Distal pancreatectomy (DP) represents the best therapeutic option for patients with body-tail pancreatic neoplasms (PNs). The enhanced recovery after surgery protocol is widely used for treating ...patients with PN to speed up postoperative recovery. This study aims to describe our institute's experience in the application of fast recovery protocol in a cohort of patients treated with DP, identifying predictors facilitating a decrease in the length of hospital stay.
Were retrospectively enrolled 60 consecutive cases of DP performed from January 2016 to June 2022 in patients treated with enhanced recovery protocol, 25% of them were treated with spleen preserving procedure. Single-variable logistic regression models were used to evaluate the potential association between patient characteristics and the probability of postoperative complications. Standard linear regression models were used for length of stay, number of postoperative days (PODs) from surgery to full bowel function recovery, and PODs to the interruption of intravenous analgesia administration.
Thirty-four (57%) patients underwent open surgery and 26 (43%) laparoscopic surgery. Patients who underwent laparoscopic surgery and spleen-preserving procedures experienced a lower complication rate (
= .037), shorter length of stay, and time of analgesic requirements. With single-variable logistic regression models patients treated with laparoscopic surgery had statistically significant higher recovery times in terms of nasogastric tube removal (
= .004) and early enteral nutrition (
= .001).
Continual refinement with enhanced recovery protocol for treating PN patients based on perioperative counseling and surgical decision-making is crucial to reduce patient morbidity and time for recovery.
The adoption of extended criteria for donors remains the best strategy to widen the pool of available liver graft against the chronic shortage of donors. Benchmarking in liver transplantation (LT) ...offers the unprecedented opportunity to compare clinical outcome measures to a set of validated reference values. We aimed to evaluate the impact of marginal grafts usage in a cohort of low-risk benchmark cases from an area with a very low rate of deceased donation.
A cohort of low-risk benchmark cases was identified from all adult patients who underwent LT at our center. Among these patients, those transplanted with a graft from an extended-criteria donor (ECD) were identified. Benchmark metrics (length of hospital and intensive care unit stay, incidences of mortality, graft loss, and postoperative complication) were compared with benchmark cutoffs and between the 2 groups.
Two hundred forty-five patients satisfied the inclusion criteria, 146 (60%) of whom received an organ from an ECD. Overall, all benchmark metrics where within the cutoffs limits, except for graft loss (14% vs 11%) and mortality (10% vs 9% 1 year after LT). The ECD group was associated with more grade III complications (60% vs 45%, P = .031), graft loss (18% vs 8%, P = .038), and mortality (14% vs 4%, P = .009). Hepatocellular carcinoma diagnosis was found to be associated with less mortality (odds ratio = 0.42, P = .048).
While ECD graft usage is associated with slightly worse prognosis, our experience suggests that their use can be considered safe, especially when matched on hepatocellular carcinoma recipients.
Liver resection (LR) remains the best therapeutic option for patients with early-stage hepatocellular carcinoma (HCC) with preserved hepatic function and who are not eligible for liver ...transplantation. After its inception, the enhanced recovery after surgery (ERAS) protocol was widely used for treating patients with liver cancer, although there are still no clear indications for improving upon it in both open and laparoscopic surgery.
This study aims to describe our institute's experience in the application of the ERAS protocol in a cohort of HCC patients, and to explore possible factors that could have an impact on postoperative outcomes.
We retrospectively analyzed our experience with LR performed from September 2017 to January 2020 in patients treated with ERAS protocol, focusing on describing impact on postoperative nutrition, analgesic requirements, and length of hospitalization. Demographics, operative factors, and postoperative complications of patients were reviewed.
During the study period, 89 HCC patients were eligible for LR, and 75% of patients presented with liver cirrhosis. The most prevalent among etiologic factors was hepatitis C virus infection (53 patients out of 89, 60%), followed by nonalcoholic steatohepatitis (18 patients, 20%). The median age was 70 years. Liver cirrhosis did not have an impact on postoperative course of patients. Patients who underwent laparoscopic surgery and nonanatomic LR experienced low complication rates, shorter length of stay, and shorter time of intravenous analgesic requirements.
Continual refinement with ERAS protocol for treating HCC patients based on perioperative counseling and surgical decision-making is crucial to guarantee low complication rates, and reduce patient morbidity and time for recovery.
ABSTRACT The evolution of the inner accretion flow of a black hole X-ray binary during an outburst is still a matter of active research. X-ray reverberation lags are powerful tools for constraining ...disk-corona geometry. We present a study of X-ray lags in the black hole transient H1743-322. We compared the results obtained from analysis of all the publicly available XMM-Newton observations. These observations were carried out during two different outbursts that occurred in 2008 and 2014. During all the observations the source was caught in the hard state and at similar luminosities ( ). We detected a soft X-ray lag of ∼60 ms, most likely due to thermal reverberation. We did not detect any significant change of the lag amplitude among the different observations, indicating a similar disk-corona geometry at the same luminosity in the hard state. On the other hand, we observe significant differences between the reverberation lag detected in H1743-322 and in GX 339-4 (at similar luminosities in the hard state), which might indicate variations of the geometry from source to source.
