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2. Robotized MIS Instruments: Filling the Gap Between Rigid Tools and Large Robotic Systems

Author

Amir Szold and Nienke Warnaar

Subjects
Computer-assisted surgery, Robotic systems, Computer science, Human–computer interaction, medicine.medical_treatment, Invasive surgery, medicine, Robotic surgery, Mobile device
Abstract

Most minimally invasive surgery (MIS) instruments are rigid, therefore restricting hand movement and creating a barrier for full adoption of MIS techniques in many fields. To address this, there has been a surge in the development of articulating and flexible instruments to improve the surgeon’s dexterity, precision, and ergonomics. The commercially available systems are large and not cost-effective, but the potential space between primitive rigid tools and large electromechanical systems has opened an opportunity to develop a spectrum of smaller, handheld, or table-mounted robotized instruments that enhance the surgeon’s performance in a cost-effective, simple manner.

Published
2021
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3. Students' participation in collaborative research should be recognised

Author

Aditya Borakati, Kenneth McLean, Thomas M. Drake, Ewen M. Harrison, Sivesh K. Kamarajah, Chetan Khatri, Dmitri Nepogodiev, Minaam Abbas, Muhammad Abdalkoddus, Areej Abdel-Fattah, Reem Abdelgalil, Haweya Abdikadir, Ryan Adams, Sarah Adams, Inioluwa Adelaja, Abiola Adeogun, Helena Adjei, Amirul Adlan, Hussamuddin Adwan, Sara Aeyad, Raiyyan Aftab, Amir Afzul, Vani Agarwal, Hosam Aglan, Medha Agrawal, Rishi Agrawal, Fiza Ahmed, Sobia Akhtar, Onyinye Akpenyi, Maithem Al-Attar, Muhammed Al-Ausi, Waleed Al-Khyatt, Alia Al-Mousawi, Zainab Al-Nasser, Anand Alagappan, Justin Alberts, Maryam Alfa-Wali, Abdulmajid Ali, Adnan Ali, Tamara Ali, Bilal Alkhaffaf, Rachael Allen, Kassem Alubaidi, Edemanwan Andah, Richard Anderson, Kirstine Andrew, Andrew Ang, Eshen Ang, Theophilus Anyomih, James Archer, Matt Archer, Steven Arnell, Matthew Arnold, Esha Arora, Nadeem Ashraf, Raees Ashraf, Jordan Ashwood, Usama Asif, Andrew Atayi, Sameera Auckburally, Ralph Austin, Sultana Azam, Aishah Azri Yahaya, Fiyin Babatunde, Simon Bach, Roudi Bachar, Abdul Badran, Caroline Baillie, Edward Balai, Alexander Baldwin, Vartan Balian, Danielle Banfield, Jonathan Bannard-Smith, Connor Barker, Behrad Barmayehvar, Jane Barnfield, David Bartlett, Richard Bartlett, Kwaku Baryeh, Siddharth Basetti, Kellie Bateman, Michael Bath, Andrew Beamish, William Beasley, Simon Beecroft, Ardit Begaj, Gurpreet Beghal, Jessica Belchos, Katarzyna Bera, Tara Bergara, Anna Betts, Aneel Bhangu, Gayathri Bhaskaran, Amina Bhatti, Mihai Bica, Caitlin Billyard, Emily Birkin, Jane Blazeby, Harry Blege, Natalie Blencowe, Christopher Blore, Alex Boddy, Matthew Boissaud-Cooke, Anita Bolina, William Bolton, David Bosanquet, Doug Bowley, Kathryn Boyce, Graham Branagan, Jessica Brayley, Joanna Brecher, Kristina Bresges, Emily Briggs, Ryan Broll, Damien Brown, Elliot Brown, Leo Brown, Robin Brown, Rory Brown, Connor Bruce, Pepa Bruce, Rory Buckle, Emily Budd, Richard Buka, Dermot Burke, Joshua Burke, Alisha Burman, Laura Burney, Amy Burrows, Mohammed Bux, Ronan Cahill, Clementina Calabria, Julian Camilleri-Brennan, Amy Campbell, Bill Campbell, Matthew Cant, Yun Cao, Sophie Carlson, Grace Carr, Luke Carr, Rebecca Carr, Richard Carr, Eleanor Cartwright, Alice Castle, Kirsty Cattle, Daniel Cave, Stephen Chapman, Alexandros Charalabopoulos, Sanjay Chaudhri, Ahmad Chaudhry, Paresh Chauhan, Priyesh Chauhan, Ryad Chebbout, Yunzi Chen, Louisa Chenciner, Jingjie Cheng, Natalie Cheng, Lin Chew, Zenab China, Abhishek Chitnis, Praminthra Chitsabesan, Paul Choi, Sarah Choi, Mariam Choudhry, Chern Choy, Claudia Ciurleo, Henry