Comparison of phytochemical properties and expressional profiling of artemisinin synthesis-related genes in various Artemisia species

The Artemisia genus belongs to the Asteraceae family and is used in the treatment of many different diseases such as hepatitis and cancer. So far, around 500 species of Artemisia have been found in different regions of the world. Artemisinin is one of the medicinal compounds found in Artemisia species. Hence, this medical feature encourages researchers to pay attention to various species of this genus to discover more genetic and phytochemical information. In the present study, five species of Artemisia including A. fragrans, A. annua, A. biennis, A. scoparia, and A. absinthium were compared to each other in terms of the artemisinin content and other phytochemical components. Moreover, the relative expression profiles of eight genes related to the accumulation and synthesis of artemisinin [including 4FPSF, DBR2, HMGR1, HMGR2, WIRKY, ADS, DXS, and SQS] were determined in investigated species. The result of high-performance liquid chromatography (HPLC) analysis showed that the content of artemisinin in various species was in the order of A. fragrans > A. annua > A. biennis > A. scoparia > A. absinthium. Based on the gas chromatography-mass spectrometry (GC-MS) analysis, 34, 26, 26, 24, and 20 phytochemical compounds were identified for A. scoparia, A. biennis, A. fragrans, A. absinthum, and A. annua species, respectively. Moreover, camphor (38.86%), β-thujone (68.42%), spathulenol (48.33%), β-farnesene (48.16%), and camphor (29.04%) were identified as the considerable compounds A. fragrans, A. absinthium, A. scoparia, A. biennis, and A. annua species, respectively. Considering the relative expression of the targeted genes, A. scoparia revealed higher expression for the 4FPSF gene. The highest relative expression of the DBR2, WIRKY, and SQS genes was found in A. absinthium species. Moreover, A. annua showed the highest expression of the ADS and DXS genes than the other species. In conclusion, our findings revealed that various species of Artemisia have interesting breeding potential for further investigation of different aspects such as medicinal properties and molecular studies.

Robotic colectomy with CME versus laparoscopic colon resection with or without CME for colon cancer: a systematic review and meta-analysis

INTRODUCTION

This systematic review with meta-analysis aimed to compare the robotic complete mesocolon excision (RCME) to laparoscopic colectomy (LC) with (LCME) or without CME (LC non-CME) in postoperative outcomes, harvested lymph nodes and disease-free survival.

METHODS

We performed a systematic review with meta-analysis according to PRISMA 2020 and AMSTAR 2 guidelines.

RESULTS

The literature search yielded seven comparative studies including 677 patients: 269 patients in the RCME group and 408 in the LC group. The pooled analysis concluded to a lower conversion rate in the RCME group (OR=0.17; 95% CI [0.04, 0.74], p=0.02). There was no difference between the two groups in terms of morbidity (OR=1.03; 95% CI [0.70, 1.53], p=0.87), anastomosis leakage (OR=0.83; 95% CI [0.18, 3.72], p=0.81), bleeding (OR=1.90; 95% CI [0.64, 5.58], p=0.25), wound infection (OR=1.37; 95% CI [0.51, 3.68], p=0.53), operative time (mean difference (MD)=36.32; 95% CI [-24.30, 96.93], p=0.24), hospital stay (MD=-0.94; 95% CI [-2.03, 0.15], p=0.09) and disease-free survival (OR=1.29; 95% CI [0.71, 2.35], p=0.41). In the subgroup analysis, the operative time was significantly shorter in the LCME group than RCME group (MD=50.93; 95% CI [40.05, 61.81], p<0.01) and we noticed a greater number of harvested lymph nodes in the RCME group compared with LC non-CME group (MD=8.96; 95% CI [5.98, 11.93], p<0.01).

CONCLUSIONS

The robotic approach for CME ensures a lower conversion rate than the LC. RCME had a longer operative time than the LCME subgroup and a higher number of harvested lymph nodes than the LC non-CME group.

Dragon 1 Protocol Manuscript: Training, Accreditation, Implementation and Safety Evaluation of Portal and Hepatic Vein Embolization (PVE/HVE) to Accelerate Future Liver Remnant (FLR) Hypertrophy

STUDY PURPOSE

The DRAGON 1 trial aims to assess training, implementation, safety and feasibility of combined portal- and hepatic-vein embolization (PVE/HVE) to accelerate future liver remnant (FLR) hypertrophy in patients with borderline resectable colorectal cancer liver metastases.

METHODS

The DRAGON 1 trial is a worldwide multicenter prospective single arm trial. The primary endpoint is a composite of the safety of PVE/HVE, 90-day mortality, and one year accrual monitoring of each participating center. Secondary endpoints include: feasibility of resection, the used PVE and HVE techniques, FLR-hypertrophy, liver function (subset of centers), overall survival, and disease-free survival. All complications after the PVE/HVE procedure are documented. Liver volumes will be measured at week 1 and if applicable at week 3 and 6 after PVE/HVE and follow-up visits will be held at 1, 3, 6, and 12 months after the resection.

RESULTS

Not applicable.

CONCLUSION

DRAGON 1 is a prospective trial to assess the safety and feasibility of PVE/HVE. Participating study centers will be trained, and procedures standardized using Work Instructions (WI) to prepare for the DRAGON 2 randomized controlled trial. Outcomes should reveal the accrual potential of centers, safety profile of combined PVE/HVE and the effect of FLR-hypertrophy induction by PVE/HVE in patients with CRLM and a small FLR.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT04272931 (February 17, 2020). Toestingonline.nl: NL71535.068.19 (September 20, 2019).

Delayed Surgery for Perforated Appendicitis is Feasible in Children Without Compromising the Outcome in Selected Cases

BACKGROUND AND AIM

The relationship between time to surgery and risk of postoperative complications and re-intervention has not been conclusively investigated in pediatric perforated appendicitis (PA). The aim of this study was to determine whether time to appendectomy (TTA) is a risk factor for postoperative complications and re-intervention in a cohort of children undergoing appendectomy for PA.

