Blood loss during liver transplantation (OLTx) is a common consequence of pre-existing abnormalities of the hemostatic system,portal hypertension with multiple collateral vessels,portal vein thrombosis,previous abdomi...Blood loss during liver transplantation (OLTx) is a common consequence of pre-existing abnormalities of the hemostatic system,portal hypertension with multiple collateral vessels,portal vein thrombosis,previous abdominal surgery,splenomegaly,and poor "functional" recovery of the new liver.The intrinsic coagulopathic features of end stage cirrhosis along with surgical technical difficulties make transfusion-free liver transplantation a major challenge,and,despite the improvements in understanding of intraoperative coagulation profiles and strategies to control blood loss,the requirements for blood or blood products remains high.The impact of blood transfusion has been shown to be significant and independent of other well-known predictors of posttransplant-outcome.Negative effects on immunomodulation and an increased risk of postoperative complications and mortality have been repeatedly demonstrated.Isovolemic hemodilution,the extensive utilization of thromboelastogram and the use of autotransfusion devices are among the commonly adopted procedures to limit the amount of blood transfusion.The use of intraoperative blood salvage and autologous blood transfusion should still be considered an important method to reduce the need for allogenic blood and the associated complications.In this article we report on the common preoperative and intraoperative factors contributing to blood loss,intraoperative transfusion practices,anesthesiologic and surgical strategies to prevent blood loss,and on intraoperative blood salvaging techniques and autologous blood transfusion.Even though the advances in surgical technique and anesthetic management,as well as a better understanding of the risk factors,have resulted in a steady decrease in intraoperative bleeding,most patients still bleed extensively.Blood transfusion therapy is still a critical feature during OLTx and various studies have shown a large variability in the use of blood products among different centers and even among individual anesthesiologists within the same center.Unfortunately,despite the large number of OLTx performed each year,there is still paucity of large randomized,multicentre,and controlled studies which indicate how to prevent bleeding,the transfusion needs and thresholds,and the "evidence based" perioperative strategies to reduce the amount of transfusion.展开更多
Shipwreck salvage is a risky,time-consuming,and expensive process.Although there are many sunken ships along coastlines and in the open seas,the salvage process of a sunken ship has rarely been reported.The integrated...Shipwreck salvage is a risky,time-consuming,and expensive process.Although there are many sunken ships along coastlines and in the open seas,the salvage process of a sunken ship has rarely been reported.The integrated salvage of the"Yangtze River EstuaryⅡ"shipwreck used a novel method with 22 closely locked curved rectangular pipes to form a watertight base that wrapped the shipwreck inside.The basing was lifted out of the water using a powerful crane situated on an engineering ship.For the first time,the tunneling method was used in a shipwreck salvage project,significantly reducing the disturbance to the shipwreck and its stowage,thereby preserving the original state and integrity of the shipwreck to the greatest extent.In this study,the basic concepts of the salvage method and process are explained.Solutions to critical issues in the new salvage method are provided,including jacking force prediction and major considerations for the structural design of the salvage system.The design of the salvage system and salvage process of the"Yangtze River EstuaryⅡ"shipwreck are introduced.The monitored jacking force,pipe deformation,and observed water-tightness verified that the proposed method was effective and efficient.Other possible application scenarios for the proposed method are presented at the end.展开更多
When microdissection testicular sperm extraction(micro-TESE)fails,a redo procedure may be the only option for patients who want a biological child.However,there are many gaps of knowledge surrounding the procedure,whi...When microdissection testicular sperm extraction(micro-TESE)fails,a redo procedure may be the only option for patients who want a biological child.However,there are many gaps of knowledge surrounding the procedure,which need to be addressed to help clinicians and patients make informed decisions.This review explores redo micro-TESE in the context of nonobstructive azoospermia(NOA).Literature was searched using Google Scholar,Medline,and PubMed.Search terms were“NOA”AND“second microdissection testicular sperm extractions”AND“redo microdissection testicles sperm extraction”AND“repeat microdissection testicular sperm extractions”AND“failed microdissection testicular sperm extractions”AND“salvage microdissection testicular sperm extractions”.Only original articles in English were included.A total of nine articles were included,consisting of four retrospective and five prospective studies.The time gap between the first and second micro-TESE varied from 6 months to 24 months.Most of the included studies reported successful surgical sperm retrieval(SSR)in the second micro-TESE in the range of 10%–21%,except in one study where it reached 42%.It has not been presented any definitive information about the use of hormonal treatment or the benefit of varicocelectomy prior to the second micro-TESE.Patients with hypospermatogenesis and Klinefelter syndrome(KS)had the highest chance of success in redo surgery.In conclusion,redo micro-TESE following a negative procedure can lead to sperm recovery in 10%–21%.Patients with hypospermatogenesis and KS have a higher chance of success.There is no enough evidence to conclude which is the best hormonal stimulation if any before a redo surgery.展开更多
Commercially managed forests are often poor in terms of biodiversity.Saproxylic beetle species could be a useful bioindicating group for the conservation of forest stands.In recent decades,oak stands have been affecte...Commercially managed forests are often poor in terms of biodiversity.Saproxylic beetle species could be a useful bioindicating group for the conservation of forest stands.In recent decades,oak stands have been affected by a wide range of factors that have intensified stand decline.Saproxylic beetle richness was investigated in declining oak stands that have been consequently targeted for clearcutting due to concerns about insect pest outbreaks.The research was conducted at six managed oak forests,where we compared beetle occurrences in declining stands and in healthy stands that did not show any symptoms of decline.Beetles were collected using window traps placed on the basal and mid-trunk sections of trees.A total of 2925 adults belonging to 239 saproxylic beetle species were captured,of which 56 species are on the IUCN Red List.The results show that declining stands were richer in saproxylic species,and that the diversity of beetle species was greater in these stands.Approximately 1.4 times more species were caught within declining stands than in healthy ones(1.6 times for Red List species).Declining stands hosted more pest species(e.g.,cambiophagous and xylophagous species).However,only low numbers of these species were recorded in these stands.In summary,results of this study suggest that decline of managed oak stands is creating a wide spectrum of habitats for many saproxylic species.Thus,salvage logging of declining oak trees can represent a natural trap and reduce local beetle biodiversity,mainly for saproxylic,endangered or low-mobility species that would be attracted by new suitable habitats.展开更多