Claireaux, Peter Coe, Simon Cole, Katy Concannon, Edward Cope, Olivia Corbridge, Jessica Court, Louise Cox, Anna Craig-Mcquaide, Ben Cresswell, Lauren Crozier, Neil Cruickshank, Lucy Cuckow, Helen Cui, Elspeth Cumber, Sarah Cumming, Olivia Cundy, Melissa Cunha, Pedro Cunha, Laura Cunliffe, Jazleen Dada, Prita Daliya, Jeffrey Dalli, Ian Daniels, James Daniels, Ahmed Daoub, Sabeera Dar, Emma Das, Kaustuv Das, Emily Davies, Gareth Davies, Kirsty Davies, Kristen Davies, Rachel Davies, Victoria Dawe, Joshua Lucas de Carvalho, Katie De Jong, Katherine Deasy, Praveena Deekonda, Sahil Deepak, Henal Desai, Karishma Desai, Ryan Devlin, Nishat Dewan, Akashdeep Dhillon, Priya Dhillon, Tanya Dhir, Salomone Di Saverio, Julia Diamond, Peter Dib, Panagiotis A. Dimitriadis, Shiva Dindyal, Matthew Doe, Ciaran Doehrty, Tara Dogra, Arpan Doshi, Alison Downey, Joseph Doyle, Ashleigh Draper, Sarah Duff, Joseph Duncumb, Sophie Dupre, Justine Durno, Michal Dzieweczynski, Nicola Eardley, Sarah Easby, Sam Easdon, Hamdi Ebdewi, Lydon Eccles, Jacob Edwards, Padma Eedarapalli, Mohamed Elbuzidi, Patrick Elder, Lucy Elliott, Malaz Elsaddig, Ysabelle Embury-Young, Sophie Emesih, Alec Engledow, William English, Christos Episkopos, Jonathan Epstein, Rahim Esmail, Taher Fatayer, Nicolò Favero, Nicola Fearnhead, Maxine Feldman, Evelyn Fennelly, Stephen Fenwick, Lucie Ferguson, Stuart Fergusson, Petros Fessas, Isabel FitzGerald, J. Edward Fitzgerald, Harry Fitzpatrick, Daniel Fletcher, Tonia Forjoe, Beniamino Forte, Alex Fowler, Benjamin France, Abraham Francis, Niroshan Francis, Sunil Francis, Sam Freeman, Vicky Fretwell, Teresa Fung, Hugh Furness, Michael Gallagher, Stuart Gallagher, Chuanyu Gao, Lothaire Garard, Shona Gardner, Andrew Gaukroger, Daniel George, Simi George, Jamal Ghaddar, Ali Ghaffar, Shamira Ghouse, Amanda Gilbert, Ashveen Gill, Francesco Giovinazzo, Carey Girling, Lolade Giwa, James Glasbey, Paul Glen, Mary Goble, Jenna Godfrey, Shreya Goel, Wenn Goh, Kajal Gohil, Shyam Gokani, David Gold, David Golding, Andrea Gonzalez-Ciscar, Ross Goodson, Melissa Gough, Shubhangi Govil, Thomas Gower, Christopher Graham, Sam Gray, Patrick Green, Samuel Greenhalgh, Kyriacos Gregoriou, Rhiannon Gribbell, Mary Catherine Gribbon, Charlotte Grieco, Emma Griffiths, Ewen Griffiths, Nathan Griffiths, Sara Griffiths, Cathleen Grossart, Daniel Guerero, Christianne Guillotte, Rishi Gupta, Claire Guy, Adam Gwozdz, James Haddow, Shazia Hafiz, Constantine Halkias, Elisabeth Hall, Hasseb Hamid, Emma Hamilton, Gurvinder Singh Harbhajan Singh, John Hardman, Rhiannon Harries, Rhydian Harris, Suzanne Harrogate, Megan Harty, Jessica Harvey, Rahima Hashemi, Ahmed Hassane, Helen Hawkins, Thomas Hawthorne, John Hayes, Phoebe Hazenberg, Harry Heath, Madhusoodhana Hebbar, R. Heer, Roisin Hegarty O'Dowd, David Henshall, Philip Herrod, Elizabeth Hester, Emily Heywood, Nick Heywood, Frances Hill, James Hill, Kirsty Hill, May Ho, Marianne Hollyman, David Holroyd, Joseph Home, Steve Hornby, Laura Horne, Charlotte Horseman, Huma Hosamuddin, Amy Hough, George Hourston, Nathan Hudson-Peacock, Belinda Hughes, Katie Hughes, Isabel Huppatz, Penelope Hurst, Mahrukh Hussain, Shoaib Fahad Hussain, Syeda Hussain, Imogen Hutchings, Bilal Ibrahim, Lema Imam, Rory Ingham, Rose Ingleton, Rizwan Iqbal, Jenny Isherwood, Abdurrahman Islim, Omar Ismail, Shashank Iyer, Toby Jackman, Prashant Jain, Nadeem Jamal, Sabine Jamal, Ellen James, Nirmitha Jayaratne, Nathan Jeffreys, Hiral Jhala, Courtney Johnson, Zoe Johnston, Conor Jones, Emma-Jane Jones, Keaton Jones, Victor Jones, Roshan Joseph, Dilan Joshi, Holly Joyce, Claire Joyner, Aditya Kale, Sagar Kanabar, Lina Kanapeckaite, Hadyn Kankam, Sarantos Kaptanis, Edward Karam, Dimitrios Karponis, Anne Karunatilleke, Veeru Kasivisvanathan, Geeta Kaur, Samina Kauser, Nigel