METHODS

A total of 254 children (age: 8.7 ± 3.7 years) undergoing appendectomy for PA were retrospectively evaluated and stratified into Group I-III according to the Clavien-Dindo classification for postoperative complications (Group I n = 218, 86%; Group II n = 7, 3%; Group III n = 29, 11%).

RESULTS

The TTA was comparable between all groups (group I: 8.8 ± 9.2 h; group II: 7.8 ± 5.3 h; group III: 9.5 ± 9.6 h; overall: 8.8 ± 9.1 h; p = 0.885). A C-reactive protein (CRP) value at admission of  ≥128.6 mg/l indicated a higher risk for developing Grade II complications with no need for re-intervention (OR: 3.963; 95% CI: 1.810-8.678; p = 0.001) and Grade III complications with the need for re-intervention (OR: 3.346; 95% CI: 1.456-7.690; p = 0.004). This risk was independent of the TTA (OR: 1.007; 95% CI: 0.980-1.035; p = 0.613).

CONCLUSIONS

Appendectomy can be delayed by an average time delay of about 9 h in children with PA without increasing the risk of postoperative complications and re-intervention, also in patients at high risk defined by the initial CRP level ≥ 128.6 mg/l. This data may support the correct risk-adjusted scheduling of surgical interventions in times of limited capacity.

Learning Curves in Open, Laparoscopic, and Robotic Pancreatic Surgery: A Systematic Review and Proposal of a Standardization

Objective

To depict and analyze learning curves for open, laparoscopic, and robotic pancreatoduodenectomy (PD) and distal pancreatectomy (DP).

Background

Formal training is recommended for safe introduction of pancreatic surgery but definitions of learning curves vary and have not been standardized.

Methods

A systematic search on PubMed, Web of Science, and CENTRAL databases identified studies on learning curves in pancreatic surgery. Primary outcome was the number needed to reach the learning curve as defined by the included studies. Secondary outcomes included endpoints defining learning curves, methods of analysis (statistical/arbitrary), and classification of learning phases.

Results

Out of 1115 articles, 66 studies with 14,206 patients were included. Thirty-five studies (53%) based the learning curve analysis on statistical calculations. Most often used parameters to define learning curves were operative time (n = 51), blood loss (n = 17), and complications (n = 10). The number of procedures to surpass a first phase of learning curve was 30 (20-50) for open PD, 39 (11-60) for laparoscopic PD, 25 (8-100) for robotic PD (P = 0.521), 16 (3-17) for laparoscopic DP, and 15 (5-37) for robotic DP (P = 0.914). In a three-phase model, intraoperative parameters improved earlier (first to second phase: operating time -15%, blood loss -29%) whereas postoperative parameters improved later (second to third phase: complications -46%, postoperative pancreatic fistula -48%). Studies with higher sample sizes showed higher numbers of procedures needed to overcome the learning curve (rho = 0.64, P < 0.001).

Conclusions

This study summarizes learning curves for open-, laparoscopic-, and robotic pancreatic surgery with different definitions, analysis methods, and confounding factors. A standardized reporting of learning curves and definition of phases (competency, proficiency, mastery) is desirable and proposed.

Applying an intraoperative predictive indicator for postoperative pancreatic fistula: randomized preclinical trial

Leaking pancreatic fluid can contribute to postoperative pancreatic fistula (POPF), which can complicate pancreatic surgery. Surgeons lack reliable tools to identify pancreatic leaks, so a novel hydrogel indicator called SmartPAN was developed for intraoperative application. In this preclinical efficacy assessment study, SmartPAN was capable of detecting sites associated with biochemical leak and POPF-related symptoms, thereby guiding effective closure. Thus, SmartPAN may help to reduce POPF development in upcoming clinical trials.

Effect of mycophenolic acid on inosine monophosphate dehydrogenase (IMPDH) activity in liver transplant patients

BACKGROUND

Due to the development of immunosuppressants, the focus in transplanted patients has shifted from short-term to long-term survival as well as a better adjustment of these drugs in order to prevent over- and under-immunosuppression. Mycophenolic acid (MPA) is a noncompetitive inhibitor of inosine monophosphate dehydrogenase (IMPDH) and approved for prophylaxis of acute rejection after kidney, heart, and liver transplantation, where it has become a part of the standard therapy. Targeting inosine monophosphate IMPDH activity as a surrogate pharmacodynamic marker of MPA-induced immunosuppression may allow a more accurate assessment of efficacy and aid in limiting toxicity in liver transplanted patients.

AIM

Assess IMPDH-inhibition in liver transplant recipients and its impact on biliary/infectious complications, acute cellular rejection (ACR) and liver dependent survival.

METHODS

This observational cohort study comprises 117 liver transplanted patients that were treated with mycophenolate mofetil (MMF) for at least 3 months. Blood samples (BS) were collected and MPA serum level and IMPDH activity were measured before (t(0)), 30minutes (t(30)) and 2h after (t(120)) MMF morning dose administration. Regarding MPA, we assessed the area under the curve (AUC). Patients were prospectively followed up for one year and assessed for infectious and biliary complications, episodes of ACR and liver dependent survival.

RESULTS

The MPA levels showed a broad interindividual variability at t(0) (2.0±1.8ng/ml), t(30) (12.7±9.0ng/ml) and t(120) (7.5±4.3ng/ml). Corresponding IMPDH activity was at t(o) (23.2±9.5 nmol/h/mg), at t(30) (16.3±8.8 nmol/h/mg) and t(120) (18.2±8.7 nmol/h/mg). With regard to MPA level we found no correlation with infectious or biliary complications within the follow-up period. Patients with baseline IMPDH(a) below the median had significant more viral infections (6 (10.2%) vs. 17 (29.3%); P=0.009) with especially more cytomegalovirus (CMV) infections (1 (3.4%) vs. 6 (21.4%); P=0.03)). Furthermore, patients with baseline IMPDH(a) above the median developed more often non-anastomotic biliary strictures (8 (13.6%) vs. 1 (1.7%), P=0.03). We found the group reaching the combined clinical endpoint of death and re-transplantation showing significantly lower MPA baseline values (t(0) 0.9±0.7 vs. 2.1±1.8μg/ml Mann-Whitney-U: P=0.02). We calculated a simplified MPA(AUC) with the MPA level at baseline, 30 and 120minutes after MPA administration. Whereas we found no differences with regard to baseline characteristics at entry into the study patients with MPA (AUC) below the median experienced significantly more often the combined clinical endpoint (12.1% (7/58) vs. 0.0% (0/57); P=0.002) and had a reduced actuarial re-transplantation-free survival (1.0 year vs. 0.58 years; Log-rank: P=0.007) during the prospective one-year follow-up period. In univariate and multivariate analysis including gender, age, BMI, ACR, MPA (AUC) and IMPDH(a) only BMI, MPA (AUC) and IMPDH(a) were independently associated with reduced actuarial re-transplantation-free survival.