BACKGROUND Salvage surgery following conversion therapy[transcatheter arterial chemoembolization(TACE)combined with tyrosine kinase inhibitors(TKIs)and anti-programmed cell death protein 1(PD-1)antibodies]provides a c...BACKGROUND Salvage surgery following conversion therapy[transcatheter arterial chemoembolization(TACE)combined with tyrosine kinase inhibitors(TKIs)and anti-programmed cell death protein 1(PD-1)antibodies]provides a chance for a cure in patients with unresectable hepatocellular carcinoma(uHCC).AIM To primarily analyze the efficacy and safety of salvage surgery in patients initially diagnosed with uHCC who underwent conversion therapy.METHODS We retrospectively collected data from patients at the First Affiliated Hospital of the University of Science and Technology of China(Anhui Provincial Hospital)who met the study criteria.These patients were initially diagnosed with uHCC and received TACE combined with TKIs and anti-PD-1 antibodies as conversion therapy.The main endpoints studied were the safety of salvage surgery,overall survival(OS),and recurrence-free survival(RFS)after surgery.Secondary endpoints included postoperative complications.We performed univariate and multivariate Cox regression analyses to identify independent risk factors for postoperative RFS.RESULTS A total of 117 patients were enrolled in this study,including 28 patients(23.9%)who underwent curative surgery after triplet therapy conversion treatment.Among the 28 patients who underwent salvage surgery,the 1-year and 2-year RFS rates were 75.0%and 59.4%,respectively,and the 1-year and 2-year OS rates were 92.7%and 87.6%,respectively.The median follow-up time after surgery was 15.0 months(range:1.6-37.2 months),with median OS and RFS not yet reached.Pathological complete response was achieved in 14 cases(50.0%),and postoperative complications occurred in 20 patients(71.4%).Univariate and multivariate Cox regression analyses indicated that pathological complete response and preoperative albumin levels were risk factors for postoperative RFS.CONCLUSION Salvage surgery following conversion therapy with TACE combined with TKIs and anti-PD-1 antibodies appears to be an effective and safe treatment option for patients with uHCC.It extends OS and may offer additional potential benefits to uHCC patients.展开更多
BACKGROUND Esophageal squamous cell carcinoma(ESCC)is often managed with surgery,which is the first-line treatment option for stage I–III lesions.However,definitive chemoradiotherapy(dCRT)is associated with a recurre...BACKGROUND Esophageal squamous cell carcinoma(ESCC)is often managed with surgery,which is the first-line treatment option for stage I–III lesions.However,definitive chemoradiotherapy(dCRT)is associated with a recurrence rate of 30%in stage I ESCC and higher rates in advanced-staged lesions.However,several patients prefer dCRT because their general condition is poor.Salvage therapies,including esophagectomy and endoscopic resection[endoscopic submucosal dissection(ESD)/endoscopic mucosal resection],are important for residual or recurrent tumors that develop after dCRT.Esophagectomy can have curative potential.However,it has high complication and mortality rates.Therefore,ESD is a safer alternative.CASE SUMMARY A Japanese man in his 70s was concurrently diagnosed with right hypopha-ryngeal cancer(T2N1M0,cStage III),left oropharyngeal cancer(T1N0M0,cStage I),and left hard palate cancer(T1N0M0,cStage I).Esophagogastroduodenoscopy(EGD)revealed a 20 mm reddish 0-Is+IIb lesion in the upper thoracic esophagus,with an invasion depth of SM2.The lesion was diagnosed as an esophageal mo-derately differentiated squamous cell carcinoma(T1bN0M0,cStage I).As the pharyngeal cancers were in advanced stages,chemoradiotherapy(docetaxel and cisplatin with a radiation dose of 66 Gy)was prioritized.Post-chemoradiotherapy EGD showed that the lesion had flattened into a 0-IIb lesion,thereby indicating a reduced invasion depth(epi-thelium or lamina propria mucosa).ESD achieved en bloc and histologically confirmed curative resection.At 22 months after ESD,the patient did not present with signs of recurrence.CONCLUSION This case emphasizes that ESD can be successfully utilized as a salvage treatment for ESCC after chemoradio-therapy for otolaryngological cancers.展开更多
Prostate cancer is the most common non-cutaneous cancers occurring in American men,and whilemost men with early-stage prostate cancers are cured,up to a third might manifest with biochemical recurrence(BCR)of prostate...Prostate cancer is the most common non-cutaneous cancers occurring in American men,and whilemost men with early-stage prostate cancers are cured,up to a third might manifest with biochemical recurrence(BCR)of prostate cancer.BCR is a disease entitywhich is characterized by a rising prostate-specific antigen(PSA)in the setting of a previously treated localized prostate cancerwith either surgery or radiation therapywith curativeintent.展开更多
Esophageal diverticulum can be broadly classified into three main types:Phar-yngoesophageal diverticulum located near the upper esophageal sphincter(including Zenker’s diverticulum,Killian-Jamieson diverticulum,and L...Esophageal diverticulum can be broadly classified into three main types:Phar-yngoesophageal diverticulum located near the upper esophageal sphincter(including Zenker’s diverticulum,Killian-Jamieson diverticulum,and Laimer’s diverticulum);Mid-esophageal diverticulum,and epiphrenic diverticulum loca-ted just above the lower esophageal sphincter.Most asymptomatic esophageal diverticulum are incidentally detected during routine imaging studies,such as barium swallow,computed tomography scans,or esophagogastroduodenoscopy.For these patients,regular follow-up is typically sufficient.However,a small subset may experience persistent symptoms such as dysphagia and acid reflux.Patients with symptomatic diverticulum should be assessed for the potential need for surgical intervention to prevent serious complications,including aspiration pneumonia and malnutrition.The treatment options for symptomatic esophageal diverticulum encompass both endoscopic and surgical approaches.Due to the technical complexity and significant risks associated with surgical intervention,endoscopic treatment has gained increasing preference,achieving remarkable results with the advancements in endoscopic instruments and techniques.Given the anatomical location and pathophysiological differences among esophageal diverticulum,a personalized endoscopic strategy is essential to achieve optimal results.This review provides an overview of the characteristics of esophageal diverticulum and offers a comprehensive discussion of diverticular peroral endoscopic myotomy and its related variations as the primary endoscopic treat-ment strategy.展开更多