Keelty, Denise Kelly, Jessica Kennett, Molly Kerr, Ahmed Kerwan, Apoorva Khajuria, Mostafa Khalil, Mehnoor Khaliq, Ayushah Khan, Hamzah Khan, Haroon Khan, Maaz Khan, Maria Khan, Shahab Khan, Kaywaan Khan, Rachel Khaw, Ashni Kheterpal, Parisa Khonsari, Miraen Kiandee, Samuel Kim, Suji Kim, Sung-Hee Kim, Harry King, Anna Kinsella, Ajit Kishore, Stefan Klimach, Angelos G. Kolias, Anna Kolodziejczyk, Chia Yew Kong, Tseun Han James Kong, Omar Kouli, Sebi Kukran, Sevi Kukran, Geev Kumaran, Vladislav Kutuzov, Chris Laing, Georgina Laing, Kulvinder Lal, Peter Lalor, Joel Lambert, Sai Geethan Lambotharan, Eve Lancaster, Jasmine Latter, Michelle Latter, Kenny Lau, Alexa Lazarou, Madeline Leadon, Gabriel Lee, Jeyoung Lee, Kathryn Lee, Matthew Lee, Samuel Lee, Zong Lee, Edward Leung, Thomas Lewis, Hansen Li, Mimi Li, Wan Jane Liew, Yao Ren Liew, Alexander Light, Lydia Lilis, Diana Lim, Hui Lim, Joseph Lim, Zhi Lim, Siyin Liu, James Lloyd, Andrew Logan, Priya Loganathan, M. Long, Lydia Longstaff, Luisa Lopez Rojas, Richard Lovegrove, Jack Lowe-Zinola, Byron Lu Morrell, Joshua Luck, Andreas Luhmann, Surabhika Lunawat, Jon Lund, Cong Luo, Lorna Luo, Iona Lyell, Panagis Lykoudis, Jonathan Macdonald, Aliya Mackenzie, Conor Magee, Pooja Mahankali-Rao, Kamal Mahawar, Mehreen Mahfooz, Faisal Mahmood, Samir Makwana, Tom Malik, Sohaib Mallick, Jyothis Manalayil, Tinaye Mandishona, Sudhakar Mangam, Maniragav Manimaran, Natarajan Manimaran, Chris Manson, Sufyan Mansoor, Fatima Mansour, Alejandro Marcos Rodrigo, Nicholas Markham, Maria Marks, Paul Marriott, Hannah Marsden, Laura Martin, Tiago Martins, John Mason, Luke Mason, Mariam Masood, Nikhil Math, Ginimol Mathew, Jacob Matthews, Jonathan Mayes, Ursula Mc Gee, Ross Mcallister, Sandra Mcallister, Scott Mccain, Conor Mccann, Emmet Mccann, Cathal McCarthy, Gillian Mccoll, Greg Mcconaghie, Ace Mcdermott, Frank McDermott, Rachel Mcdougall, Mark McDowell, Gordon McFarlane, Richard McGregor, Doug McKechnie, Jillian McKenna, Scott McKinstry, Georgia Mclachlan, E. Mclean, Elizabeth McLennan, Angus McNair, Kenneth Mealy, Lauren Mecia, Alexander Mehta, Aidan Mellan, Arathi Menon, Donald Menzies, Zhubene Mesbah, David Messenger, George Miller, Aseem Mishra, Sona Mistry, Tahira Mohamed, Nisha Mohamed Mushaini, Midhun Mohan, Ameerah Mohd Azmilssss, Ajay Mohite, Krishna Moorthy, Jalal Moradzadeh, Richard Morgan, Gabriella Morley, Alice Mortimer, Hannah Mownah, Paul Moxey, Gagira Mudalige, Umarah Muhammad, Samuel Munday, Ben Murphy, Ciaran Murphy, Caoimhe Murray, Hannah Murray, Michael Murray, Mohammed Ibrar Murtaza, Jameel Mushtaq, Ameer Mustafa, Shams Mustafa, Laura Myers, Sam Myers, Adeeb Naasan, Kiran Nadeem, Hanzla Naeem, Prashant Naik, Arun Nair, Keshav K. Nambiar, Muhammad Naqi, Zehra Naqvi, Yan Ning Neo, Georgia Irene Neophytou, Jonathan Neville, Tom Newman, Benjamin Ng, Guat Ng, Jing Qi Ng, Vincent Ng, Zhan Herr Ng, Maire Ni Bhoirne, James Nicholas, Gary Nicholson, George Ninkovic-Hall, Gemma Nixon, Mike Norwood, Toby Noton, Romman Nourzaie, Richard Novell, Donald Nyanhongo, James O'Brien, Rory O'Kane, Stephen O'Neill, Hugh O'Sullivan, Thomas Oakley, Chinomso Ogbuokiri, Oluwafunto Ogunleye, Su Oh, Emezie Okorocha, James Olivier, Rele Ologunde, Sharif Omara, Alice Ormrod, Caroline Osborne, Joanna Osmanska, Raisah Owasil, Sebastian Owczarek, Ezgi Ozcan, Sri Palaniappan, Francesco Palazzo, Abbas Palkhi, Gargi Pandey, James Park, Jennifer Parker, Anna Parry, James Parsonage, Lauren Passby, Bhavi Patel, Bhavik Patel, Chantal Patel, Dinisha Patel, Kirtan Patel, Panna Patel, Pratiksha Patel, Trupesh Patel, Mariasoosai Pathmarajah, Amogh Patil, Pradeep Patil, Yusuf Patrick, Jessica Pearce, Lyndsay Pearce, Colin Peirce, Bryony Peiris, Amy Pendrill, Sreelata Periketi, Michael Perry, George Petrov, Charlotte Phillips, Grace Pike, Ana