Liver and Hepatocyte Transplantation: What Can Pigs Contribute?

About one-fifth of the population suffers from liver diseases in China, meaning that liver disorders are prominent causative factors relating to the Chinese mortality rate. For patients with end-stage liver diseases such as hepatocellular carcinoma or acute liver diseases with life-threatening liver dysfunction, allogeneic liver transplantation is the only life-saving treatment. Hepatocyte transplantation is a promising alternative for patients with acute liver failure or those considered high risk for major surgery, particularly for the bridge-to-transplant period. However, the lack of donors has become a serious global problem. The clinical application of porcine xenogeneic livers and hepatocytes remains a potential solution to alleviate the donor shortage. Pig grafts of xenotransplantation play roles in providing liver support in recipients, together with the occurrence of rejection, thrombocytopenia, and blood coagulation dysfunction. In this review, we present an overview of the development, potential therapeutic impact, and remaining barriers in the clinical application of pig liver and hepatocyte xenotransplantation to humans and non-human primates. Donor pigs with optimized genetic modification combinations and highly effective immunosuppressive regimens should be further explored to improve the outcomes of xenogeneic liver and hepatocyte transplantation.

Hyperoxemia in postsurgical sepsis/septic shock patients is associated with reduced mortality

Background Despite growing interest in treatment strategies that limit oxygen exposure in ICU patients, no studies have compared conservative oxygen with standard oxygen in postsurgical patients with sepsis/septic shock, although there are indications that it may improve outcomes. It has been proven that high partial pressure of oxygen in arterial blood (PaO2) reduces the rate of surgical-wound infections and mortality in patients under major surgery. The aim of this study is to examine whether PaO2 is associated with risk of death in adult patients with sepsis/septic shock after major surgery. Methods We performed a secondary analysis of a prospective observational study in 454 patients who underwent major surgery admitted into a single ICU. Patients were stratified in two groups whether they had hyperoxemia, defined as PaO2 > 100 mmHg (n = 216), or PaO2 ≤ 100 mmHg (n = 238) at the day of sepsis/septic shock onset according to SEPSIS-3 criteria maintained during 48 h. Primary end-point was 90-day mortality after diagnosis of sepsis. Secondary endpoints were ICU length of stay and time to extubation. Results In patients with PaO2 ≤ 100 mmHg, we found prolonged mechanical ventilation (2 [8] vs. 1 [4] days, p < 0.001), higher ICU stay (8 [13] vs. 5 [9] days, p < 0.001), higher organ dysfunction as assessed by SOFA score (9 [3] vs. 7 [5], p < 0.001), higher prevalence of septic shock (200/238, 84.0% vs 145/216) 67.1%, p < 0.001), and higher 90-day mortality (37.0% [88] vs. 25.5% [55], p = 0.008). Hyperoxemia was associated with higher probability of 90-day survival in a multivariate analysis (OR 0.61, 95%CI: 0.39–0.95, p = 0.029), independent of age, chronic renal failure, procalcitonin levels, and APACHE II score > 19. These findings were confirmed when patients with severe hypoxemia at the time of study inclusion were excluded. Conclusions Oxygenation with a PaO2 above 100 mmHg was independently associated with lower 90-day mortality, shorter ICU stay and intubation time in critically ill postsurgical sepsis/septic shock patients. Our findings open a new venue for designing clinical trials to evaluate the boundaries of PaO2 in postsurgical patients with severe infections.

An Observational Study of Paediatric Preoperative Transfusion Practice in a Resource-Limited Setting

Background Paediatric anaemia is highly prevalent in low–middle-income countries and can negatively impact postoperative outcomes. Currently, there are no guidelines for the management of paediatric preoperative anaemia. To ensure optimal care in resource-limited settings: balancing the risks of anaemia and using resources such as blood transfusion, we first need to understand current practices. To address this, a joint UK–Bangladesh team conducted an observational study at a paediatric surgical centre in Bangladesh. Methods A total of 464 patients ≤16 years who underwent elective and emergency surgery were categorised into major (351/464), moderate (92/464) and minor (21/464) surgery groups according to anticipated blood loss. Preoperative anaemia testing and transfusion was assessed retrospectively through patient notes. Results Median age was 4 years and 73% were male. 32.5% (151/464) patients had preoperative blood testing for anaemia. 17.5% (81/464) children were transfused preoperatively. Of those children transfused, 40.7% (33/81) underwent transfusion solely based on visible signs of anaemia on clinical examination. Seventy-five percentage (36/48) of children who underwent transfusion after blood testing had haemoglobin ≥80 g/L. Major surgery category had the highest proportion of children who were transfused and tested for anaemia. Conclusion A liberal transfusion approach is evident here. Discussion with local clinicians revealed that this was due to limitations in obtaining timely blood results and reduction in laboratory costs incurred by families when clinical suspicion of anaemia was high. Further research is needed to analyse the potential of using bedside haemoglobin testers in conjunction with patient blood management strategies to limit blood transfusions and its associated risks.