Background:Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality. While liver transplantation (LT) provides the best long-term survival, it is constrained by organ scarcity and strict criteria....Background:Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality. While liver transplantation (LT) provides the best long-term survival, it is constrained by organ scarcity and strict criteria. Liver resection (LR) is often the initial treatment for patients with solitary tumors and preserved liver function. The high recurrence rates associated with LR has prompted the exploration of sequential living donor liver transplantation (seq LDLT) after LR as a strategy for HCC patients with high-risk of recurrence.Methods:We analyzed data from 27 adult patients who underwent seq LDLT after LR for HCC at Kaohsiung Chang Gung Memorial Hospital (KCGMH) between June 1994 and December 2023. Patients were selected based on high-risk histopathological features post-LR or as part of downstaging strategy. Outcomes measured included overall survival (OS) and disease-free survival (DFS).Results:Among 765 HCC patients who underwent LDLT, 204 received LR before LDLT, and 27 underwent seqL DLT. Five patients (19%) underwent living donor liver transplantation (LDLT) following LR as a downstaging strategy while the rest received seqL DLT as a preemptive strategy. The median age was 53.5 years with 85%males. Chronic hepatitis B was the predominant underlying disease (74%). The 1-, 3-, and 5-year OS and DFS rates were 100%, 96.0%, 96.0%and 100%, 96.2%, 96.2%, respectively, with two patients experiencing HCC recurrence. One patient died from HCC recurrence. High-risk histopathological features included microvascular invasion (52%), satellite nodules (15%), multiple tumors (26%), tumors> 5 cm(19%), and a total tumor diameter> 10 cm (7%).Conclusions:Seq LDLT offers a promising, tailored approach for managing HCC with adverse histopathologic features. Combining seq LDLT, downstaging strategies, and multidisciplinary treatments can achieve satisfactory OS and DFS in carefully selected patients, highlighting the need for refined criteria to identify the best candidates.展开更多
AIM: There are limited reports in the United States demonstrating outcomes of primarily thinned fasciocutaneous flaps in the setting of critical limb ischemia, Charcot collapse and osteomyelitis. We hope to determine ...AIM: There are limited reports in the United States demonstrating outcomes of primarily thinned fasciocutaneous flaps in the setting of critical limb ischemia, Charcot collapse and osteomyelitis. We hope to determine patient and flap related outcomes in advanced lower extremity disease. Methods: The authors conducted a retrospective review of fasciocutaneous free flaps of variable thickness for lower extremity salvage. Osteomyelitis and non-osteomyelitis patients were compared according to our primary outcome measures: functional ambulation, bone healing and complications to flap and patient. Subgroups with critical limb ischemia, Charcot collapse and diabetic foot were analyzed separately. Results: Fifty-nine patients underwent free flap reconstruction: osteomyelitis (n = 20, 34%), Charcot collapse (n = 22, 37%), and/or critical limb ischemia (n = 12, 20%). All patients underwent anterolateral thigh flaps tailored for defect-specific thicknesses: 17 superthin, 25 suprafascial, 17 subfascial. There were no significant differences between groups in terms of partial and complete flap loss (P = 1.000 and P = 0.108). Ninety-one percent of patients were ambulatory at follow up. Eighty-tive percent of individuals with osteomyelitis cleared their infection demonstrating radiographic bone healing. Two patients developed recalcitrant deep space infections ultimately requiring amputation. Subgroup analysis did not show any differences in flap related complications within the diabetic Charcot population. In multivariate regression, preoperative revascularization was independently associated with failure of limb salvage. ;Conclusion: Primarily thinned perforator flaps performed well in the setting of lower extremity limb salvage, critical limbischemia, osteomyelitis, and the Charcot foot - expanding their role in the armamentarium for lower extremity care.展开更多
It is important for surgeons performing sarcoma surgery to know that bone resection and tumor prosthesis applications in soft tissue sarcomas(STS)have unique features in terms of indication,surgical approach and follo...It is important for surgeons performing sarcoma surgery to know that bone resection and tumor prosthesis applications in soft tissue sarcomas(STS)have unique features in terms of indication,surgical approach and follow-up,in terms of the management of these cases.Some STS are associated with bone and major neurovascular structures.Bone-associated STS are generally relatively large and relatively deep-seated.Additionally,the tendency for metastasis is high.In some cases,the decision about which structures to resect is difficult.These cases are often accompanied by poor oncological and surgical outcomes.Management of cases should be done by a multidisciplinary team in advanced centers specialized in this field.The surgical team must have sufficient knowledge and experience in the field of limb-sparing surgery.Preoperative evaluation and especially good planning of bone and soft tissue reconstruction are vital.展开更多
BACKGROUND Testicular torsion is the most common acute scrotum worldwide and mainly occurs in children and adolescents.Studies have demonstrated that the duration of symptoms and torsion grade lead to different outcom...BACKGROUND Testicular torsion is the most common acute scrotum worldwide and mainly occurs in children and adolescents.Studies have demonstrated that the duration of symptoms and torsion grade lead to different outcomes in children diagnosed with testicular torsion.AIM To predict the possibility of testicular salvage(TS)in patients with testicular torsion in a tertiary center.METHODS We reviewed the charts of 75 pediatric patients with acute testicular torsion during a 12-year period from November 2011 to July 2023 at the Suzhou Hospital of Anhui Medical University.Univariate and multivariate logistic regression analyses were used to determine independent predictors of testicular torsion.The data included clinical findings,physical examinations,laboratory data,color Doppler ultrasound findings,operating results,age,presenting institution status,and follow-up results.RESULTS Our study included 75 patients.TS was possible in 57.3%of all patients;testicular torsion occurred mostly in winter,and teenagers aged 11-15 years old accounted for 60%.Univariate logistic regression analyses revealed that younger age(P=0.09),body mass index(P=0.004),torsion angle(P=0.013),red blood cell count(P=0.03),neutrophil-to-lymphocyte ratio(P=0.009),and initial presenting institution(P<0.001)were associated with orchiectomy.In multivariate analysis,only the initial presenting institution predicted TS(P<0.05).CONCLUSION The initial presenting institution has a predictive value for predicting TS in patients with testicular torsion.Children with scrotal pain should be admitted to a tertiary hospital as soon as possible.展开更多