Catarina Pinho-Gomes, Parhana Polly, Arachchige Ponweera, Yanish Poolovadoo, Raunak Poonawala, Petya Popova, Dimitri Pournaras, Brooke Powell, Praveena Prabakaran, Esha Prakash, Tapani Pratumsuwan, Anusha Prem Kumar, Helen Puddy, Michael Pullinger, Nikita Punjabi, Oliver Charles Putt, Omar Qadir, Mubasher Qamar, Patrick Quinn, Arham Qureshi, Mohamed Rabie, Angus Radford, Anand Radhakrishnan, Ansh Radotra, Nasir Rafiq, Aria Rahem, Nahim Rahman, Syed Rahman, Ramesh Rajagopal, Nick Rajan, Nikitha Rajaraman, Sumetha Rajendran, Liandra Ramachenderam, Divya Ramakrishnan, Denisha Ramjas, James Rammell, Ritika Rampal, George Ramsay, Ratan Randhawa, Ellis Rea, Stephanie Rees, Saad Rehman, Salwah Rehman, Nabila Rehnnuma, Melina Rejayee, Zakaria Rob, Charlotte Roberts, Grace Roberts, Ben Roberts, Harry Robinson, Stephen Robinson, Ailin Rogers, Alex Rogers, William Rook, Talisa Ross, Chloe Roy, Azelea Rushd, Duncan Rutherford, Michael Saat, Kaushik Sadanand, Rebecca Sagar, Harkiran Sagoo, Arin Saha, Kapil Sahnan, Mohammed Salik Sait, Saif Sait, Damien Salekin, Mostafa Salem, Nadia Salloum, Emma Sanders, Jasmesh Sandhu, N. Sandhu, Lorna Sandison, Laura Sandland-Taylor, Ron Sangal, Chandan Sanghera, Josephine Saramunda, Lauren Satterthwaite, Moritz Schramm, Rupert Scott, Chloe Searle, Harkiran Seehra, Juan Jose Segura-Sampedro, Harpreet Kaur Sekhon Inderjit Singh, Shaikh Sanjid Seraj, Ishani Seth, Rajiv Sethi, Apar Shah, Mario Shaid, Shafaque Shaikh, Awad Shamali, Elizabeth Sharkey, Abhi Sharma, Neil Sharma, Sachin Sharma, Aniruddh Shenoy, Maleasha Shergill, Shahram Shirazi, Imran Siddiqui, Raykal Sim, Lucy Simmonds, Andrew Simon, William Simpson, Bharpoor Singh, J. Singh, Prashant Singh, Anant Sinha, Sidhartha Sinha, Robert Sinnerton, Chaamanti Sivakumar, Brendan Skelly, Richard Slater, Samuel Small, Neil Smart, Yat Wing Smart, Alexander Smith, Charlotte Smith, Jason Smith, Rebecca Smith, Scott Smith, Peter Sodde, Zhi Min Soh, Aniket Sonsale, Ahmed Soualhi, John Spearman, Robert Spencer, Harry Spiers, Philip Stather, Michael Stoddart, Bradley Storey, Howard Stringer, Thomas Stringfellow, Ben Stubbs, Niv Sukir, Nivian Sukirthan, Yasir Suleman, Aparnah Sureshkumar, Ashwin Suri, Timen Swartbol, Hyder Tahir, E. Tian Tan, Huai Ling Tan, Laura Tan, Alethea Tang, Priyal Taribagil, Yao Zong Tay, Beth Taylor, Zara Taylor, Alexandra Thatcher, Rachel Thavayogan, Michael Thomaa, Daniah Thomas, Jenny Thomas, Paul Thomas, Thomas Pinkney, Chris Thompson, Mag Ting, Ethan Toner, Godwin Tong, Jared Torkington, Molly Traish, Miles Triniman, John Trotter, Kwong Tsang, Sanchit Turaga, Hannah Turley, James Turner, Tomas Urbonas, Alexandra Urquhart, Nimai Vadgama, Aashay Vaidya, Gijs van Boxel, Swati Vara, Massimo Varcada, Rebecca Varley, Dee Varma, Martinique Vella-Baldacchino, Sara Venturini, Naina Verma, Saurabh Verma, Gabrielle Vernet, Mark Vipond, Alex von Roon, Qasim Wadood, Kathryn Waite, Lewis Walker, Nathan Walker, Jonathan C.M. Wan, Liyang Wang, Xue Wang, Alex Ward, Thomas Ward, Nienke Warnaar, Lloyd Warren, Oliver Warren, Sam Waters, Angus Watson, Laura Jayne Watson, Dominic Waugh, Daniel Weinberg, Malcolm West, Carla White, Tim White, Katharine Whitehurst, Robert Whitham, Tharindri Wijekoon, Manuk Wijeyaratne, Richard Wilkin, Alex Wilkins, Adam Williams, Gethin Williams, Luke Williams, Robert Williams, Andrew Williamson, Jacinthe Willson, Andrew Wilson, Holly Wilson, James Wilson, Lizzie Wilson, Megan Wilson, Michael Wilson, Rebekah Wilson, Tim Wilson, Evelina Woin, Esther Wright, Jenny Wright, Nicholas Wroe, Joanne Wylie, Yiwang Xu, Satheesh Yalamarthi, Angela Yan, Narisu Yang, Eda Yardimci, Ibrahim Yasin, Ismael Yasin, Noor Yasin, Joseph Yates, Jih Dar Yau, Tricia Yeoh, Joshua Yip, Cissy Yong, Vasudev Zaver, Tatiana Zhelezniakova, and Adreana Zulkifli