CONCLUSION

MPA-levels and IMPDH-activity in liver transplanted patients allows individual risk assessment. Patients with higher IMPDH inhibition acquire more often viral infections. Insufficient IMPDH inhibition is associated with development of non-anastomotic bile duct strictures and reduced re-transplantation-free survival.

Consensus on definition and severity grading of lymphatic complications after kidney transplantation

BACKGROUND

The incidence of lymphatic complications after kidney transplantation varies considerably in the literature. This is partly because a universally accepted definition has not been established. This study aimed to propose an acceptable definition and severity grading system for lymphatic complications based on their management strategy.

METHODS

Relevant literature published in MEDLINE and Web of Science was searched systematically. A consensus for definition and a severity grading was then sought between 20 high-volume transplant centres.

RESULTS

Lymphorrhoea/lymphocele was defined in 32 of 87 included studies. Sixty-three articles explained how lymphatic complications were managed, but none graded their severity. The proposed definition of lymphorrhoea was leakage of more than 50 ml fluid (not urine, blood or pus) per day from the drain, or the drain site after removal of the drain, for more than 1 week after kidney transplantation. The proposed definition of lymphocele was a fluid collection of any size near to the transplanted kidney, after urinoma, haematoma and abscess have been excluded. Grade A lymphatic complications have a minor and/or non-invasive impact on the clinical management of the patient; grade B complications require non-surgical intervention; and grade C complications require invasive surgical intervention.

CONCLUSION

A clear definition and severity grading for lymphatic complications after kidney transplantation was agreed. The proposed definitions should allow better comparisons between studies.

Does vancomycin resistance increase mortality in Enterococcus faecium bacteraemia after orthotopic liver transplantation? A retrospective study

BACKGROUND

The relevance of vancomycin resistance in enterococcal blood stream infections (BSI) is still controversial. Aim of this study was to outline the effect of vancomycin resistance of Enterococcus faecium on the outcome of patients with BSI after orthotopic liver transplantation (OLT).

METHODS

The outcome of OLT recipients developing BSI with vancomycin-resistant (VRE) versus vancomycin-susceptible Enterococcus faecium (VSE) was compared based on data extraction from medical records. Multivariate regression analyses identified risk factors for mortality and unfavourable outcomes (defined as death or prolonged intensive care stay) after 30 and 90 days.

RESULTS

Mortality was similar between VRE- (n = 39) and VSE- (n = 138) group after 30 (p = 0.44) or 90 days (p = 0.39). Comparable results occurred regarding unfavourable outcomes. Mean SOFA_Non-GCS score during the 7-day-period before BSI onset was the independent predictor for mortality at both timepoints (HR 1.32; CI 1.14-1.53; and HR 1.18; CI 1.08-1.28). Timely appropriate antibiotic therapy, recent ICU stay and vancomycin resistance did not affect outcome after adjusting for confounders.

CONCLUSION

Vancomycin resistance did not influence outcome among patients with Enterococcus faecium bacteraemia after OLT. Only underlying severity of disease predicted poor outcome among this homogenous patient population.

TRIAL REGISTRATION

This study was registered at the German clinical trials register (DRKS-ID: DRKS00013285).

Outcome after liver resection for primary and recurrent intrahepatic cholangiocarcinoma

BACKGROUND

Liver resection is the only curative therapeutic option for intrahepatic cholangiocarcinoma (ICC), but the approach to recurrent ICC is controversial. This study analysed the outcome of liver resection in patients with recurrent ICC.

METHODS

Demographic, radiological, clinical, operative, surgical pathological and follow-up data for all patients with a final surgical pathological diagnosis of ICC treated in a tertiary referral centre between 2001 and 2015 were collected retrospectively and analysed.

RESULTS

A total of 190 patients had liver resection for primary ICC. The 1-, 3- and 5-year overall survival (OS) rates were 74·8, 56·6 and 37·9 per cent respectively. Independent determinants of OS were age 65 years or above (hazard ratio (HR) 2·18, 95 per cent c.i. 1·18 to 4·0; P = 0·012), median tumour diameter 5 cm or greater (HR 2·87, 1·37 to 6·00; P = 0·005), preoperative biliary drainage (HR 2·65, 1·13 to 6·20; P = 0·025) and local R1-2 status (HR 1·90, 1·02 to 3·53; P = 0·043). Recurrence was documented in 87 patients (45·8 per cent). The mean(s.d.) survival time after recurrence was 16(17) months. Independent determinants of recurrence were median tumour diameter 5 cm or more (HR 1·71, 1·09 to 2·68; P = 0·020), high-grade (G3-4) tumour (HR 1·63, 1·04 to 2·55; P = 0·034) and local R1 status (HR 1·70, 1·09 to 2·65; P = 0·020). Repeat resection with curative intent was performed in 25 patients for recurrent ICC, achieving a mean survival of 25 (95 per cent c.i. 16 to 34) months after the diagnosis of recurrence. Patients deemed to have unresectable disease after recurrence received chemotherapy or chemoradiotherapy alone, and had significantly poorer survival.

CONCLUSION

Patients with recurrent ICC may benefit from repeat surgical resection.

Surgical outcomes after pediatric kidney transplantation at the University of Heidelberg

BACKGROUND

Kidney transplantation (KTx) is the treatment of choice for children with end-stage renal disease (ESRD).