Approximately 45 percent of malignant bone tumors are seen under the age of 16 and one of the important results of growth plate sacrification in patients with immature skeletons is limb inequality.Until the early 1990...Approximately 45 percent of malignant bone tumors are seen under the age of 16 and one of the important results of growth plate sacrification in patients with immature skeletons is limb inequality.Until the early 1990s,the treatment options for these patients were rotationplasty or amputation.Multimodal approaches that combine imaging,chemotherapy,and surgical techniques have enabled the development of limb-preserving methods with satisfactory results.In order to overcome inequality problems,expandable prostheses have been developed in the 1980s.Extendable endoprosthesis replacements have been improved over the years and are now an established and safe alternative.Noninvasive prostheses appear to be advantageous compared to minimally invasive expandable prostheses that require multiple surgical procedures,but the complication rate remains high.Therefore,although expandable prostheses are not the definitive answer to the treatment of bone sarcomas in skeletally immature children,they are still a suitable interim choice until full adulthood is achieved.Due to reported high complication rates,the procedures require significant experience and are recommended for use only in specialized cancer centers.展开更多
After Hurricane Katrina in 2005,literary works related to such a crisis sprouted the southern America,which are known as Post-Katrina Literature.This thesis,taking Salvage the Bones and The Not Yet as examples,scrutin...After Hurricane Katrina in 2005,literary works related to such a crisis sprouted the southern America,which are known as Post-Katrina Literature.This thesis,taking Salvage the Bones and The Not Yet as examples,scrutinizes how writers respond to the Post-Katrina environmental crisis in different ways.In Salvage the Bones,Jesmyn Ward employs a biographical genre to record the Katrina disaster,thereby,writings serving as a way of healing the psychic trauma of the writer herself;and in The Not Yet,Moira Crone presents a post-natural world by the employment of the Cli-Fi genre.Both writers enrich the tradition of Southern literature as well as American eco-literature.展开更多
Limb salvage after devastating traumatic injuries, cancer extirpation, and intrinsic disease is a complex decision-making process. Although several scoring and evaluation tools have been created to attempt to apply al...Limb salvage after devastating traumatic injuries, cancer extirpation, and intrinsic disease is a complex decision-making process. Although several scoring and evaluation tools have been created to attempt to apply algorithmic decision-making to the process, thoughtful clinical decision-making remains the most important standard. When limb salvage is deemed appropriate, selection of a tissue flap for limb reconstruction is dependent on the size and location of the defect, patient comorbidities, nicotine dependence, mechanism of injury to the limb, patient lifestyle, occupation, and ambulatory status. This case involves a male trauma patient with significant comorbidities and a large lower extremity wound requiring multiple operations to attempt limb reconstruction with a rectus abdominis free flap. This patient’s complex injury and comorbidities made the risk of flap failure high, illustrating that the importance of patient- and case-specific factors cannot be overstated when planning for a limb reconstruction. This extreme resort of limb reconstruction, where limb loss is the only other option and a likely consequence of even heroic efforts, is aptly called “limb salvage”.展开更多
BACKGROUND Congenital short bowel syndrome(SBS)associated with malrotation,gut volvulus and jejuno-ileal atresia is a very rare condition.It is a severe challenge for surgeons to preserve residual ischemic bowel segme...BACKGROUND Congenital short bowel syndrome(SBS)associated with malrotation,gut volvulus and jejuno-ileal atresia is a very rare condition.It is a severe challenge for surgeons to preserve residual ischemic bowel segment in the management of short bowel syndrome,especially in neonates.CASE SUMMARY We report a newborn baby with gut malrotation associated with jejuno-ileal atresia,congenital SBS and jejunal volvulus.Hematemesis and abdominal distention were noted.At laparotomy,malrotation associated with jejuno-ileal atresia,congenital SBS and jenunal volvulus was confirmed.The total length of the small bowel was 63 cm with proximal jejunal bowel segment measuring 38 cm,including 18 cm necrotic segment below the Treitz’s ligament and 20 cm severe ischemic segment.The distal part of the small bowel was 25 cm in length and only about 0.8 cm in diameter.Ladd’s procedure,necrotic segment resection and end-to-back duodeno-ileal anastomosis were performed.The residual severe ischemic jejunum was preserved with single proximal stoma and distal end closure.Three months later,to restore the continuity of the isolated gut segment,end-to-end duodeno-jejunal and jejuno-ileal anastomosis was performed.The entire functional small bowel length increased to 80 cm.Intravenous fluid therapy and parenteral nutrition were discontinued on the 10th day postoperatively.Twelve months later,her body weight was 9.5 kg.CONCLUSION Isolation of severe ischemic bowel segment and staged anastomosis to restore the gut continuity for infants with SBS are safe and feasible.展开更多
Living in modern world,the civilization is highly developed.Human beings are living an unprecedented prosperous life,but the spiritual waste land is still invisibly existed.Highly mechanism alienates people even more ...Living in modern world,the civilization is highly developed.Human beings are living an unprecedented prosperous life,but the spiritual waste land is still invisibly existed.Highly mechanism alienates people even more serious than what it is in the Waste Land.So the fighting against the Waste land to salvage it as well as ourselves is endless and circulatory.The Waste Land thus is not decaying and hopeless,but natural and common as at any time.Moreover,the new conditions of life required“a new discipline of suffering”.So we should do as the poet does:accept reality,positively indulge in it to feel and experience fully,to suffer it.Then we will feel that The Waste Land brings us not a melancholy mood,but a positive encouragement for the salvage of ourselves.展开更多