Subjects
Medical education, Manchester Cancer Research Centre, business.industry, ResearchInstitutes_Networks_Beacons/mcrc, MEDLINE, General Medicine, 030230 surgery, Collaborative research, 03 medical and health sciences, 0302 clinical medicine, Foundation Programme, Medicine, Surgery, 030212 general & internal medicine, business
Published
2017
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5. Long-term results of urgent revascularization for hepatic artery thrombosis after pediatric liver transplantation

Author

Henkjan J. Verkade, Koert P. de Jong, Robert J. Porte, Nienke Warnaar, Marieke T. de Boer, Egbert Sieders, W.G. Polak, and P. M. J. G. Peeters

Subjects
Transplantation, medicine.medical_specialty, Hepatology, business.industry, Bile duct, medicine.medical_treatment, Retrospective cohort study, Thrombolysis, Liver transplantation, medicine.disease, Revascularization, Surgery, Stenosis, medicine.anatomical_structure, Medicine, business, Complication, Survival rate
Abstract

Hepatic artery thrombosis (HAT) after pediatric orthotopic liver transplantation (OLT) is a serious complication resulting in bile duct necrosis and often requiring retransplantation. Immediate surgical thrombectomy/thrombolysis has been reported to be a potentially successful treatment for restoring blood flow and avoiding urgent retransplantation. The long-term results of this strategy remain to be determined. In 232 pediatric liver transplants, we analyzed long-term outcomes after urgent revascularization for early HAT. HAT developed in 32 patients (13.7%). In 16 children (50%), immediate surgical thrombectomy was performed in an attempt to salvage the graft. Fourteen patients (44%) underwent urgent retransplantation, and 2 (6%) died before further intervention. Immediate thrombectomy resulted in long-term restoration of the hepatic artery flow in 6 of 16 patients (38%) and in 1- and 5-year graft and patient survival rates of 83% and 67%, respectively. In 10 patients, revascularization was unsuccessful, and retransplantation was inevitable. The 1- and 5-year patient survival rates in this group decreased to 50% and 40%, respectively. After immediate retransplantation, the 5-year patient survival rate was 71%. In conclusion, immediate surgical thrombectomy for HAT after pediatric OLT results in long-term graft salvage in about one-third of patients. However, when thrombectomy is unsuccessful, long-term patient survival is lower than the survival of patients who underwent immediate retransplantation.

Published
2010
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6. Aprotinin and the risk of thrombotic complications after liver transplantation: A retrospective analysis of 1492 patients

Author

John R. Klinck, Andrew K. Burroughs, Nancy Rolando, Marieke T. de Boer, Nienke Warnaar, Neville V. Jamieson, Susan Mallett, Robert J. Porte, and Keith Rolles

Subjects
Transplantation, medicine.medical_specialty, Antifibrinolytic, Hepatology, medicine.drug_class, business.industry, medicine.medical_treatment, Odds ratio, Liver transplantation, medicine.disease, Thrombosis, Pulmonary embolism, Surgery, Fibrinolysis, medicine, Aprotinin, business, Tranexamic acid, medicine.drug
Abstract

Aprotinin is an antifibrinolytic drug that reduces blood loss during orthotopic liver transplantation (OLT). Case reports have suggested that aprotinin may be associated with an increased risk of thromboembolic complications. Recent studies in cardiac surgery also have suggested a higher risk of renal failure and postoperative mortality. Despite these concerns, no large-scale safety assessment has been performed in OLT. In a retrospective observational study involving 1492 liver transplants, we studied the occurrence of postoperative thromboembolic or thrombotic events and mortality in patients who received aprotinin (n = 907) and patients who did not (n = 585). The overall incidence of hepatic artery thrombosis and central venous complications (pulmonary embolism or inferior vena cava thrombosis) was 3.2% and 0.9%, respectively. In propensity score-adjusted analyses (C-index = 0.79), aprotinin was not associated with an increased risk of hepatic artery thrombosis [odds ratio (OR) = 1.00, 95% confidence interval (CI) = 0.50-2.01, P = 0.86]. Although central venous complications were found more frequently in patients receiving aprotinin, the difference was not statistically significant (OR = 2.95, 95% CI = 0.54-16.23, P = 0.32). In addition, no significant differences were found in 1-year mortality (OR = 1.21, 95% CI = 0.86-1.71, P = 0.32). In conclusion, this study did not demonstrate an increased risk of thrombotic complications or mortality when aprotinin is used during OLT.

Published
2009
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7. Intraoperative pulmonary embolism and intracardiac thrombosis complicating liver transplantation: a systematic review

Author

A. De Wolf, Saadia S. Sherwani, Maarten J. H. Slooff, Nienke Warnaar, Steven D. Colquhoun, I. Q. Molenaar, and Robert J. Porte

Subjects
Adult, Male, medicine.medical_specialty, Circulatory collapse, Adolescent, Heart Diseases, Hypertension, Pulmonary, medicine.medical_treatment, Liver transplantation, Risk Factors, medicine.artery, Humans, Medicine, Hospital Mortality, Child, Intraoperative Complications, business.industry, Infant, Newborn, Infant, Shock, Thrombosis, Hematology, Thrombolysis, Middle Aged, medicine.disease, Combined Modality Therapy, Pulmonary hypertension, Liver Transplantation, Thrombelastography, Surgery, Pulmonary embolism, Embolism, Child, Preschool, Pulmonary artery, Female, Hypotension, Pulmonary Embolism, business
Abstract

