatly aid the future development of NOTES and SPS by enhancing the safety and ease of performing these procedures. Further development is being conducted in order to integrate this camera into standard instruments and to allow an even better image quality.

Background An adverse event in laparoscopic bariatric surgery that has not received much scrutiny involves tube/probe stapling or suturing during gastrectomy or gastroenterostomy. Methods A retrospective analysis was performed using a questionnaire sent to all bariatric surgeons (n = 43) in Israel. Results Eight surgeons reported on 17 cases in which intraoperative nasogastric/orogastric tube (n = 8), temperature probe (n = 6), or bougie stapling (n = 3) was identified. Laparoscopic sleeve gastrectomy was performed in 14 patients and laparoscopic gastric bypass in 3 patients. The patient demographics, operative details, and postoperative results are reported. Conclusion Tube/probe complications can occur during laparoscopic bariatric surgery but are seldom reported. However, they can be associated with significant morbidity. The treatment options are dependent on the situation. More importantly, prevention strategies must include constant communication with the anesthesiologist and removal or relocation of a tube before stapling or suturing.

Cough can be associated with many complications. We present a 59-year-old male patient with a very rare combination of a cough-related stress fracture of the ninth rib and herniation through the diaphragm and abdominal wall to the subcutaneous tissue of the chest wall. We suggest thoracotomy through the affected intercostal defect as a surgical approach. The diaphragm, chest wall and abdominal tears were repaired separately, and the abdominal wall was reinforced with mesh. Technical aspects were discussed. Though each individual injury is well documented in the literature, this is a rare combination of defects, requiring early recognition to provide repair before incarceration and further enlargement of the defects occur.

Laparoscopic Heller esophagomyotomy is the standard of care for achalasia treatment. This procedure, although effective, must be performed with the patient under general anesthesia and is associated with several serious potential complications. The authors aimed to develop a method of performing transesophageal endoscopic esophagomyotomy (TEEM) that would obviate the need for both general anesthesia and external incisions while offering lower intra- and postoperative complications. The TEEM procedure was performed on eight pigs. For six of the pigs, the procedure aimed at survival. A mid-esophageal mucosal incision was performed using an endoscope, and a submucosal plane was developed. The lower esophageal sphincter (LES) muscle fibers were clearly visualized and divided. The mucosal incision was closed using fibrin sealant. After 2 weeks of survival, a gastrografin swallow study and necropsy were performed. The TEEM procedure was performed successfully in all eight porcine models. The myotomy included the LES fibers and extended 4 to 6 cm proximally to the esophagus. The proximal gastric muscle was divided up to 1 to 2 cm. No injuries to the abdominal or mediastinal structures occurred. One pig died on postoperative day 1 due to an unrecognized pneumothorax. Two pigs had ischemic ulcers at the myotomy site. The last three pigs had an uneventful recovery. The mucosal incision site healed completely in all the survived pigs, and except for the pig with mediastinal sepsis, all ate heartily and gained weight as expected. The TEEM procedure is technically feasible. Due to the morbidity encountered in the first three pigs, the reported technique was modified to include a slimmer endoscope, a shorter tunnel, and a partial-thickness myotomy. These changes together with an understanding of the pitfalls involved in this procedure led to successful results for the next three pigs. Nevertheless, the authors believe that TEEM is not yet ready for prime time. Perfection of the technique and development of dedicated instruments are mandatory before safe translation of this method to human patients.

Techniques that preserve the right hepatic artery and the common bile duct in continuity during the dissection may be associated with lower rates of biliary complications in living-donor liver transplants. This study sought to determine whether en bloc hilar dissections were associated with fewer biliary complications in living-donor liver transplants.This was a retrospective review of 41 adult LDLTs performed in a single, liver transplant center between February 2007 and September 2014. The primary outcome of interest was the occurrence of at least one of the following biliary complications: anastomotic leak, stricture, or biloma. The primary predictor of interest was the hilar dissection technique: conventional hilar dissection vs. en bloc hilar dissection.A total of 41 LDLTs were identified, 24 had a conventional, and 17 an en bloc hilar biliary dissection. The occurrence of any biliary complication was significantly more common in the conventional hilar dissection group compared to the en bloc hilar dissection group (66.7 vs. 35.3%, respectively, p = 0.047). In particularly, anastomotic strictures were significantly more common in the conventional hilar dissection group compared to the en bloc hilar dissection group (54.2 vs. 23.5%., respectively, p = 0.049).En bloc hilar dissection technique may decrease biliary complication rates in living donor liver transplants.

Background The most common bariatric operation in Europe, laparoscopic adjustable gastric banding (LAGB), is reported to have a high incidence of long-term complications. Also, insufficient weight loss is reported. The optimal conversion technique is unknown. Our objective was to report our experience in the conversions of failed laparoscopic gastric banding procedures to 4 different bariatric procedures at a university hospital. Methods From March 2006 to December 2010, 630 bariatric operations were performed. Of these patients, 45 underwent conversion of failed LAGB (n = 38) and nonadjustable gastric banding (n = 7). Using a prospectively collected database, we analyzed these procedures. Results The 45 patients underwent laparoscopic conversion of failed LAGB (n = 38) and nonadjustable gastric banding (n = 7) to 4 different procedures. Of the 45 patients, 18 underwent conversion to laparoscopic sleeve gastrectomy, 18 to laparoscopic Roux-en-Y gastric bypass, 7 to laparoscopic biliopancreatic diversion with duodenal switch, and 2 to laparoscopic biliopancreatic diversion. All conversions but 1 were completed laparoscopically. The mean operating time and hospital stay for laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, laparoscopic biliopancreatic diversion with duodenal switch, and biliopancreatic diversion was 111 ± 28 minutes and 4.3 ± 1.4 days, 195 ± 59 minutes and 3.9 ± 1.5 days, 248 ± 113 minutes, and 5.9 ± 2.6 days, and 203 minutes and 6.5 days, respectively. No patient died. Perioperative complications occurred in 4 patients (9.8%). The mean body mass index decreased from 41.5 ± 8 kg/m 2 to 31.3 ± 6.8 kg/m 2 during a mean follow-up period of 13.7 ± 9.6 months. Although laparoscopic biliopancreatic diversion with and without duodenal switch had the greatest preoperative body mass index, they achieved the greatest excess weight loss. Conclusion Conversion of LAGB or nonadjustable gastric banding to laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic biliopancreatic diversion with or without duodenal switch is feasible and effective to treat the complications of LAGB and to further reduce the weight of morbidly obese patients.

We report a case of iatrogenic resection of both the superior mesenteric artery (SMA) and celiac artery during left nephrectomy and adrenalectomy. A 47-year-old woman was diagnosed with a large adrenal tumor and underwent a laparoscopic left adrenalectomy that was converted to open adrenalectomy and nephrectomy as a result of a bulky tumor. Both the SMA and celiac artery were inadvertently cut at their origin because of adherence of the tumor to the aorta. Both arteries were revascularized by anastomosing the distal splenic artery to the aorta after performing splenectomy to revascularize the celiac circulation and using an autologous saphenous vein graft to revascularize the SMA. The patient had no postoperative complications. To our knowledge, this is the first description of use of the splenic artery for celiac revascularization.