ABSTRACT
We study the structure of the accretion flow in the hard state of the black hole X-ray binary MAXI J1820+070 with NICER data. The power spectra show broad-band variability which can be fit ...with four Lorentzian components peaking at different time-scales. Extracting power spectra as a function of energy enables the energy spectra of these different power spectral components to be reconstructed. We found significant spectral differences among Lorentzians, with the one corresponding to the shortest variability time-scales displaying the hardest spectrum. Both the variability spectra and the time-averaged spectrum are well-modelled by a disc blackbody and thermal Comptonization, but the presence of (at least) two Comptonization zones with different temperatures and optical depths is required. The disc blackbody component is highly variable, but only in the variability components peaking at the longest time-scales ($\lower.5ex\hbox{$\,\, \buildrel\gt \over \sim \,\,$}1$ s). The seed photons for the spectrally harder zone come predominantly from the softer Comptonization zone. Our results require the accretion flow in this source to be structured, and cannot be described by a single Comptonization region upscattering disc blackbody photons, and reflection from the disc.
We study high-energy γ-rays observed from Cyg X-3 by the Fermi Large Area Telescope and the 15-GHz emission observed by the Ryle Telescope and the Arcminute Microkelvin Imager. We measure the γ-ray ...spectrum averaged over strong flares much more accurately than before and find it well modelled by Compton scattering of stellar radiation by relativistic electrons with the power-law index of ≃3.5 and a low-energy cutoff at the Lorentz factor of ∼10^3. We find a weaker spectrum in the soft spectral state but only upper limits in the hard and intermediate states. We measure strong orbital modulation during the flaring state, well modelled by anisotropic Compton scattering of blackbody photons from the donor by jet relativistic electrons. We discover a weaker orbital modulation of the 15-GHz radio emission, which is well modelled by free–free absorption by the stellar wind. We then study cross-correlations between radio, γ-ray, and X-ray emissions. We find the cross-correlation between the radio and γ-ray emission peaks at a lag less than 1 d, while we detect a distinct radio lag of ∼50 d with respect to the soft X-rays in the soft spectral state.
Abstract
We study X-ray spectra from the outburst rise of the accreting black hole binary MAXI J1820+070. We find that models having the disk inclinations within those of either the binary or the jet ...imply significant changes of the accretion disk inner radius during the luminous part of the hard spectral state, with that radius changing from >100 to ∼10 gravitational radii. The main trend is a decrease with the decreasing spectral hardness. Our analysis requires the accretion flow to be structured, with at least two components with different spectral slopes. The harder component dominates the bolometric luminosity and produces strong, narrow, X-ray reflection features. The softer component is responsible for the underlying broader reflection features. The data are compatible with the harder component having a large scale height, located downstream the disk truncation radius, and reflecting mostly from remote parts of the disk. The softer component forms a corona above the disk up to some transition radius. Our findings can explain the changes of the characteristic variability timescales, found in other works, as being driven by the changes of the disk characteristic radii.
ABSTRACT
We report the first detection of an Fe Kα line and soft X-ray lag in the ultraluminous X-ray (ULX) source NGC 7456 ULX-1. The XMM–Newton spectra show the presence of the 6.4 keV Fe line at ...2.6σ confidence and an upper limit on the FWHM of 32900 km s−1. Assuming that the line arises by reflection from a Keplerian disk, it must originate beyond 85rg from the compact object. As a result of Fourier timing analysis, we found that the soft X-ray photons lag behind the hard X-ray photons with a ∼1300 s delay. The covariance spectra indicate that the hard spectral component is responsible for the correlated variability and the soft X-ray lag. This is the second ULX in which an Fe Kα line is found, the fifth with a soft X-ray lag, and the first with both features detected.
Portal vein shunt is common in chronic hepatic diseases and after a liver transplant. Ensuring a satisfactory portal flow is essential to support a rapid liver recovery, of paramount importance to ...meet the recipient's metabolic needs.
We report the case of a 32-year-old female undergoing a third liver transplant due to recurrence of graft failure secondary to portosystemic shunting. The patient, affected with biliary atresia, was first transplanted in 2009 with a right split liver graft. The clinical course was complicated by biliary stenosis of the Roux-en-Y anastomosis and multiple episodes of acute rejection treated with steroid boluses, plastic dilation of the biliary anastomosis, and biliary catheter placement. Unfortunately, in 2017 a liver biopsy showed an autoimmunity with histological evidence of ANA 1:80 (granular and nucleolar pattern). This was a contributing factor of liver function impairment, leading to the need to perform a second liver transplant, complicated by an acute rejection, with only a partial response to steroid therapy. Due to the further worsening of the liver function (MELD: 40, Child-Pugh: C11), the patient was relisted for a liver transplant. After five days, she received her third liver transplant, with an entire graft of an AB0 identical group. Intraoperative exploration revealed multiple collaterals and large splenocaval shunts, with a significant alteration of the portal flow and hypertension, isolated and closed with a vascular stapler to restore the graft's regular portal vein flow.
In patients listed for a liver transplant, portal steal syndrome should be identified prior to the transplant. Our recommendation is to consider intraoperative or perioperative closure of the portal collateral varices.
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