Liver Transplantation for Hepatocellular Carcinoma: How Should We Improve the Thresholds?

Hepatocellular carcinoma (HCC) is the third highest cause of cancer-related mortality, and liver transplantation is the ideal treatment for this disease. The Milan criteria provided the opportunity for HCC patients to undergo LT with favorable outcomes and have been the international gold standard and benchmark. With the accumulation of data, however, the Milan criteria are not regarded as too restrictive. After the implementation of the Milan criteria, many extended criteria have been proposed, which increases the limitations regarding the morphological tumor burden, and incorporates the tumor’s biological behavior using surrogate markers. The paradigm for the patient selection for LT appears to be shifting from morphologic criteria to a combination of biologic, histologic, and morphologic criteria, and to the establishment of a model for predicting post-transplant recurrence and outcomes. This review article aims to characterize the various patient selection criteria for LT, with reference to several surrogate markers for the biological behavior of HCC (e.g., AFP, PIVKA-II, NLR, 18F-FDG PET/CT, liquid biopsy), and the response to locoregional therapy. Furthermore, the allocation rules in each country and the present evidence on the role of down-staging large tumors are addressed.

Thrombolysis in Acute Stroke

The first step in stroke care is early detection of stroke patients and recanalization of the occluded vessel. Rapid and effective revascularization is the cornerstone of acute ischemic stroke management. Intravenous thrombolysis is the only approved pharmacological reperfusion therapy for patients with acute ischemic stroke. Patient selection criteria based on patient characteristics, time, clinical findings and advanced neuroimaging techniques have positively affected treatment outcomes. Recent studies show that the presence of salvageable brain tissue can extend the treatment window for intravenous thrombolysis and that these patients can be treated safely. Recent evidence provides stronger support for another thrombolytic agent, tenecteplase, as an alternative to alteplase. Endovascular thrombectomy is not a contraindication for intravenous thrombolysis. Evidence shows that the bridging approach provides better clinical outcomes. It is seen that intravenous thrombolysis is beneficial in stroke patients, whose symptom onset is not known, after the presence of penumbra tissue is revealed by advanced neuroimaging techniques. Reperfusion therapy with intravenous thrombolysis is beneficial in selected pregnant stroke patients. Pregnancy should not be an absolute contraindication for thrombolysis therapy. This chapter aims to review only the current evaluation of intravenous thrombolytic therapy, one of the reperfusion therapies applied in the acute phase of stroke.

Laparoscopic and open operations in the treatment of hepatic echinococcosis. Analysis of short- and long-term results

Aim: to evaluate the short- and long-term outcomes of laparoscopic and open operations in the treatment of hepatic echinococcosis.Materials and methods. The results of laparoscopic and open echinococcectomies performed from 2013 to 2020 were retrospectively studied. Laparoscopic operations were considered the method of choice. Open operations were performed in cases with contraindications to the laparoscopic approach.Results. In total, 57 patients were operated: 47 laparoscopically (including robotic approach in 4 cases), 9 patients underwent open surgery. Radical procedures prevailed among laparoscopic cystectomies: 46 (98%). In the groups of laparoscopic/open cystectomies, partial pericystectomy was performed in 1/3 of patients, subtotal – in 24/4, total – in 13/0, and liver resection – in 9/2 patients, respectively. Laparoscopic procedures were performed mainly for types 1 and 3 of cysts, open procedures – for type 2 (WHO), recurrent and extrahepatic abdominal cysts were indication for open surgery. The frequency of severe complications did not differ between the groups. In the laparoscopic group, 1 (2%) patient died. After laparoscopic cystectomies, the mean (median) hospital stay (8 vs 10 days) and duration of abdominal drainage (10 vs 12 days) were significantly shorter. Relapse occurred only after conservative cystectomies, in one patient in each group.Conclusion. Laparoscopic radical surgery for liver hydatid cysts may be the method of choice if performed in a specialized HPB center. Patient selection criteria should be based on the center's experience in laparoscopic liver surgery.

Insights from patients screened but not randomised in the HYPERION trial

Background Few data are available about outcomes of patients screened for, but not enrolled in, randomised clinical trials. Methods We retrospectively reviewed patients who had non-inclusion criteria for the HYPERION trial comparing 33 °C to 37 °C in patients comatose after cardiac arrest in non-shockable rhythm, due to any cause. A good neurological outcome was defined as a day-90 Cerebral Performance Category score of 1 or 2. Results Of the 1144 patients with non-inclusion criteria, 1130 had day-90 information and, among these, 158 (14%) had good functional outcomes, compared to 7.9% overall in the HYPERION trial (10.2% with and 5.7% without hypothermia). Considerable centre-to-centre variability was found in the proportion of non-included patients who received hypothermia (0% to 83.8%) and who had good day-90 functional outcomes (0% to 31.3%). The proportion of patients with a good day-90 functional outcome was significantly higher with than without hypothermia (18.5% vs. 11.9%, P = 0.003). Conclusion Our finding of better functional outcomes without than with inclusion in the HYPERION trial, despite most non-inclusion criteria being of adverse prognostic significance (e.g., long no-flow and low-flow times and haemodynamic instability), raises important questions about the choice of patient selection criteria and the applicability of trial results to everyday practice. At present, reserving hypothermia for patients without predictors of poor prognosis seems open to criticism.