OBJECTIVE

An update of 48 years of surgical experience with pediatric KTx (PKTx) is presented, and the results between recipients of organs from deceased donors (DDs) and living donors (LDs) are compared.

STUDY DESIGN

All patients younger than 18 years who underwent KTx between 1967 and 2015 were evaluated. Data from 540 PKTx operations (409 DD and 131 LD) were obtained from the transplant center database. Peri-operative data and graft and patient survival were analyzed in the DD and LD groups.

RESULTS

Fewer recipients in the LD group underwent dialysis before PKTx than those in the DD group (50.8% in LD vs. 94.9% in DD, P < 0.001). The mean duration of dialysis (DD: 798 ± 525 days vs. LD: 625 ± 650 days, P = 0.03), time on the waiting list (DD: 472 ± 435 days vs. LD: 120 ± 243 days, P < 0.001), cold ischemia time (CIT) (DD: 1206 ± 368 min vs. LD: 140 ± 63 min, P < 0.001), operation time, and hospital stay were lower in the LD group. Except for arterial stenosis, the rates of postoperative vascular and urological complications were not different between the two groups. The cumulative 25-year graft and patient survival rates were 46.4% and 84.1% in the DD group and 76.5% and 96.1% in the LD group, respectively.

DISCUSSION

PKTx is the treatment of choice for children with ESRD. Graft quality has a direct impact on KTx outcome and rate of graft failure. Better HLA compatibility and shorter CIT reduce the impairment of graft function after LD PKTx. In addition, Establishment of an interdisciplinary approach using an individualized risk assessment and prevention model can improve PKTx outcomes.

CONCLUSION

Compared with DD PKTx, LD PKTx has better graft survival associated with a shorter duration of preceding dialysis, waiting time, and CIT and seems to be more beneficial for children.

Randomized clinical trial of stapler hepatectomy versus LigaSure™ transection in elective hepatic resection

BACKGROUND

Previous studies have demonstrated stapler hepatectomy and use of various energy devices to be safe alternatives to the clamp-crushing technique in elective hepatic resection. In this randomized trial, the effectiveness and safety of stapler hepatectomy were compared with those of parenchymal transection with the LigaSure™ vessel sealing system.

METHOD

Patients scheduled for elective liver resection at two tertiary-care centres were randomized during surgery to stapler hepatectomy or transection with the LigaSure™ device. Total intraoperative blood loss was the primary efficacy endpoint. Transection time, duration of operation, perioperative complications and length of hospital stay were recorded as secondary endpoints.

RESULTS

A total of 138 patients were analysed, 69 in the LigaSure™ and 69 in the stapler hepatectomy group. Baseline characteristics were well balanced between the groups. Mean intraoperative blood loss was significantly higher in the LigaSure™ group than the stapler hepatectomy group: 1101 (95 per cent c.i. 915 to 1287) versus 961 (752 to 1170) ml (P = 0·028). The parenchymal transection time was significantly shorter in the stapler group (P = 0·005), as was the total duration of operation (P = 0·027). Surgical morbidity did not differ between the groups, nor did the grade of complications.

CONCLUSION

Stapler hepatectomy was associated with reduced blood loss and a shorter duration of operation than the LigaSure™ device for parenchymal transection in elective partial hepatectomy. Registration number: NCT01858987 (http://www.clinicaltrials.gov).

Meta-analysis of the prognostic role of perioperative platelet count in posthepatectomy liver failure and mortality

BACKGROUND

Emerging evidence suggests that the perioperative platelet count (PLT) can predict posthepatectomy liver failure (PHLF). In this systematic review and meta-analysis, the impact of perioperative PLT on PHLF and mortality was evaluated.

METHODS

MEDLINE and Web of Science databases were searched systematically for relevant literature up to January 2018. All studies comparing PHLF or mortality in patients with a low versus high perioperative PLT were included. Study quality was assessed using methodological index for non-randomized studies (MINORS) criteria. Meta-analyses were performed using Mantel-Haenszel tests with a random-effects model, and presented as odds ratios (ORs) with 95 per cent confidence intervals.

RESULTS

Thirteen studies containing 5260 patients were included in the meta-analysis. Two different cut-off values for PLT were used: 150 and 100/nl. Patients with a perioperative PLT below 150/nl had higher PHLF (4 studies, 817 patients; OR 4·79, 95 per cent c.i. 2·89 to 7·94) and mortality (4 studies, 3307 patients; OR 3·78, 1·48 to 9·62) rates than patients with a perioperative PLT of 150/nl or more. Similarly, patients with a PLT below 100/nl had a significantly higher risk of PHLF (4 studies, 949 patients; OR 4·65, 2·60 to 8·31) and higher mortality rates (7 studies, 3487 patients; OR 6·35, 2·99 to 13·47) than patients with a PLT of 100/nl or greater.

CONCLUSION

A low perioperative PLT correlates with higher PHLF and mortality rates after hepatectomy.

Association of pre- and early post-transplant serum amino acids and metabolites of amino acids and liver transplant outcome

The aim of the present study was to investigate association of serum amino (AA) acids and metabolites of AAs with post-transplant outcome in liver transplant recipients. Eighty-nine patients with end-stage liver diseases and available pre- and early post-transplant serum were characterised as patients with (GI) and without one-year mortality (GII) and patients with and without early graft dysfunction (EAD). A panel of pre- and early post-transplant serum levels of AAs and early and metabolites of tryptophan were measured using tandem mass spectrometry. Patient groups had significantly higher pre-transplant serum levels of phenylalanine, tryptophan, and tryptophan metabolites than healthy controls (for all p<0.001). Pre-transplant serum levels of all these parameters were significantly higher in GI than in GII (for all p<0.001). GI had a higher MELD score and re-transplantation number than GII (p≤0.005 for both investigations). Serum bilirubin on day 5 and serum phenylalanine on day 10 post-transplant were associated parameters of mortality, whereas day 1post-transplant phenylalanine and kynurenine and female gender were associated parameters of EAD. Our results indicate that pre- and early post-transplant levels of phenylalanine, tryptophan and metabolites of tryptophan are increased in patients and are associated with EAD and one-year mortality in liver transplant recipients.