There is wide variation in the management of coagulation and blood transfusion practice in liver transplantation. The use of blood products intraoperatively is declining and transfusion free transplantations take plac...There is wide variation in the management of coagulation and blood transfusion practice in liver transplantation. The use of blood products intraoperatively is declining and transfusion free transplantations take place ever more frequently. Allogenic blood products have been shown to increase morbidity and mortality. Primary haemostasis, coagulation and fibrinolysis are altered by liver disease. This, combined with intraoperative disturbances of coagulation, increases the risk of bleeding. Meanwhile, the rebalancing of coagulation homeostasis can put patients at risk of hypercoagulability and thrombosis. The application of the principles of patient blood management to transplantation can reduce the risk of transfusion. This includes: preoperative recognition and treatment of anaemia, reduction of perioperative blood loss and the use of restrictive haemoglobin based transfusion triggers. The use of point of care coagulation monitoring using whole blood viscoelastic testing provides a picture of the complete coagulation process by which to guide and direct coagulation management. Pharmacological methods to reduce blood loss include the use of anti-fibrinolytic drugs to reduce fibrinolysis, and rarely, the use of recombinant factor VIIa. Factor concentrates are increasingly used; fibrinogen concentrates to improve clot strength and stability, and prothrombin complex concentrates to improve thrombin generation. Non-pharmacological methods to reduce blood loss include surgical utilisation of the piggyback technique and maintenance of a low central venous pressure. The use of intraoperative cell salvage and normovolaemic haemodilution reduces allogenic blood transfusion. Further research into methods of decreasing blood loss and alternatives to blood transfusion remains necessary to continue to improve outcomes after transplantation.展开更多
文摘Blood loss during liver transplantation (OLTx) is a common consequence of pre-existing abnormalities of the hemostatic system,portal hypertension with multiple collateral vessels,portal vein thrombosis,previous abdominal surgery,splenomegaly,and poor "functional" recovery of the new liver.The intrinsic coagulopathic features of end stage cirrhosis along with surgical technical difficulties make transfusion-free liver transplantation a major challenge,and,despite the improvements in understanding of intraoperative coagulation profiles and strategies to control blood loss,the requirements for blood or blood products remains high.The impact of blood transfusion has been shown to be significant and independent of other well-known predictors of posttransplant-outcome.Negative effects on immunomodulation and an increased risk of postoperative complications and mortality have been repeatedly demonstrated.Isovolemic hemodilution,the extensive utilization of thromboelastogram and the use of autotransfusion devices are among the commonly adopted procedures to limit the amount of blood transfusion.The use of intraoperative blood salvage and autologous blood transfusion should still be considered an important method to reduce the need for allogenic blood and the associated complications.In this article we report on the common preoperative and intraoperative factors contributing to blood loss,intraoperative transfusion practices,anesthesiologic and surgical strategies to prevent blood loss,and on intraoperative blood salvaging techniques and autologous blood transfusion.Even though the advances in surgical technique and anesthetic management,as well as a better understanding of the risk factors,have resulted in a steady decrease in intraoperative bleeding,most patients still bleed extensively.Blood transfusion therapy is still a critical feature during OLTx and various studies have shown a large variability in the use of blood products among different centers and even among individual anesthesiologists within the same center.Unfortunately,despite the large number of OLTx performed each year,there is still paucity of large randomized,multicentre,and controlled studies which indicate how to prevent bleeding,the transfusion needs and thresholds,and the "evidence based" perioperative strategies to reduce the amount of transfusion.
基金supported by Science and Technology Innovation Action Plan(Grant Nos.21DZ1201103 and 21DZ1201104)the National Natural Science Foundation of China(Grant No.52278407).
文摘Shipwreck salvage is a risky,time-consuming,and expensive process.Although there are many sunken ships along coastlines and in the open seas,the salvage process of a sunken ship has rarely been reported.The integrated salvage of the"Yangtze River EstuaryⅡ"shipwreck used a novel method with 22 closely locked curved rectangular pipes to form a watertight base that wrapped the shipwreck inside.The basing was lifted out of the water using a powerful crane situated on an engineering ship.For the first time,the tunneling method was used in a shipwreck salvage project,significantly reducing the disturbance to the shipwreck and its stowage,thereby preserving the original state and integrity of the shipwreck to the greatest extent.In this study,the basic concepts of the salvage method and process are explained.Solutions to critical issues in the new salvage method are provided,including jacking force prediction and major considerations for the structural design of the salvage system.The design of the salvage system and salvage process of the"Yangtze River EstuaryⅡ"shipwreck are introduced.The monitored jacking force,pipe deformation,and observed water-tightness verified that the proposed method was effective and efficient.Other possible application scenarios for the proposed method are presented at the end.
文摘When microdissection testicular sperm extraction(micro-TESE)fails,a redo procedure may be the only option for patients who want a biological child.However,there are many gaps of knowledge surrounding the procedure,which need to be addressed to help clinicians and patients make informed decisions.This review explores redo micro-TESE in the context of nonobstructive azoospermia(NOA).Literature was searched using Google Scholar,Medline,and PubMed.Search terms were“NOA”AND“second microdissection testicular sperm extractions”AND“redo microdissection testicles sperm extraction”AND“repeat microdissection testicular sperm extractions”AND“failed microdissection testicular sperm extractions”AND“salvage microdissection testicular sperm extractions”.Only original articles in English were included.A total of nine articles were included,consisting of four retrospective and five prospective studies.The time gap between the first and second micro-TESE varied from 6 months to 24 months.Most of the included studies reported successful surgical sperm retrieval(SSR)in the second micro-TESE in the range of 10%–21%,except in one study where it reached 42%.It has not been presented any definitive information about the use of hormonal treatment or the benefit of varicocelectomy prior to the second micro-TESE.Patients with hypospermatogenesis and Klinefelter syndrome(KS)had the highest chance of success in redo surgery.In conclusion,redo micro-TESE following a negative procedure can lead to sperm recovery in 10%–21%.Patients with hypospermatogenesis and KS have a higher chance of success.There is no enough evidence to conclude which is the best hormonal stimulation if any before a redo surgery.
基金supported by grant No.QL24020204funded by the Ministry of Agriculture of the Czech Republic and Internal Grant Agency of Faculty of Forestry and Wood Science CZU(reg.no.A_01_22)"EVA 4.0"No.CZ.02.1.01/0.0/0.0/16_019/0000803 financed by OP RDE.