Đánh giá hiệu quả giảm đau bằng gây tê ngoài màng cứng trong phẫu thuật nội soi cắt đại, trực tràng

TÓM TẮT Đặt vấn đề: Gây tê ngoài màng cứng để giảm đau trong và sau mổ được áp dụng rộng rãi trên thế giới từ nhiều thập niên qua. Kết quả của nhiều công trình nghiên cứu cho thấy phương pháp này làm giảm những biến chứng trong và sau mổ, giảm tỉ lệ tử vong sau mổ của các phẫu thuật nặng. Nghiên cứu nhằm đánh giá hiệu quả và các tác dụng phụ của gây tê ngoài màng cứng trong phẫu thuật ung thư đại, trực tràng. Phương pháp: Nghiên cứu mô tả cắt ngang trên 28 bệnh nhân được gây tê ngoài màng cứng trong mổ ung thư đại, trực tràng có phối hợp gây mê nội khí quản. Sinh hiệu và tình trạng sức khỏe của bệnh nhân được theo dõi trước và sau khi tiêm thuốc giảm đau. Ghi nhận mức độ giảm đau theo Visual Analog Scale (VAS), mức độ liệt vận động theo Bromage và các tác dụng phụ sau mổ. Kết quả: Hiệu quả giảm đau sau mổ tốt, tại các thời điểm sau mổ VAS đều ≤ 1,5. Tỉ lệ các biến chứng: tụt huyết áp: 7,14%, đau đầu: 7,14%, lạnh run: 10,71%, buồn nôn, nôn: 17,86%. Kết luận: Kỹ thuật gây tê ngoài màng cứng phối hợp với gây mê toàn thân là kỹ thuật giảm đau hiệu quả và an toàn cho phẫu thuật vùng bụng trong mổ và 24 giờ sau mổ. ABSTRACT THE EFFICIENCY OF SPINAL EPIDURAL ANESTHESIA FOR LAPAROSCOPIC COLORECTAL CANCER SURGERY Background: Epidural anesthesia for pain relief during and after surgery has been widely applied in the world for decades. The results of many studies show that this method reduces intra - and postoperative complications and reduces the postoperative mortality rate of major surgery. The study aimed to evaluate epidural anesthesia’s effectiveness and side effects in colorectal cancer surgery. Methods: A cross - sectional descriptive study on 28 patients receiving epidural anesthesia in surgery for colorectal cancer in combination with endotracheal anesthesia. The patient’s vital signs and health status were monitored before and after the injection of pain medication. Record the level of pain relief according to the Visual Analog Scale (VAS), the degree of motor paralysis according to Bromage, and the side effects after surgery. Results: Good postoperative pain relief effect, at all times after surgery, VAS was ≤ 1.5. Rate of complications: hypotension: 7.14%, headache: 7.14%, shiver: 10.71%, nausea, vomiting: 17.86%. Conclusion: The epidural anesthesia combined with general anesthesia is an effective and safe analgesia technique for abdominal surgery during surgery and 24 hours after surgery. Keywords: Epidural anesthesia, colorectal cancersurgery

Efficacy and Safety of Forced-Air Warming System versus Passive Warming Measures in Major Surgeries: A Systematic Review