Summary. Background: Pulmonary embolism (PE) and intracardiac thrombosis (ICT) are rare but potentially lethal complications during orthotopic liver transplantation (OLT). Methods: We aimed to review clinical and pathological correlates of PE and ICT in patients undergoing OLT. A systematic review of the literature was conducted using MEDLINE and ISI Web of Science. Results: Seventy-four cases of intraoperative PE and/or ICT were identified; PE alone in 32 patients (43%) and a combination of PE and ICT in 42 patients (57%). Most frequent clinical symptoms included systemic hypotension and concomitant rising pulmonary artery pressure, often leading to complete circulatory collapse. PE and ICT occurred in every stage of the operation and were reported equally in patients with or without the use of venovenous bypass or antifibrinolytics. A large variety of putative risk factors have been suggested in the literature, including the use of pulmonary artery catheters or certain blood products. Nineteen patients underwent urgent thrombectomy or thrombolysis. Overall mortality was 68% (50/74) and 41 patients (82%) died intraoperatively. Conclusion: Mortality was significantly higher in patients with an isolated PE, compared to patients with a combination of PE and ICT (91% and 50%, respectively; P

Published
2008
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8. The Impact of Aprotinin on Renal Function After Liver Transplantation: An Analysis of 1043 Patients

Author

Nancy Rolando, Nienke Warnaar, M. T. De Boer, A.K. Burroughs, Susan Mallett, Maarten W. N. Nijsten, Robert J. Porte, Maarten J.H. Slooff, Keith Rolles, Critical care, Anesthesiology, Peri-operative and Emergency medicine (CAPE), and Groningen Institute for Organ Transplantation (GIOT)

Subjects
Male, medicine.medical_treatment, Kidney, Kidney Function Tests, Hemostatics, DOUBLE-BLIND, chemistry.chemical_compound, Postoperative Complications, Risk Factors, Antifibrinolytic agent, FAILURE, Immunology and Allergy, Pharmacology (medical), Aprotinin, antifibrinolytics, Fibrinolysis, Liver Diseases, Middle Aged, Renal Replacement Therapy, PROPENSITY SCORE, Creatinine, ANTIFIBRINOLYTIC AGENTS, Regression Analysis, Female, hormones, hormone substitutes, and hormone antagonists, medicine.drug, Adult, medicine.medical_specialty, Antifibrinolytic, medicine.drug_class, Urology, Renal function, REPLACEMENT THERAPY, BLOOD-LOSS, renal dysfunction, medicine, Humans, Renal replacement therapy, Retrospective Studies, Transplantation, business.industry, renal function, medicine.disease, Survival Analysis, Liver Transplantation, Surgery, TRANSFUSION REQUIREMENTS, chemistry, Multivariate Analysis, RISK-FACTORS, Liver function, business, CARDIAC-SURGERY, Kidney disease
Abstract

Renal dysfunction is frequently seen after orthotopic liver transplantation (OLT). Aprotinin is an antifibrinolytic drug which reduces blood loss during OLT. Recent studies in cardiac surgery suggested a higher risk of postoperative renal complications when aprotinin is used. The impact of aprotinin on renal function after OLT, however, is unknown. In 1043 adults undergoing OLT, we compared postoperative renal function in patients who received aprotinin (n = 653) or not (n = 390). Using propensity score stratification (C-index 0.82) and multivariate regression analysis, aprotinin was identified as a risk factor for severe renal dysfunction within the first week, defined as increase in serum creatinine by >= 100% (OR = 1.97, 95% CI = 1.14-3.39; p = 0.02). No differences in renal function were noted at 30 and 365 days postoperatively. Moreover, no significant differences were found in the need for renal replacement therapy (OR = 1.52, 95% CI = 0.94-2.46; p = 0.11) or in 1-year patient survival rate (OR = 1.14, 95% CI = 0.73-1.77; p = 0.64) in patients who received aprotinin or not. In conclusion, aprotinin is associated with a higher risk of transient renal dysfunction in the first week after OLT, but not with a higher need for postoperative renal replacement therapy or an increased risk of mortality.

Published
2007
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9. Efficacy and safety of antifibrinolytic drugs in liver transplantation

Author

Robert J. Porte, Maarten J.H. Slooff, I. Q. Molenaar, Elisabeth M. TenVergert, Nienke Warnaar, and Harry J.M. Groen

Subjects
Adult, Male, Antifibrinolytic, medicine.drug_class, medicine.medical_treatment, Liver transplantation, blood transfusion, PROPHYLACTIC USE, Aprotinin, Hepatic Artery, Antifibrinolytic agent, Thromboembolism, medicine, Immunology and Allergy, Humans, FIBRINOLYSIS, Pharmacology (medical), Aged, antifibrinolytics, Venous Thrombosis, Transplantation, liver transplantation, business.industry, PULMONARY THROMBOEMBOLISM, TRANEXAMIC ACID, Perioperative, Middle Aged, EMBOLISM, Antifibrinolytic Agents, Clinical trial, Survival Rate, meta-analysis, THROMBOSIS, Treatment Outcome, Anesthesia, Aminocaproic Acid, Female, Controlled Clinical Trials as Topic, HIGH-DOSE APROTININ, business, BLOOD-CELL TRANSFUSION, REQUIREMENTS, Tranexamic acid, medicine.drug, CARDIAC-SURGERY
Abstract

Although several randomized controlled trials (RCTs) have shown the efficacy of antifibrinolytic drugs in liver transplantation, their use remains debated due to concern for thromboembolic complications. None of the reported RCTs has shown a higher incidence of these complications in treated patients; however, none of the individual studies has been large enough to elucidate this issue completely. We therefore performed a systematic review and meta-analysis of efficacy and safety endpoints in all published controlled clinical trials on the use of antifibrinolytic drugs in liver transplantation. Studies were included if antifibrinolytic drugs (epsilon-aminocaproic acid, tranexamic acid (TA) or aprotinin) were compared with each other or with controls/placebo. Intraoperative red blood cell and fresh frozen plasma requirements, the perioperative incidence of hepatic artery thrombosis, venous thromboembolic events and mortality were analyzed. We identified 23 studies with a total of 1407 patients which met the inclusion criteria. Aprotinin and TA both reduced transfusion requirements compared with controls. No increased risk for hepatic artery thrombosis, venous thromboembolic events or perioperative mortality was observed for any of the investigated drugs. This systematic review and meta-analysis does not provide evidence for an increased risk of thromboembolic events associated with antifibrinolytic drugs in liver transplantation.