文摘Commercially managed forests are often poor in terms of biodiversity.Saproxylic beetle species could be a useful bioindicating group for the conservation of forest stands.In recent decades,oak stands have been affected by a wide range of factors that have intensified stand decline.Saproxylic beetle richness was investigated in declining oak stands that have been consequently targeted for clearcutting due to concerns about insect pest outbreaks.The research was conducted at six managed oak forests,where we compared beetle occurrences in declining stands and in healthy stands that did not show any symptoms of decline.Beetles were collected using window traps placed on the basal and mid-trunk sections of trees.A total of 2925 adults belonging to 239 saproxylic beetle species were captured,of which 56 species are on the IUCN Red List.The results show that declining stands were richer in saproxylic species,and that the diversity of beetle species was greater in these stands.Approximately 1.4 times more species were caught within declining stands than in healthy ones(1.6 times for Red List species).Declining stands hosted more pest species(e.g.,cambiophagous and xylophagous species).However,only low numbers of these species were recorded in these stands.In summary,results of this study suggest that decline of managed oak stands is creating a wide spectrum of habitats for many saproxylic species.Thus,salvage logging of declining oak trees can represent a natural trap and reduce local beetle biodiversity,mainly for saproxylic,endangered or low-mobility species that would be attracted by new suitable habitats.
基金Supported by the Anhui Provincial Department of Education,No.2022AH020077.
文摘BACKGROUND Salvage surgery following conversion therapy[transcatheter arterial chemoembolization(TACE)combined with tyrosine kinase inhibitors(TKIs)and anti-programmed cell death protein 1(PD-1)antibodies]provides a chance for a cure in patients with unresectable hepatocellular carcinoma(uHCC).AIM To primarily analyze the efficacy and safety of salvage surgery in patients initially diagnosed with uHCC who underwent conversion therapy.METHODS We retrospectively collected data from patients at the First Affiliated Hospital of the University of Science and Technology of China(Anhui Provincial Hospital)who met the study criteria.These patients were initially diagnosed with uHCC and received TACE combined with TKIs and anti-PD-1 antibodies as conversion therapy.The main endpoints studied were the safety of salvage surgery,overall survival(OS),and recurrence-free survival(RFS)after surgery.Secondary endpoints included postoperative complications.We performed univariate and multivariate Cox regression analyses to identify independent risk factors for postoperative RFS.RESULTS A total of 117 patients were enrolled in this study,including 28 patients(23.9%)who underwent curative surgery after triplet therapy conversion treatment.Among the 28 patients who underwent salvage surgery,the 1-year and 2-year RFS rates were 75.0%and 59.4%,respectively,and the 1-year and 2-year OS rates were 92.7%and 87.6%,respectively.The median follow-up time after surgery was 15.0 months(range:1.6-37.2 months),with median OS and RFS not yet reached.Pathological complete response was achieved in 14 cases(50.0%),and postoperative complications occurred in 20 patients(71.4%).Univariate and multivariate Cox regression analyses indicated that pathological complete response and preoperative albumin levels were risk factors for postoperative RFS.CONCLUSION Salvage surgery following conversion therapy with TACE combined with TKIs and anti-PD-1 antibodies appears to be an effective and safe treatment option for patients with uHCC.It extends OS and may offer additional potential benefits to uHCC patients.
文摘BACKGROUND Esophageal squamous cell carcinoma(ESCC)is often managed with surgery,which is the first-line treatment option for stage I–III lesions.However,definitive chemoradiotherapy(dCRT)is associated with a recurrence rate of 30%in stage I ESCC and higher rates in advanced-staged lesions.However,several patients prefer dCRT because their general condition is poor.Salvage therapies,including esophagectomy and endoscopic resection[endoscopic submucosal dissection(ESD)/endoscopic mucosal resection],are important for residual or recurrent tumors that develop after dCRT.Esophagectomy can have curative potential.However,it has high complication and mortality rates.Therefore,ESD is a safer alternative.CASE SUMMARY A Japanese man in his 70s was concurrently diagnosed with right hypopha-ryngeal cancer(T2N1M0,cStage III),left oropharyngeal cancer(T1N0M0,cStage I),and left hard palate cancer(T1N0M0,cStage I).Esophagogastroduodenoscopy(EGD)revealed a 20 mm reddish 0-Is+IIb lesion in the upper thoracic esophagus,with an invasion depth of SM2.The lesion was diagnosed as an esophageal mo-derately differentiated squamous cell carcinoma(T1bN0M0,cStage I).As the pharyngeal cancers were in advanced stages,chemoradiotherapy(docetaxel and cisplatin with a radiation dose of 66 Gy)was prioritized.Post-chemoradiotherapy EGD showed that the lesion had flattened into a 0-IIb lesion,thereby indicating a reduced invasion depth(epi-thelium or lamina propria mucosa).ESD achieved en bloc and histologically confirmed curative resection.At 22 months after ESD,the patient did not present with signs of recurrence.CONCLUSION This case emphasizes that ESD can be successfully utilized as a salvage treatment for ESCC after chemoradio-therapy for otolaryngological cancers.
文摘Prostate cancer is the most common non-cutaneous cancers occurring in American men,and whilemost men with early-stage prostate cancers are cured,up to a third might manifest with biochemical recurrence(BCR)of prostate cancer.BCR is a disease entitywhich is characterized by a rising prostate-specific antigen(PSA)in the setting of a previously treated localized prostate cancerwith either surgery or radiation therapywith curativeintent.
基金Supported by the Department of Science and Technology of Liaoning Province,No.2024JH2/102600288.
文摘Esophageal diverticulum can be broadly classified into three main types:Phar-yngoesophageal diverticulum located near the upper esophageal sphincter(including Zenker’s diverticulum,Killian-Jamieson diverticulum,and Laimer’s diverticulum);Mid-esophageal diverticulum,and epiphrenic diverticulum loca-ted just above the lower esophageal sphincter.Most asymptomatic esophageal diverticulum are incidentally detected during routine imaging studies,such as barium swallow,computed tomography scans,or esophagogastroduodenoscopy.For these patients,regular follow-up is typically sufficient.However,a small subset may experience persistent symptoms such as dysphagia and acid reflux.Patients with symptomatic diverticulum should be assessed for the potential need for surgical intervention to prevent serious complications,including aspiration pneumonia and malnutrition.The treatment options for symptomatic esophageal diverticulum encompass both endoscopic and surgical approaches.Due to the technical complexity and significant risks associated with surgical intervention,endoscopic treatment has gained increasing preference,achieving remarkable results with the advancements in endoscopic instruments and techniques.Given the anatomical location and pathophysiological differences among esophageal diverticulum,a personalized endoscopic strategy is essential to achieve optimal results.This review provides an overview of the characteristics of esophageal diverticulum and offers a comprehensive discussion of diverticular peroral endoscopic myotomy and its related variations as the primary endoscopic treat-ment strategy.