Resuming elective orthopaedic services during the COVID-19 pandemic

Aims The aim of this study was to surveil whether the standard operating procedure created for the NHS Golden Jubilee sufficiently managed COVID-19 risk to allow safe resumption of elective orthopaedic surgery. Methods This was a prospective study of all elective orthopaedic patients within an elective unit running a green pathway at a COVID-19 light site. Rates of preoperative and 30-day postoperative COVID-19 symptoms or infection were examined for a period of 40 weeks. The unit resumed elective orthopaedic services on 29 June 2020 at a reduced capacity for a limited number of day-case procedures with strict patient selection criteria, increasing to full service on 29 August 2020 with no patient selection criteria. Results A total of 2,373 cases were planned in the 40-week study period. Surgery was cancelled in 59 cases, six (10.2%) of which were due to having a positive preoperative COVID-19 screening test result. Of the remaining 2,314, 996 (43%) were male and 1,318 (57%) were female. The median age was 67 years (interquartile range 59.2 to 74.6). The median American Society of Anesthesiologists grade was 2. Hip and knee arthroplasties accounted for the majority of the operations (76%). Six patients tested positive for COVID-19 preoperatively (0.25%) and 39 patients were tested for COVID-19 within 30 days after discharge, with only five patients testing positive (0.22%). Conclusion Through strict application of a COVID-19 green pathway, elective orthopaedic surgery could be safely delivered to a large number of patients with no selection criteria. Cite this article: Bone Jt Open 2021;2(11):951–957.

Current Management of Oligometastatic Lung Cancer and Future Perspectives: Results of Thermal Ablation as a Local Ablative Therapy

A growing body of evidence shows improved overall survival and progression-free survival after thermal ablation in non-small cell lung carcinoma (NSCLC) patients with a limited number of metastases, combined with chemotherapy or tyrosine kinase inhibitors or after local recurrence. Radiofrequency ablation and microwave ablation are the most evaluated modalities, and target tumor size <3 cm (and preferably <2 cm) is a key factor of technical success and efficacy. Although thermal ablation offers some advantages over surgery and radiotherapy in terms of repeatability, safety, and quality of life, optimal management of these patients requires a multidisciplinary approach, and further randomized controlled trials are required to help refine patient selection criteria. In this article, we present a comprehensive review of available thermal ablation modalities and recent results supporting their use in oligometastatic and oligoprogressive NSCLC disease along with their potential future implications in the emerging field of immunotherapy.

A Literature-Based Resource for the Development of Outpatient Arthroplasty Patient Selection Criteria

Total joint arthroplasty (TJA) is moving towards the outpatient setting. Teams must develop patient selection criteria to ensure appropriate candidates are treated at the optimal site of care. Protocols and recommendations have been developed to aid care teams in developing patient selection criteria, but these come from multiple disparate sources. We review the available literature on patient selection criteria and optimization in the outpatient TJA population, and synthesize this information into a workable format for care design. We hope to provide a resource to stakeholders that can be tailored to their unique outpatient facility. Keywords: Total joint arthroplasty, outpatient, same day discharge, selection criteria, patient optimization.

Incidental testicular masses and the role of organ-sparing approach

Objectives: The widespread use of ultrasonography for the investigation of common urological conditions, such as infertility or pain, has resulted in an increased incidence of incidental non-palpable testicular masses. The majority of these are expected to be benign therefore a conservative approach, either active monitoring or organsparing approach, is recommended. However, there are no clinical or radiological parameters which define the exact nature of such lesions and optimal patient selection criteria are lacking. In this comprehensive review we discuss the significance of incidental, small testicular masses (STMs) and the role of organ-sparing approach in the management of these lesions. Materials and methods: A non-systematic search was performed using PubMed to identify articles that covered the following topics; clinical implications at diagnosis, role of imaging in identifying the malignant capabilities of a lesion, role of surgery and the final pathology. Results: Incidental STMs are routinely identified following ultrasound examination of infertile men. STMs usually measure a few millimeters in size and the majority of these are benign. Therefore, strict follow up or an organ-sparing approach, with utilisation of frozen section analysis (FSA), is favored for STMs. FSA has a high correlation with final pathology and prevents unnecessary orchidectomies. Advances in imaging, namely ultrasound and magnetic resonance imaging may provide enhanced assessment of STMs and guidance intraoperatively. Conclusions: The optimal approach is not well defined and there is no specific clinical parameter that can predict the nature of STMs. The increasing incidence of small, benign testicular masses has resulted in the development of organ-sparing surgery to investigate and manage these lesions. Organ-sparing surgery has been shown to be practical and carries excellent oncological outcomes.

Mortality and risk factors associated with pulmonary embolism in coronavirus disease 2019 patients: a systematic review and meta-analysis

To determine, in patients with coronavirus disease 2019 (COVID-19) infection, the associations of pulmonary embolism (PE) with mortality and risk factors for PE as well as the therapeutic benefit of anticoagulant prophylaxis. Embase, PubMed, Cochrane controlled trials register, and Web of Science databases were searched from inception to October 10, 2020. We included all published trials on PE in patients diagnosed with COVID-19 with eligibility of the trials assessed following the PRISMA guidelines. Sixteen clinical trials with 5826 patients were eligible. There were significant associations of PE with the male gender [odd ratio (OR) = 1.59, 95% CI 1.28–1.97], mechanical ventilation (OR = 3.71, 95% CI 2.57–5.36), intensive care unit admission (OR = 2.99, 95% CI 2.11–4.23), circulating D-dimer [mean difference (MD) = 5.04 µg/mL, 95% CI 3.67–6.42) and CRP (MD = 1.97 mg/dL, 95% CI 0.58– 3.35) concentrations without significant correlation between PE and mortality (OR = 1.31, 95% CI 0.82–2.08) as well as other parameters or comorbidities. After omitting one trial with strict patient selection criteria for anticoagulant prophylaxis, significant prophylactic benefit was noted (OR = 0.31, 95% CI 0.1–0.91). Our findings identified the risk factors associated with PE in COVID-19 patients and supported the therapeutic benefit of anticoagulant prophylaxis against PE in this patient population.