Surgery:

CONCLUSIONS: This international initiative developed by surgeons and GIs together, summarizes the state of our knowledge of the use of HRM pre-ARS and post-ARS. The Padova Classification was developed to facilitate the interpretation of HRM studies of patients underwent ARS.

Advocacy, one of the five domains of global neurosurgery, represents a powerful avenue to influence public policy to expand access to safe, timely, and affordable neurosurgical care. In this manuscript, we characterize advocacy in global neurosurgery, describe specific neurosurgeon-led initiatives, and delineate how neurosurgeons can become involved in global neurosurgery advocacy efforts. Advocacy in global neurosurgery involves working together in organized neurosurgery with organizations focused on clinical provisions, training, and policy initiatives. Effective advocacy uses a data-driven approach with myriad facilitators, including collaboration and approach strategies for sharing information and a variety of contextual, ideological, and practical barriers. The main action fronts for global neurosurgery include identifying needs, broadening access, and assuring quality. Neurosurgery-led initiatives transforming public policy have occurred on regional and global scales and accelerated since 2019. Folate fortification of staple foods to prevent neural tube defects represents a recent and notably successful area of advocacy and remains in progress. Neurosurgeons who aspire to become involved in advocacy efforts must obtain competencies and skills distinct from, yet complementary to, the traditional neurosurgical training curriculum.

No abstract available

CONCLUSIONS: Among Medicare beneficiaries with degenerative mitral regurgitation, an increase in TEER utilization was associated with worse survival, increased heart failure readmissions, and more mitral reinterventions. Randomized trials are needed to better inform treatment choice.

CONCLUSIONS: RLT is a promising technique to further reduce the impact of liver transplantation thanks to smaller incision, gentle tissue manipulation, high magnification and precision for vascular and biliary anastomosis, and reduced postoperative pain. This is the first step toward the demonstration of the feasibility of minimally invasive surgery in liver transplantation, although further selection and technical refinements are needed to improve reproducibility.

CONCLUSIONS: The ROBOT4HPB consensus represents a collaborative and multidisciplinary initiative, defining state-of-the-art expertise in HPB robotics procedures. It produced the first guidelines to encourage their safe use and promotion.

Patients with cirrhosis-associated and portal hypertension-associated complications may benefit from TIPS and/or liver transplantation. In many patients, the decision of whether or not TIPS should be placed prior to liver transplantation is fairly clear-cut. Nevertheless, there are some patients in whom the decision can be more complex. On one hand, TIPS is easily available in contrast to liver transplantation, and patients with TIPS may have clinical improvement. On the other hand, although TIPS may improve the situation of the patient, this improvement may not be sufficient to significantly improve the quality of life. Furthermore, TIPS malposition may be challenging for liver transplantation surgery. This review approaches the advantages and disadvantages of TIPS placement in patients who are candidates for liver transplantation and proposes decision pathways for patients with complications of portal hypertension on the liver transplant waiting list.

Anterior cruciate ligament reconstruction is one of the most common orthopaedic sports medicine surgeries. Its prevalence in the sports medicine sphere is matched by the numerous options of different techniques. Chief among these is graft selection, which most commonly falls into 1 of 4 options: bone-patellar tendon-bone (BPTB) autograft, hamstring tendon autograft (HT), quadriceps tendon autograft, and allografts. The most frequently used allografts include BPTB, HT, tibialis anterior or posterior tendon, and Achilles tendon. Each graft option possesses unique advantages and disadvantages. BPTB autograft demonstrates the fastest incorporation via bone-to-bone healing. It also yields a lower revision rate and greater return-to-sport rate compared with HT. However, because of donor-site morbidity, anterior knee pain and kneeling pain can occur. There is also a small risk of patellar fracture as well as patellar tendon rupture. HT autograft requires a smaller incision than BPTB and preserves the extensor mechanism. Patients are at risk for knee flexion weakness, saphenous nerve injury, and potential graft loosening over time secondary to bone tunnel widening. Quadriceps tendon autograft may be harvested with minimally invasive techniques. As with HT, the all soft-tissue composition allows use in skeletally immature patients. Although early studies show promise, knee extension weakness has been documented, and long-term outcomes are less clear. Allograft possesses no donor-site morbidity and reduced surgical time; however, allografts are associated with the greatest failure rate in young athletes and a lower return-to-sport rate compared with autografts. They also incur a greater financial cost than autografts. To be proficient at performing anterior cruciate ligament reconstruction, it is important that the sports medicine surgeon be well versed in the various graft options and the ideal patient populations for whom they are best used.