文摘Background:Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality. While liver transplantation (LT) provides the best long-term survival, it is constrained by organ scarcity and strict criteria. Liver resection (LR) is often the initial treatment for patients with solitary tumors and preserved liver function. The high recurrence rates associated with LR has prompted the exploration of sequential living donor liver transplantation (seq LDLT) after LR as a strategy for HCC patients with high-risk of recurrence.Methods:We analyzed data from 27 adult patients who underwent seq LDLT after LR for HCC at Kaohsiung Chang Gung Memorial Hospital (KCGMH) between June 1994 and December 2023. Patients were selected based on high-risk histopathological features post-LR or as part of downstaging strategy. Outcomes measured included overall survival (OS) and disease-free survival (DFS).Results:Among 765 HCC patients who underwent LDLT, 204 received LR before LDLT, and 27 underwent seqL DLT. Five patients (19%) underwent living donor liver transplantation (LDLT) following LR as a downstaging strategy while the rest received seqL DLT as a preemptive strategy. The median age was 53.5 years with 85%males. Chronic hepatitis B was the predominant underlying disease (74%). The 1-, 3-, and 5-year OS and DFS rates were 100%, 96.0%, 96.0%and 100%, 96.2%, 96.2%, respectively, with two patients experiencing HCC recurrence. One patient died from HCC recurrence. High-risk histopathological features included microvascular invasion (52%), satellite nodules (15%), multiple tumors (26%), tumors> 5 cm(19%), and a total tumor diameter> 10 cm (7%).Conclusions:Seq LDLT offers a promising, tailored approach for managing HCC with adverse histopathologic features. Combining seq LDLT, downstaging strategies, and multidisciplinary treatments can achieve satisfactory OS and DFS in carefully selected patients, highlighting the need for refined criteria to identify the best candidates.
文摘AIM: There are limited reports in the United States demonstrating outcomes of primarily thinned fasciocutaneous flaps in the setting of critical limb ischemia, Charcot collapse and osteomyelitis. We hope to determine patient and flap related outcomes in advanced lower extremity disease. Methods: The authors conducted a retrospective review of fasciocutaneous free flaps of variable thickness for lower extremity salvage. Osteomyelitis and non-osteomyelitis patients were compared according to our primary outcome measures: functional ambulation, bone healing and complications to flap and patient. Subgroups with critical limb ischemia, Charcot collapse and diabetic foot were analyzed separately. Results: Fifty-nine patients underwent free flap reconstruction: osteomyelitis (n = 20, 34%), Charcot collapse (n = 22, 37%), and/or critical limb ischemia (n = 12, 20%). All patients underwent anterolateral thigh flaps tailored for defect-specific thicknesses: 17 superthin, 25 suprafascial, 17 subfascial. There were no significant differences between groups in terms of partial and complete flap loss (P = 1.000 and P = 0.108). Ninety-one percent of patients were ambulatory at follow up. Eighty-tive percent of individuals with osteomyelitis cleared their infection demonstrating radiographic bone healing. Two patients developed recalcitrant deep space infections ultimately requiring amputation. Subgroup analysis did not show any differences in flap related complications within the diabetic Charcot population. In multivariate regression, preoperative revascularization was independently associated with failure of limb salvage. ;Conclusion: Primarily thinned perforator flaps performed well in the setting of lower extremity limb salvage, critical limbischemia, osteomyelitis, and the Charcot foot - expanding their role in the armamentarium for lower extremity care.
文摘It is important for surgeons performing sarcoma surgery to know that bone resection and tumor prosthesis applications in soft tissue sarcomas(STS)have unique features in terms of indication,surgical approach and follow-up,in terms of the management of these cases.Some STS are associated with bone and major neurovascular structures.Bone-associated STS are generally relatively large and relatively deep-seated.Additionally,the tendency for metastasis is high.In some cases,the decision about which structures to resect is difficult.These cases are often accompanied by poor oncological and surgical outcomes.Management of cases should be done by a multidisciplinary team in advanced centers specialized in this field.The surgical team must have sufficient knowledge and experience in the field of limb-sparing surgery.Preoperative evaluation and especially good planning of bone and soft tissue reconstruction are vital.
基金Supported by Anhui Province Translational Medicine Research Fund Project,No.2021zhyx-C59 and No.2021zhyx-C75.
文摘BACKGROUND Testicular torsion is the most common acute scrotum worldwide and mainly occurs in children and adolescents.Studies have demonstrated that the duration of symptoms and torsion grade lead to different outcomes in children diagnosed with testicular torsion.AIM To predict the possibility of testicular salvage(TS)in patients with testicular torsion in a tertiary center.METHODS We reviewed the charts of 75 pediatric patients with acute testicular torsion during a 12-year period from November 2011 to July 2023 at the Suzhou Hospital of Anhui Medical University.Univariate and multivariate logistic regression analyses were used to determine independent predictors of testicular torsion.The data included clinical findings,physical examinations,laboratory data,color Doppler ultrasound findings,operating results,age,presenting institution status,and follow-up results.RESULTS Our study included 75 patients.TS was possible in 57.3%of all patients;testicular torsion occurred mostly in winter,and teenagers aged 11-15 years old accounted for 60%.Univariate logistic regression analyses revealed that younger age(P=0.09),body mass index(P=0.004),torsion angle(P=0.013),red blood cell count(P=0.03),neutrophil-to-lymphocyte ratio(P=0.009),and initial presenting institution(P<0.001)were associated with orchiectomy.In multivariate analysis,only the initial presenting institution predicted TS(P<0.05).CONCLUSION The initial presenting institution has a predictive value for predicting TS in patients with testicular torsion.Children with scrotal pain should be admitted to a tertiary hospital as soon as possible.