Published
2007
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10. Matrix metalloproteinases as profibrotic factors in terminal ileum in Crohnʼs disease

Author

Gerard Dijkstra, A.H. Bruggink, Mark H. J. Maathuis, Jan Niesing, Nienke Warnaar, Rutger J. Ploeg, H. Sijbrand Hofker, Theo A. Schuurs, Groningen Institute for Gastro Intestinal Genetics and Immunology (3GI), Groningen Institute for Organ Transplantation (GIOT), and Translational Immunology Groningen (TRIGR)

Subjects
Adult, Male, EXPRESSION, Pathology, medicine.medical_specialty, recurrence, Constriction, Pathologic, Matrix metalloproteinase, Biology, Anastomosis, Inflammatory bowel disease, Gene Expression Regulation, Enzymologic, matrix metalloproteinases (MMPs), FECAL STREAM, Crohn Disease, Ileum, Transforming Growth Factor beta, TISSUE INHIBITOR, MESALAMINE, Submucosa, medicine, Humans, Immunology and Allergy, RNA, Messenger, Interleukin-16, Crohn's disease, Tissue Inhibitor of Metalloproteinase-1, Tumor Necrosis Factor-alpha, resection margin, SMOOTH-MUSCLE CELLS, Gastroenterology, Middle Aged, medicine.disease, PREVENTION, Matrix Metalloproteinases, Up-Regulation, POSTOPERATIVE RECURRENCE, medicine.anatomical_structure, Resection margin, Collagenase, Immunohistochemistry, Female, Matrix Metalloproteinase 3, ILEAL RESECTION, Matrix Metalloproteinase 1, COLLAGENASE, INFLAMMATORY-BOWEL-DISEASE, medicine.drug
Abstract

BACKGROUND: Returning stenosis in Crohn's disease (CD) patients is poorly understood. After resection, newly developed strictures are seen within 10 years in 50% to 70%. Matrix metalloproteinases (MMPs) are involved in matrix-turnover processes. This study analyzes spatial expression of MMP-1, MMP-3, MMP-9, tissue inhibitor of MMP-1, and collagen III to get better insight in tissue remodeling of terminal ileum of CD patients. METHODS: Expressions were analyzed on mRNA and the protein level (MMP-1, MMP-3) in segments from resected terminal ileum from CD and control patients. In CD, macroscopic distinction was made between proximal resection margin, prestenotic, and stenotic tissue. Immunohistochemistry allowed for expression analyses transmurally. RESULTS: MMP-1 and MMP-3 gene expression was up-regulated (P < 0.05) in both prestenotic and stenotic tissue. MMP-1 protein was significantly up-regulated in submucosal and muscular tissue of prestenotic parts and in muscular tissue of stenotic Crohn samples. MMP-3 protein was significantly up-regulated in all layers of prestenotic and stenotic Crohn samples. Even in submucosa of proximal resection margin tissue, MMP-3 expression was significantly higher than in controls. CONCLUSION: Surprisingly, in proximal resection margin tissue up-regulated MMP-3 was seen. This suggests that in nonresected terminal ileum, in which anastomosis is made, tissue turnover is present, which may account for the high recurrence of intestinal strictures.

Published
2006
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11. Biochemical indicators of in-hospital complications following pancreatic surgery

Author

Biku J, John, Sanjay, Wijeyekoon, Nienke, Warnaar, Prasoona, Shasi, Sakirullah H, Rahman, B R, Davidson, and G, Fusai

Subjects
Leukocyte Count, C-Reactive Protein, Pancreatectomy, Postoperative Complications, ROC Curve, Platelet Count, Splenectomy, Humans, Serum Albumin, Pancreaticoduodenectomy, Retrospective Studies
Abstract

Early recognition of complications following pancreatic surgery could reduce morbidity and mortality. White cell counts (WCCs), platelets (PLTs), C-reactive protein (CRP) and albumin (ALB) are commonly used as guides in clinical decision making. However, the evidence to support their role as early indicators of complications is unclear. A retrospective cohort analysis of consecutive pancreatic surgical procedures between 2004 and 2008 was performed. Operative procedures, inflammatory markers--WCCs, PLTs, CRP, and ALB--preoperatively and on postoperative days (PODs) 1, 3, 5, 7, 9, 12, and 15, and clinical outcomes were recorded. WCC11 x 10(9)/L on POD5 was significantly associated with complications [odds ratio (OR), 2.60; P = 0.0067]. ALB28 g/L on POD7 was significantly associated with a postoperative complication (OR, 2.94; P = 0.0031). WCC12.2 x 10(9)/L and ALBor = 28 g/L on POD7 were more likely to be associated with a complication (OR, 4.86; P = 0.0002). Postoperative WCC and ALB levels may be useful as aids to the early diagnosis of complications following pancreatic surgery.