Analysis of the biliostatic potential of two sealants in a standardized porcine model of liver resection

BACKGROUND

Improved resection techniques has decreased mortality rate following liver resections(LRx). Sealants are known as effective adjuncts for haemostasis after LRx. We compared biliostatic effectiveness of two sealants in a standardized porcine model of LRx.

MATERIAL AND METHODS

We accomplished left hemihepatectomy on 27 pigs. The animals were randomized in control group(n = 9) with no sealant and treatment groups (each n = 9), in which resection surfaces were covered with TachoSil^® and TissuFleece^®/Tissucol Duo^®. After 5 days the volume of ascites(ml), bilioma and/or bile leakages and degree of intra-abdominal adhesions were analysed.

RESULTS

Proportion of ascites was lower in TissuFleece/Tissucol Duo^® group. The ascites volume was lower in TachoSil^® group. In sealant groups, increased adhesion specially in the TachoSil^® group was seen. A reduction of the "bilioma rate" was seen in sealant groups, which was significantly lower in TissuFleece^®/Tissucol Duo^® group.

CONCLUSION

In a standardized condition sealants have a good biliostatic effect but with heterogeneous potentials. This property in combination with the cost-benefit analysis should be the focus of future prospective studies.

Long-term outcome in displaced lateral humeral condyle fractures following internal screw fixation in children

BACKGROUND

The aim of this study was to investigate the long-term clinical outcome following open reduction and internal screw fixation of displaced lateral condyle fractures (LCFs) of the distal humerus and compare the outcome of primary and secondary LCFs.

METHODS

The clinical outcome in 31 children (mean age 5.8±2.4 years) operated for primary or secondary LCFs was retrospectively analyzed by standardized clinical examination and compared using the Mayo score, Morger score, and Patients Satisfaction score.

RESULTS

The scores did not differ significantly between the primary and secondary displacement groups (Mayo score: 99.3±3.3 vs. 100±0, p=0.852; Morger score: 3.8±0.5 vs. 3.9±0.3, p=0.852; Patients Satisfaction score: 3.7±0.6 vs. 3.9±0.3, p=0.546). Deficits in range of motion and joint axis deviation were minor (< 10°) and no elbow instabilities were observed.

CONCLUSIONS

Surgical treatment of a secondary displaced LCF with open reduction and internal screw fixation leads to a favorable long-term outcome. The long-term outcome is similar between primary and secondary displaced LCFs.

Predicting Postoperative Complications After Pediatric Perforated Appendicitis

PURPOSE

Assessment of risk factors for postoperative complications following surgical treatment of pediatric perforated appendicitis (PA) is necessary to identify those patients in need of closer monitoring. In this study, we have investigated the impact of different risk factors on the occurrence of complications after an appendectomy in children with PA.

MATERIAL AND METHODS

The study was a retrospective, single-centre analysis of all pediatric PA conducted over a 10-year period. Preoperative clinical and laboratory results, intraoperative findings, and postoperative complications were analyzed. Risk factors were defined and a risk score was determined for postoperative complications and reinterventions.

RESULTS

Surgical treatment for appendicitis was performed in 840 pediatric patients during the observation period. 163 of the included patients were diagnosed with PA (mean age 8.9 ± 3.6 years). 19 (11.7%) patients developed postoperative complications, 17 (10.4%) of which required complication-related intervention. We identified five predictors of postoperative complications: the C-related protein value at admission, purulent peritonitis, open appendectomy (primary, secondary, or converted), placement of an abdominal drain, and administration of antibiotics not compliant to results from the subsequent antibiogram. The determined risk score was significantly higher in the complication group (p < .0001) and reintervention group (p < .001).

CONCLUSIONS

Postoperative complications following pediatric PA can be predicted using specific preoperative, intraoperative, and postoperative risk factors. In the high-risk group, an active prevention, detection, and intervention of any occurring complication is necessary and we present a new specific pediatric risk score to define patients at risk for complications.

Nuclear accumulation of CDH1 mRNA in hepatocellular carcinoma cells

Expression of E-cadherin has a central role in maintaining epithelial morphology. In solid tumors, reduction of E-cadherin results in disruption of intercellular contacts. Consequently, cells lose adhesive properties and gain more invasive mesenchymal properties. Nevertheless, the mechanism of E-cadherin regulation is not completely elucidated. Here we analyzed the distribution of E-cadherin expression at the cell level in human hepatocellular carcinoma, in which human liver paraffin blocks from 25 hepatocellular carcinoma patients were prepared from cancerous (CA) and noncancerous areas (NCA). In situ hybridization (ISH) was performed to detect E-cadherin and hypoxia-induced factor-1α (HIF1α) mRNAs and immunohistochemistry to stain E-cadherin protein. In parallel, RNA was extracted from CA and NCA, and E-cadherin and HIF1α were quantified by quantitative reverse transcription PCR. ISH revealed abundant E-cadherin mRNA in nuclei of hepatocellular carcinoma cells (HCCs), whereas immunohistochemistry showed depletion of E-cadherin protein from these areas. In sections of NCA, E-cadherin mRNA was also found in the cytosol, and E-cadherin protein was detected on the membrane of cells. Experiments in cell lines confirmed E-cadherin mRNA in nuclei of cells negative for E-cadherin protein. HIF1α expression is elevated in CAs, which is associated with a clear cytosolic staining for this mRNA. Our results demonstrate that E-caderhin mRNA is selectively retained in nuclei of HCCs, whereas other mRNAs are still exported, suggesting that translocation of E-cadherin mRNA from nuclei to cytoplasm has a role in regulating E-cadherin protein levels during epithelial mesenchymal transition.