CONCLUSIONS: Esophagectomy was associated with improved survival for cT1bN0 esophageal cancer; however, endoscopic treatment may achieve similar survival in patients with favorable tumor attributes. Further study is warranted.

Abstract: Microvascular inflammation (MVI) is a key diagnostic feature of antibody-mediated rejection (AMR); however, recipients without donor-specific antibodies (DSA) defy etiologic classification using C4d staining of peritubular capillaries (C4d) and conventional DSA assignment. We evaluated MVI ≥ 2 (Banff g + ptc ≥ 2) using Banff 2019 AMR (independent of MVI ≥ 2 but including C4d) with unconventional endothelial C4d staining of glomerular capillaries (C4d) and - arterial endothelium and/or intima (C4d) using tissue immunoperoxidase, shared-eplet and subthreshold DSA (median fluorescence intensity, [MFI] 100-499), and capillary ultrastructure from 3398 kidney transplant samples for evidence of AMR. MVI ≥ 2 (n = 202 biopsies) from 149 kidneys (12.4% prevalence) correlated with DSA+, C4d+, C4d+, Banff cg, i, t, ti scores, serum creatinine, proteinuria, and graft failure compared with 202 propensity score matched normal controls. The laboratory reported DSA- MVI ≥ 2 (MFI ≥500) occurred in 34.7%; however, subthreshold (28.6%), eplet-directed (51.4%), and/or misclassified anti-Human leukocyte antigen (HLA) DSA (12.9%) were identified in 67.1% by forensic reanalysis, with vascular C4d+ staining in 67.1%, and endothelial abnormalities in 57.1%, totaling 87.1%. Etiologic analysis attributed 62.9% to AMR (77.8% for MVI with negative reported DSA [DSA- MVI ≥2] with glomerulitis) and pure T cellular rejection in 37.1%. C4d-DSA- MVI ≥ 2 was unrecognized AMR in 48.0%. Functional outcomes and graft survival were comparable to normal controls. We concluded that DSA- MVI ≥ 2 frequently signified a mild "borderline" phenotype of AMR which was recognizable using novel serologic and pathological techniques.

Moral injury in health care is characterized as the lasting psychological, biological, and social impact on providers that occurs following an adverse patient outcome. Moral injury can contribute to second victim syndrome and lasting psychological harm. Although many surgeons face moral injury due to patient acuity and the potential for intraoperative or postoperative complications, the transplant ecosystem compounds the impact of moral injury. Institutional blame placed on the transplant surgeon following a posttransplant death or graft loss is magnified by public reporting. Centers whose outcomes fall below threshold levels are subject to regulatory citation and financial loss. Moral injury can also result in risk aversion, limiting access to transplants for higher-risk candidates and reducing acceptance of marginal organs hurting donor families. Strategies to increase resilience, reduce accusation and blame, and focus on system quality improvement are vital to mitigate the impact of moral injury on transplant professionals. The transplant community must proactively work to reduce moral injury to protect surgeons, ensure access to life-saving transplant procedures, and avoid unnecessary organ offer declines.

CONCLUSIONS: Advances in technology-based assessment, data analytics, and behavioral analysis now allow us to create personalized educational programs based on individual preferences and learning styles. If implemented properly, education technology has the promise of improving the quality and efficiency of surgical education and decreasing the demands on clinical faculty.

BACKGROUND AND OBJECTIVES: Assessment of postoperative outcomes on pediatric hydrocephalus is critical for adjusting treatment strategies. The aim of this work was to investigate the ability of MRI metrics to predict postoperative outcomes.

Despite increasing therapeutic options and evolving treatment strategies, including targeting 3 therapeutic pathways, in the management of pulmonary arterial hypertension (PAH), morbidity and mortality have remained unacceptably high. Sotatercept is a first-in-class, novel activin signaling inhibitor approved for treating PAH based on evolving efficacy and safety evidence. This state-of-the-art review summarizes the current understanding of the mechanism of action, the impact on outcomes that improve how patients feel, function, and survive, and the safety and adverse event profile to inform readers of this breakthrough novel therapy.