Purpose: To compare the clinical impact of forced-air warming system (Bair HuggerTM, BH) and passive warming measures in major surgery patients. Methods: Databases including Pubmed, Cochrane Library, Clinical Trials.Gov and CNKI were searched to collect studies published before January 2019 that were concerned the clinical effects of Bair Hugger. Two reviewers independently screened the literatures, extracted the data. The revised Jadad scale was used to evaluate the methodological quality of the literatures. Meta-analysis was performed by using Review Manager 5.3.0. Findings: A total of 27 studies were included. The result of meta-analysis showed that BH had a significant advantage in rate of hypothermia (RD = -0.42, 95%CI (-0.68, -0.16)) , shivering (RD = -0.28, 95%CI (-0.43, -0.13)), anesthesia recovery time (MD = -8.27, 95% CI (-13.49, -3.05)), hospital stay (MD = -1.27, 95% CI (-2.05) , -0.48)), while incision infection RD = -0.15, 95%CI (-0.40,0.11)) , intraoperative blood loss (MD = -16.88, 95%CI(-34.73,0.96)), intraoperative blood transfusion (MD = -41.49, 95% CI( -108.36, 25.38)) , pain RD = -0.02, 95%CI(-0.08, 0.03)) and other complications (RD = -0.13, 95%CI(-0.39,0.12)) had an advantage but not significant. Subgroup analyses showed that operation mode and operation duration was the sensitive factors. Conclusion: Compared to passive warming, Bair Hugger has significant advantages in hypothermia protection and further reduces the risk of incision chills and prolonged hospital stay. Combined with the current status of body temperature protection in China, it is necessary to enhance the awareness of body temperature protection, standardize medical behavior, and increase the popularity of active warming systems.

Migraine Headaches after Major Surgery with General or Neuraxial Anesthesia: A Nationwide Propensity-Score Matched Study

Migraine headaches can be provoked by surgical stress and vasoactive effects of anesthetics of general anesthesia in the perioperative period. However, it is unclear whether general anesthesia increases the migraine risk after major surgery. Incidence and risk factors of postoperative migraine are also largely unknown. We utilized reimbursement claims data of Taiwan’s National Health Insurance and performed propensity score matching analyses to compare the risk of postoperative migraine in patients without migraine initially who underwent general or neuraxial anesthesia. Multivariable logistic regressions were applied to calculate the adjusted odds ratio (aOR) and 95% confidence interval (CI) for migraine risk. A total of 68,131 matched pairs were analyzed. The overall incidence of migraine was 9.82 per 1000 person-years. General anesthesia was not associated with a greater risk of migraine compared with neuraxial anesthesia (aORs: 0.93, 95% CI: 0.80–1.09). This finding was consistent across subgroups of different migraine subtypes, uses of migraine medications, and varying postoperative periods. Influential factors for postoperative migraine were age (aOR: 0.99), sex (male vs. female, aOR: 0.50), pre-existing anxiety disorder (aOR: 2.43) or depressive disorder (aOR: 2.29), concurrent uses of systemic corticosteroids (aOR: 1.45), ephedrine (aOR: 1.45), and theophylline (aOR: 1.40), and number of emergency room visits before surgery. There was no difference in the risk of postoperative migraine between surgical patients undergoing general and neuraxial anesthesia. This study identified the risk factors for postoperative migraine headaches, which may provide an implication in facilitating early diagnoses and treatment.

Cancer Patients’ Experiences and Understanding of Venous Thromboembolism

Background: Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), presents an extra challenge in the management of patients with cancer, given the increase in morbidity and mortality in having both conditions. Cancer patients are well known to have a high risk of VTE; particularly; those who have had major surgery, chemotherapy and/or hormonal therapy. These groups of patients need to understand the risk factors and the prophylactic measures to prevent developing VTE. This review aims to provide an overview of the literature on cancer patients’ understanding of VTE and their experiences of cancer-associated thrombosis (CAT). Method: A scoping review was carried map the literature and explore the types of evidence available. A structured electronic search was conducted in Embase, Scopus and Medline in June 2020. All titles and abstracts from the search were evaluated independently by two reviewers and disagreements were resolved by a third arbitrator. Eligible papers were qualitative studies and reviews of adult patients' experience of cancer-associated thrombosis. Results: Ten articles met the inclusion criteria, nine primary qualitative studies and one systematic review that explored cancer patients’ experiences of living with CAT. Participants had various cancer types. Most had advanced disease and were receiving palliative care. Four major themes emerged from the data: Lack of meaningful information on CAT, cancer patients unaware of signs and symptoms of VTE, limited awareness of CAT amongst HCPs and acceptability of anticoagulant. Conclusion: All the studies explored patients’ experience of VTE in the cancer context, and all included studies showed that participants had limited information about VTE, VTE risk and VTEs’ signs and symptoms. However, no qualitative studies explored patients' understanding of VTE in prophylactic settings in high-risk cancer patients.