Toward knowledge-based liver surgery: holistic information processing for surgical decision support

PURPOSE

Malignant neoplasms of the liver are among the most frequent cancers worldwide. Given the diversity of options for liver cancer therapy, the choice of treatment depends on various parameters including patient condition, tumor size and location, liver function, and previous interventions. To address this issue, we present the first approach to treatment strategy planning based on holistic processing of patient-individual data, practical knowledge (i.e., case knowledge), and factual knowledge (e.g., clinical guidelines and studies).

METHODS

The contributions of this paper are as follows: (1) a formalized dynamic patient model that incorporates all the heterogeneous data acquired for a specific patient in the whole course of disease treatment; (2) a concept for formalizing factual knowledge; and (3) a technical infrastructure that enables storing, accessing, and processing of heterogeneous data to support clinical decision making.

RESULTS

Our patient model, which currently covers 602 patient-individual parameters, was successfully instantiated for 184 patients. It was sufficiently comprehensive to serve as the basis for the formalization of a total of 72 rules extracted from studies on patients with colorectal liver metastases or hepatocellular carcinoma. For a subset of 70 patients with these diagnoses, the system derived an average of [Formula: see text] assertions per patient.

CONCLUSION

The proposed concept paves the way for holistic treatment strategy planning by enabling joint storing and processing of heterogeneous data from various information sources.

Brain metastasis from gastrointestinal cancers: a systematic review

BACKGROUND

Brain metastases (BM) from the gastrointestinal tract (GIT) cancers are relatively rare. Despite those advances in diagnostic and treatment options, life expectancy and quality of life in these patients are still poor. In this review, we present an overview of the studies which have been previously performed as well as a comprehensive strategy for the assessment and treatment of BM from the GIT cancers.

METHOD

To obtain information on brain metastases from GIT, we performed a systematic review of Medline, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). The collected data included patient characteristics, primary tumor data and brain metastases data.

RESULT

In our search of the literature, we found 74 studies between 1980 and 2011, which included 2538 patients with brain metastases originated from gastrointestinal cancer. Analysis of available data showed that among 2538 patients who had brain metastases from GIT, a total of 116 patients (4.57%) had esophageal cancer, 148 patients (5.83%) had gastric cancer, 233 patients (9.18%) had liver cancer, 13 patients had pancreas cancer (0.52%) and 2028 patients (79.90%) had colorectal cancer. The total median age of the patients was 58.9 years.

CONCLUSION

Brain metastases have been considered the most common structural neurological complication of systemic cancer. Due to poor prognosis they influence the survival rate as well as the quality of life of the patients. The treatment of cerebral metastasis depends on the patients' situation and the decisions of the treating physicians. The early awareness of a probable metastasis from GI to the brain will have a great influence on treatment outcomes as well as the survival rate and the quality-of-life of the patients.

Randomized clinical trial of stapler versus clamp-crushing transection in elective liver resection

BACKGROUND

Various devices have been developed to facilitate liver transection and reduce blood loss in liver resections. None of these has proven superiority compared with the classical clamp-crushing technique. This randomized clinical trial compared the effectiveness and safety of stapler transection with that of clamp-crushing during open liver resection.

METHODS

Patients admitted for elective open liver resection between January 2010 and October 2011 were assigned randomly to stapler transection or the clamp-crushing technique. The primary endpoint was the total amount of intraoperative blood loss. Secondary endpoints included transection time, duration of operation, complication rates and resection margins.

RESULTS

A total of 130 patients were enrolled, 65 to clamp-crushing and 65 to stapler transection. There was no difference between groups in total intraoperative blood loss: median (i.q.r.) 1050 (525-1650) versus 925 (450-1425) ml respectively (P = 0·279). The difference in total intraoperative blood loss normalized to the transection surface area was not statistically significant (P = 0·092). Blood loss during parenchymal transection was significantly lower in the stapler transection group (P = 0·002), as were the parenchymal transection time (mean(s.d.) 30(21) versus 9(7) min for clamp-crushing and stapler transection groups respectively; P < 0·001) and total duration of operation (mean(s.d.) 221(86) versus 190(85) min; P = 0·047). There were no significant differences in postoperative morbidity (P = 0·863) or mortality (P = 0·684) between groups.

CONCLUSION

Stapler transection is a safe technique but does not reduce intraoperative blood loss in elective liver resection compared with the clamp-crushing technique.

REGISTRATION NUMBER

NCT01049607 (http://www.clinicaltrials.gov).

Models of short bowel syndrome in pigs: a technical review

BACKGROUND

Short bowel syndrome (SBS) is still a life-threatening disease in both children and adults. Although the therapeutic options are improving, challenges still remain, and to overcome these challenges is a major focus of SBS research today. In order to simulate anatomical and physiological conditions similar to those in humans for research, porcine models of SBS are often used. Various approaches for generating SBS models have been described in the literature.

METHODS/RESULTS

In this work, we present a review of different types of porcine models of SBS and outline the differences between those models regarding types of animals, surgical procedures, monitoring, and methods of assessment.

CONCLUSION

The aim of this study was to select the most suitable SBS model regarding the purpose of the research.

Pig kidney transplantation: an up-to-date guideline

BACKGROUND

Swine and human beings have many aspects in common that make swine a well-characterized large animal model for kidney transplantation (KTx). However, pigs have some peculiar anatomical characteristics that standardized techniques must adapt to. The aim of this study was to prepare an up-to-date guideline for porcine KTx.

METHODS

To achieve this goal, we performed a Medline search using the terminology 'kidney' or 'renal' and 'transplantation' and 'pig' or 'swine' or 'porcine'. We found over 1,300 published articles since 1963. Only 13 studies focused on the surgical aspect. Furthermore, we reviewed related books and articles about swine anatomical characteristics and surgery. Finally, our experimental experiences of KTx during the last few decades were added to this collection.

RESULTS

Proper hosting, fasting, anesthesia, medical therapy and monitoring can prevent postoperative complications. Explantation with a Carrel patch of the aorta facilitates the implantation and prevents future stenosis. Native nephrectomy makes the follow-up of the implanted organ more precise. KTx in the infrarenal fossa via end-to-side anastomosis to the aorta and inferior vena cava followed by ureteroureterostomy are the recommended options for KTx in pigs compared to other possible methods.