CONCLUSIONS: PE has engaged in substantial investment within surgical specialties, creating increased practice consolidation. These investments affect all levels of medical care and have notable implications for patients, practitioners, and policymakers.

The requirements for eligibility and monitoring before and after liver transplantation for alcohol-associated liver disease (ALD) and metabolic dysfunction-associated steatotic liver disease (MASLD) are different and not as well defined for MASLD as they are for ALD. Two groups of patients with ALD considered for liver transplant (LT) include those with decompensated cirrhosis from alcohol and those with severe alcohol-associated hepatitis. Both groups are required to commit to lifelong abstinence from alcohol. Pretransplant eligibility criteria for LT in those with ALD varies between transplant centers, but generally, a period of alcohol abstinence with or without counseling is required to be considered for an LT, or the candidate must meet specific requirements. In contrast to ALD, the pre-LT requirements for patients with MASLD, such as weight loss goals or control of metabolic diseases, are not as well defined. Reviews and consensus statements on MASLD and LT discuss risk stratification and management for conditions associated with MASLD, but there are no consensus recommendations regarding obesity and metabolic disease goals before and after transplant. Candidates and recipients of LT may be held to more stringent requirements and monitoring for alcohol use compared to weight loss goals and metabolic parameters advised for patients with MASLD. Because of the disparities in requirements between ALD and MASLD, consensus recommendations should be developed for pre-LT and post-LT monitoring and requirements for candidates and recipients with MASLD.

The emerging field of cancer neuroscience reshapes our understanding of the intricate relationship between the nervous system and cancer biology; this new paradigm is likely to fundamentally change and advance neuro-oncological care. The profound interplay between cancers and the nervous system is reciprocal: Cancer growth can be induced and regulated by the nervous system; conversely, tumors can themselves alter the nervous system. Such crosstalk between cancer cells and the nervous system is evident in both the peripheral and central nervous systems. Recent advances have uncovered numerous direct neuron-cancer interactions at glioma-neuronal synapses, paracrine mechanisms within the tumor microenvironment, and indirect neuroimmune interactions. Neurosurgeons have historically played a central role in neuro-oncological care, and as the field of cancer neuroscience is becoming increasingly established, the role of neurosurgical intervention is becoming clearer. Examples include peripheral denervation procedures, delineation of neuron-glioma networks, development of neuroprostheses, neuromodulatory procedures, and advanced local delivery systems. The present review seeks to highlight key cancer neuroscience mechanisms with neurosurgical implications and outline the future role of neurosurgical intervention in cancer neuroscience.

CONCLUSIONS: The case volume of recurrent dissection or the ability to detect recurrent dissection has increased over time. Acute type A recurrent dissection was associated with a higher risk of major aortic events than initial dissection. Further judicious follow-up may be crucial after type A recurrent dissection.

No abstract available

Trafficking in human organs, cells, and tissues has long been a source of concern for health authorities and professionals, and several international ethical guidance documents and national laws have affirmed the prohibition of trade in these substances of human origin (SoHOs). However, despite considerable attention to the issue of organ trafficking, this remains a substantial and widespread problem internationally. In contrast, trafficking in cells, tissues, and medical products derived from SoHOs has received comparatively little attention, and the extent and nature of such trafficking remain largely unknown. Consequently, as part of the 2023 Global Summit on Convergence in Transplantation held in Santander, Spain, an ethics working group was assigned the task of formulating actionable recommendations to support the prevention of trafficking in all SoHOs. In reporting on this work, we review factors that may influence the persistent trafficking of SoHOs, explore the potential difficulties associated with the collection and reporting of data about suspected trafficking activities, and argue that more practical and consistent guidance, training, and regulatory frameworks are needed internationally to support effective reporting, sharing of data, and collaborative responses to suspected trafficking cases. We also discuss the importance of psychosocial evaluation of living donors as a strategy to detect and prevent organ trafficking and strive to advance the implementation of this well-established recommendation by outlining minimum standards for psychosocial evaluation of living donors.