文摘Approximately 45 percent of malignant bone tumors are seen under the age of 16 and one of the important results of growth plate sacrification in patients with immature skeletons is limb inequality.Until the early 1990s,the treatment options for these patients were rotationplasty or amputation.Multimodal approaches that combine imaging,chemotherapy,and surgical techniques have enabled the development of limb-preserving methods with satisfactory results.In order to overcome inequality problems,expandable prostheses have been developed in the 1980s.Extendable endoprosthesis replacements have been improved over the years and are now an established and safe alternative.Noninvasive prostheses appear to be advantageous compared to minimally invasive expandable prostheses that require multiple surgical procedures,but the complication rate remains high.Therefore,although expandable prostheses are not the definitive answer to the treatment of bone sarcomas in skeletally immature children,they are still a suitable interim choice until full adulthood is achieved.Due to reported high complication rates,the procedures require significant experience and are recommended for use only in specialized cancer centers.
文摘After Hurricane Katrina in 2005,literary works related to such a crisis sprouted the southern America,which are known as Post-Katrina Literature.This thesis,taking Salvage the Bones and The Not Yet as examples,scrutinizes how writers respond to the Post-Katrina environmental crisis in different ways.In Salvage the Bones,Jesmyn Ward employs a biographical genre to record the Katrina disaster,thereby,writings serving as a way of healing the psychic trauma of the writer herself;and in The Not Yet,Moira Crone presents a post-natural world by the employment of the Cli-Fi genre.Both writers enrich the tradition of Southern literature as well as American eco-literature.
文摘Limb salvage after devastating traumatic injuries, cancer extirpation, and intrinsic disease is a complex decision-making process. Although several scoring and evaluation tools have been created to attempt to apply algorithmic decision-making to the process, thoughtful clinical decision-making remains the most important standard. When limb salvage is deemed appropriate, selection of a tissue flap for limb reconstruction is dependent on the size and location of the defect, patient comorbidities, nicotine dependence, mechanism of injury to the limb, patient lifestyle, occupation, and ambulatory status. This case involves a male trauma patient with significant comorbidities and a large lower extremity wound requiring multiple operations to attempt limb reconstruction with a rectus abdominis free flap. This patient’s complex injury and comorbidities made the risk of flap failure high, illustrating that the importance of patient- and case-specific factors cannot be overstated when planning for a limb reconstruction. This extreme resort of limb reconstruction, where limb loss is the only other option and a likely consequence of even heroic efforts, is aptly called “limb salvage”.
文摘BACKGROUND Congenital short bowel syndrome(SBS)associated with malrotation,gut volvulus and jejuno-ileal atresia is a very rare condition.It is a severe challenge for surgeons to preserve residual ischemic bowel segment in the management of short bowel syndrome,especially in neonates.CASE SUMMARY We report a newborn baby with gut malrotation associated with jejuno-ileal atresia,congenital SBS and jejunal volvulus.Hematemesis and abdominal distention were noted.At laparotomy,malrotation associated with jejuno-ileal atresia,congenital SBS and jenunal volvulus was confirmed.The total length of the small bowel was 63 cm with proximal jejunal bowel segment measuring 38 cm,including 18 cm necrotic segment below the Treitz’s ligament and 20 cm severe ischemic segment.The distal part of the small bowel was 25 cm in length and only about 0.8 cm in diameter.Ladd’s procedure,necrotic segment resection and end-to-back duodeno-ileal anastomosis were performed.The residual severe ischemic jejunum was preserved with single proximal stoma and distal end closure.Three months later,to restore the continuity of the isolated gut segment,end-to-end duodeno-jejunal and jejuno-ileal anastomosis was performed.The entire functional small bowel length increased to 80 cm.Intravenous fluid therapy and parenteral nutrition were discontinued on the 10th day postoperatively.Twelve months later,her body weight was 9.5 kg.CONCLUSION Isolation of severe ischemic bowel segment and staged anastomosis to restore the gut continuity for infants with SBS are safe and feasible.
文摘Living in modern world,the civilization is highly developed.Human beings are living an unprecedented prosperous life,but the spiritual waste land is still invisibly existed.Highly mechanism alienates people even more serious than what it is in the Waste Land.So the fighting against the Waste land to salvage it as well as ourselves is endless and circulatory.The Waste Land thus is not decaying and hopeless,but natural and common as at any time.Moreover,the new conditions of life required“a new discipline of suffering”.So we should do as the poet does:accept reality,positively indulge in it to feel and experience fully,to suffer it.Then we will feel that The Waste Land brings us not a melancholy mood,but a positive encouragement for the salvage of ourselves.
文摘There is wide variation in the management of coagulation and blood transfusion practice in liver transplantation. The use of blood products intraoperatively is declining and transfusion free transplantations take place ever more frequently. Allogenic blood products have been shown to increase morbidity and mortality. Primary haemostasis, coagulation and fibrinolysis are altered by liver disease. This, combined with intraoperative disturbances of coagulation, increases the risk of bleeding. Meanwhile, the rebalancing of coagulation homeostasis can put patients at risk of hypercoagulability and thrombosis. The application of the principles of patient blood management to transplantation can reduce the risk of transfusion. This includes: preoperative recognition and treatment of anaemia, reduction of perioperative blood loss and the use of restrictive haemoglobin based transfusion triggers. The use of point of care coagulation monitoring using whole blood viscoelastic testing provides a picture of the complete coagulation process by which to guide and direct coagulation management. Pharmacological methods to reduce blood loss include the use of anti-fibrinolytic drugs to reduce fibrinolysis, and rarely, the use of recombinant factor VIIa. Factor concentrates are increasingly used; fibrinogen concentrates to improve clot strength and stability, and prothrombin complex concentrates to improve thrombin generation. Non-pharmacological methods to reduce blood loss include surgical utilisation of the piggyback technique and maintenance of a low central venous pressure. The use of intraoperative cell salvage and normovolaemic haemodilution reduces allogenic blood transfusion. Further research into methods of decreasing blood loss and alternatives to blood transfusion remains necessary to continue to improve outcomes after transplantation.