CONCLUSION

Pigs, with respect to their characterizations, constitute one of the best large animal models for KTx. Preoperative preparations are as important as the intra- and postoperative management. Using the most adaptable methods of surgery with respect to the specific anatomical characteristics of pigs can prevent undermining the studies and avoid preventable complications and pitfalls.

[Neuroendocrine tumors of the duodenum and pancreas. Surgical strategy]

The incidence of neuroendocrine tumors (NET) has increased worldwide by 3-5 times over the last decades. This is mainly based on the broad use of imaging modalities such as computed tomography (CT) and endoscopic approaches. As a consequence many duodenal and pancreatic tumors are detected in an early stage resulting in an improved prognosis of these patients. Besides the measurement of serum chromogranin A and 5-hydroxy indolic acid measured in 24 h urine collection, CT, endosonographic ultrasound (EUS) and endoscopy are important diagnostic tools. About 20% of all patients with pancreatic and duodenal NETs are diagnosed because of specific symptoms. More than 95% of diagnosed NETs are sporadic tumors. Whenever possible these patients should be treated by resection. Benign neuroendocrine duodenal tumors up to 1 cm in size can be removed endoscopically. The endoscopic resection of larger tumors should be performed surgically. The therapy of hereditary NETs of the duodenum and the pancreas should be decided after interdisciplinary discussion. However, even these patients seem to benefit from resection. In case of metastatic disease debulking surgery should be considered if more than 90% of the tumor mass can be resected. In patients with extensive liver metastases but resectable primary NET, liver transplantation is a reasonable option. There is no consensus about adjuvant or neoadjuvant treatment of duodenal or pancreatic NETs. The therapy with everolimus or sunitinib in advanced tumor stages has shown promising results. The administration of somatostatin analogues or antacids is appropriate for symptom reduction.

Prevalence of Toxocara Spp. eggs in Public Parks in Tehran City, Iran

BACKGROUND

The objective of the present research was to determine the frequency of Toxocara spp. eggs in soil samples of public parks, in the city of Tehran, Iran.

METHODS

A total of 600 soil samples were taken from 120 parks between Aprils to November, 2008. Soil samples were collected from 5 distinct sites in the parks. The samples were washed with saline solution and the collected sediment from each park were equally divided and examined by floatation and Petri dish methods for Toxocara eggs.

RESULTS

Ten percent were contaminated with Toxocara spp. eggs. The number of observed Toxocara eggs in each microscopic field was varied from 1-3. No significant differences were observed between floatation and Petri dish methods.

CONCLUSION

Our public parks showed a high risk of toxocariasis and the need for preventive studies.

The role of an interdisciplinary transplant team on living donation kidney transplantation program

During the last decades, the disparity between the organ supply and the demand for kidney transplantation in Europe has led to consider living donors as a more acceptable option. In the last 7 years, we have established an interdisciplinary supporting transplant team to increase the rate of living donation. After 2001, the new interdisciplinary transplant team consisted of a transplant surgeon, a nephrologist, a pediatrician, a radiologist, a psychologist, a transplant coordinator, and a transplant nurse. We performed a prospective analysis to examine the effect of implementing this team on our living donation program. Demographic data, the annual number of procedures, the duration of waiting, and the cold ischemia time were evaluated among brain-dead and living donors. From January 2002 until December 2008, the number of patients who were annually on the waiting list increased 42% (from 377 to 536 patients). Consequently, the number of the total kidney transplants increased from 81 to 120 with an annual median of 98 cases. By implementing the interdisciplinary transplant team, a significant increase of living kidney donors was observed: from 18 to 42 cases; median = 27). In the last 7 years, a total number of 796 kidney transplants have been performed: 567 from brain-dead and 229 from living donors. In 2001, the waiting list times for recipients who received grafts from brain-dead versus living donors were 1356 versus 615 days respectively. Compared with 2008, the duration on the waiting list decreased significantly for patients receiving a living donor graft, whereas there was a slight increase for the patients in the brain-dead group: brain death versus living donors: 1407 versus 305 days. The interdisciplinary approach has also reduced the cold ischemia time for the living donor recipients: 3 hours and 42 minutes in 2001 versus 2 hours and 50 minutes in 2008. During the last years, by implementing an interdisciplinary transplant team, supporting living donor procedures has produce a gradual increase in the number of kidney transplants from living donors with a remarkable decrease in waiting and cold ischemia times, the latter presumably influencing graft quality.

Emergency liver transplantation after umbilical hernia repair: a case report

We report a rare case of acute liver failure due to embolization of the liver after an umbilical hernia repair in a patient with Child B liver cirrhosis and status posttransjugular intrahepatic portosystemic shunt (TIPSS). This patient initially presented with a symptomatic umbilical hernia. His umbilical vein was open (Cruveilhier-Baumgarten syndrome). After hernia repair the patient developed thrombosis of the umbilical vein with consequent partial embolization to, and acute failure of, the liver. The patient underwent successful emergency liver transplantation. This disease needs close collaboration among surgeons, gastroenterologists, hepatologists, radiologists, nutritionists, and transplant teams to establish an effective treatment plan.