Published
2010

12. Long-term results of urgent revascularization for hepatic artery thrombosis after pediatric liver transplantation

Author

Nienke, Warnaar, Wojciech G, Polak, Koert P, de Jong, Marieke T, de Boer, Henkjan J, Verkade, Egbert, Sieders, Paul M J G, Peeters, and Robert J, Porte

Subjects
Male, Time Factors, Adolescent, Graft Survival, Infant, Thrombosis, Kaplan-Meier Estimate, Liver Transplantation, Survival Rate, Hepatic Artery, Treatment Outcome, Risk Factors, Child, Preschool, Humans, Female, Longitudinal Studies, Child, Follow-Up Studies, Retrospective Studies, Thrombectomy
Abstract

Hepatic artery thrombosis (HAT) after pediatric orthotopic liver transplantation (OLT) is a serious complication resulting in bile duct necrosis and often requiring retransplantation. Immediate surgical thrombectomy/thrombolysis has been reported to be a potentially successful treatment for restoring blood flow and avoiding urgent retransplantation. The long-term results of this strategy remain to be determined. In 232 pediatric liver transplants, we analyzed long-term outcomes after urgent revascularization for early HAT. HAT developed in 32 patients (13.7%). In 16 children (50%), immediate surgical thrombectomy was performed in an attempt to salvage the graft. Fourteen patients (44%) underwent urgent retransplantation, and 2 (6%) died before further intervention. Immediate thrombectomy resulted in long-term restoration of the hepatic artery flow in 6 of 16 patients (38%) and in 1- and 5-year graft and patient survival rates of 83% and 67%, respectively. In 10 patients, revascularization was unsuccessful, and retransplantation was inevitable. The 1- and 5-year patient survival rates in this group decreased to 50% and 40%, respectively. After immediate retransplantation, the 5-year patient survival rate was 71%. In conclusion, immediate surgical thrombectomy for HAT after pediatric OLT results in long-term graft salvage in about one-third of patients. However, when thrombectomy is unsuccessful, long-term patient survival is lower than the survival of patients who underwent immediate retransplantation.

Published
2010

13. Aprotinin and the risk of thrombotic complications after liver transplantation: a retrospective analysis of 1492 patients

Author

Nienke, Warnaar, Susan V, Mallett, John R, Klinck, Marieke T, de Boer, Nancy, Rolando, Andrew K, Burroughs, Neville V, Jamieson, Keith, Rolles, and Robert J, Porte

Subjects
Adult, Male, Risk, Thrombosis, Middle Aged, Hemostatics, Liver Transplantation, Aprotinin, Hepatic Artery, Treatment Outcome, Odds Ratio, Humans, Female, Liver Failure, Retrospective Studies
Abstract

Aprotinin is an antifibrinolytic drug that reduces blood loss during orthotopic liver transplantation (OLT). Case reports have suggested that aprotinin may be associated with an increased risk of thromboembolic complications. Recent studies in cardiac surgery also have suggested a higher risk of renal failure and postoperative mortality. Despite these concerns, no large-scale safety assessment has been performed in OLT. In a retrospective observational study involving 1492 liver transplants, we studied the occurrence of postoperative thromboembolic or thrombotic events and mortality in patients who received aprotinin (n = 907) and patients who did not (n = 585). The overall incidence of hepatic artery thrombosis and central venous complications (pulmonary embolism or inferior vena cava thrombosis) was 3.2% and 0.9%, respectively. In propensity score-adjusted analyses (C-index = 0.79), aprotinin was not associated with an increased risk of hepatic artery thrombosis [odds ratio (OR) = 1.00, 95% confidence interval (CI) = 0.50-2.01, P = 0.86]. Although central venous complications were found more frequently in patients receiving aprotinin, the difference was not statistically significant (OR = 2.95, 95% CI = 0.54-16.23, P = 0.32). In addition, no significant differences were found in 1-year mortality (OR = 1.21, 95% CI = 0.86-1.71, P = 0.32). In conclusion, this study did not demonstrate an increased risk of thrombotic complications or mortality when aprotinin is used during OLT.

Published
2009

14. The two tales of coagulation in liver transplantation

Author

Robert J. Porte, Ton Lisman, and Nienke Warnaar

Subjects
medicine.medical_specialty, Cirrhosis, medicine.medical_treatment, Blood Loss, Surgical, Liver transplantation, Thrombophilia, Gastroenterology, Hemostatics, Liver disease, Internal medicine, Thromboembolism, Coagulation testing, Immunology and Allergy, Medicine, Humans, Transplantation, business.industry, Anticoagulants, medicine.disease, Thrombosis, Surgery, Liver Transplantation, Hemostasis, business, Tranexamic acid, medicine.drug
Abstract

Purpose of review Hemostatic alterations in cirrhosis involve molecular pathways that both promote and stabilize blood clotting and pathways that mediate clot dissolution. Orthotopic liver transplantation for end-stage liver disease historically was a long and risky procedure, accompanied by substantial blood loss. The aim of this review paper is to provide an overview of recent studies and developments that have gradually changed our understanding about the hemostatic system and changes that may occur in patients undergoing liver transplantation. Recent findings Patients with severe liver disease not only have a deficiency of procoagulant and antifibrinolytic factors, but also have a deficiency of naturally occurring anticoagulants and profibrinolytics. Studies using modern laboratory technology have shown that thrombin generation in these patients is less abnormal than traditionally believed based on standard coagulation tests. In addition, clinical observations indicated that patients with cirrhosis are not protected against thromboembolic complications. Summary Hemostatic alterations in cirrhosis concern both pro- and antihemostatic pathways and the net result is a rebalancing of the hemostatic system, albeit with narrower margins. This delicate balance will become precarious when the system is heavily challenged such as during liver transplantation. The balance may than be turned to either hypocoagulation or hypercoagulation, making patients with cirrhosis both prone to bleeding as well as thromboembolic complications.

Published
2008

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