A single center experience of combined liver kidney transplantation

With advancements in the operative techniques, patient survival following liver transplantation (LTx) has increased substantially. This has led to the acceleration of pre-existing kidney disease because of immunosuppressive nephrotoxicity making additional kidney transplantation (KTx) inevitable. On the other hand, in a growing number of patients on the waiting list to receive liver, long waiting time has resulted in adverse effect of decompensated liver on the kidney function. During the last two decades, the transplant community has considered combined liver kidney transplantation (CLKTx) to overcome this problem. The aim of our study is to present an overview of our experience as well as a review of the literature in CLKTx and to discuss the controversy in this regard. All performed CLKTx (n = 22) at our institution as well as all available reported case series focusing on CLKTx are extracted. The references of the manuscripts were cross-checked to implement further articles into the review. The analyzed parameters include demographic data, indication for LTx and KTx, duration on the waiting list, Model for End-Stage Liver Disease (MELD) score, Child-Turcotte-Pugh (CTP) score, immunosuppressive regimen, post-transplant complications, graft and patient survival, and cause of death. From 1988 to 2009, a total of 22 CLKTx were performed at our institution. The median age of the patients at the time of CLKTx was 44.8 (range: 4.5-58.3 yr). The indications for LTx were liver cirrhosis, hyperoxaluria type 1, polycystic liver disease, primary or secondary sclerosing cholangitis, malignant hepatic epithelioid hemangioendothelioma, cystinosis, and congenital biliary fibrosis. The KTx indications were end-stage renal disease of various causes, hyperoxaluria type 1, polycystic kidney disease, and cystinosis. The mean follow-up duration for CLKTx patients were 4.6 +/- 3.5 yr (range: 0.5-12 yr). Overall, the most important encountered complications were sepsis (n = 8), liver failure leading to retransplantation (n = 4), liver rejection (n = 3), and kidney rejection (n = 1). The overall patient survival rate was 80%. Review of the literature showed that from 1984 to 2008, 3536 CLKTx cases were reported. The main indications for CLKTx were oxalosis of both organs, liver cirrhosis and chronic renal failure, polycystic liver and kidney disease, and liver cirrhosis along with hepatorenal syndrome (HRS). The most common encountered complications following CLKTx were infection, bleeding, biliary complications, retransplantation of the liver, acute hepatic artery thrombosis, and retransplantation of the kidney. From the available data regarding the need for post-operative dialysis (n = 673), a total of 175 recipients (26%) required hemodialysis. During the follow-up period, 154 episodes of liver rejection (4.3%) and 113 episodes of kidney rejection (3.2%) occurred. The cumulative 1, 2, 3, and 5 yr survival of both organs were 78.2%, 74.4%, 62.4%, and 60.9%, respectively. Additionally, the cumulative 1, 2, 3, and 5 yr patient survival were 84.9%, 52.8%, 45.4%, and 42.6%, respectively. The total number of reported deaths was 181 of 2808 cases (6.4%), from them the cause of death in 99 (55%) cases was sepsis. It can be concluded that there is still no definitive evidence of better graft and patient survival in CLKTx recipients when compared with LTx alone because of the complexity of the exact definition of irreversible kidney function in LTx candidates. Additionally, CLKTx is better to be performed earlier than isolated LTx and KTx leading to the avoidance of deterioration of clinical status, high rate of graft loss, and mortality. Shorter graft ischemia time and more effective immunosuppressive regimens can reduce the incidence of graft malfunctioning in CLKTx patients. Providing a model to reliably determine the need for CLKTx seems necessary. Such a model can be shaped based upon new and precise markers of renal function, and modification of MELD system.

Interventional radiologic procedures in the treatment of complications after liver transplantation

The aim of this study is to report our interventional radiologic procedures (IRP) in liver transplant (LTX) patients. These include procedures for biliary, arterial, venous, and portal complications, as well as the treatment of infected and non-infected fluid collections. This retrospective study covered 583 patients (mean age: 44 +/- 14 yr) in whom a total of 685 LTX were performed from August 1987 to April 2005. Overall, 182 LTX patients underwent a total of 428 IRP, including digital subtraction angiography (n = 152/35.51%), percutaneous transluminal angioplasty (PTA) (n = 4/0.93%) and PTA + stent (n = 7/1.63%) of arterial anastomosis, PTA + stent of the celiac trunk (n = 2/0.46%), transjugular intrahepatic portosystemic shunt (TIPS) (n = 2/0.46%), arterial lysis (n = 4/0.93%), venous lysis (n = 2/0.46%), inferior vena cava stenting (n = 2/0.46%), percutaneous biliary drainage (n = 34/7.94%), percutaneous transluminal dilatation (PTD) of the choledocho-enteric anastomosis (n = 16/3.73%), biliary stent (n = 5/1.16%), intrahepatic biliary flushing treatment, stone and cast biliary extraction (n = 27/6.30%), other interventions (e.g., embolization in other regions, transjugular liver biopsies, lymphangiographies) (n = 9/2.10%), and ultrasound- and computer tomography-guided biopsies and percutaneous drainage (n = 153/35.74%). The overall success rate was 85.7%. Technical improvements in LTX and interventional radiology permit vascular and biliary complications to be treated successfully by interventional radiology.

Evaluation of the combined laparoscopic and mediastinoscopic esophagectomy technique

BACKGROUND

Laparoscopic esophagectomy is technically difficult especially during dissection in the upper mediastinum. This limitation may be surpassed with the help of mediastinoscopy or of the recently introduced robotic surgical systems. The aim of the present study was to evaluate in an experimental porcine model the feasibility of the combined laparoscopic and mediastinoscopic transhiatal esophagectomy technique and to compare it with the robotic-assisted transhiatal and conventional approaches.

MATERIALS AND METHODS

Transhiatal esophagectomy was performed in Landrace pigs under general anesthesia using three different techniques: Group A (n = 9): combined laparoscopic and mediastinoscopic, group B (n = 4): robotic-assisted and group C (n = 8): conventional "open". The feasibility, difficulty and accuracy of the procedure along with operative time, blood loss, intraoperative incidents and overall satisfaction of the surgical team were assessed for each technique.

RESULTS

Operations in group A were feasible and reproducible. Although the procedure was technically difficult, the constant view on the operative field was highly appreciated by the operative team and facilitated an accurate and safe dissection. The main intraoperative complications were related to the side-effects of tension pneumothorax accompanying pleural injuries. In group B the features of the robotic system reduced the difficulty of dissection and obviated the need for mediastinoscopy. Operations in group C were quick and almost incident-free, facilitated also by the particularities of the animal model that could not reproduce identically the clinical situation.

CONCLUSIONS

The combined laparoscopic and mediastinoscopic esophagectomy technique is feasible and offers certain advantages over the open approach while the robotic-assisted approach is an emerging less difficult alternative. Further studies are required to establish whether the advantages of minimally-invasive approach compensate for the increased technical difficulty and prolonged operative time.

No relevant difference in quality of life and functional outcome at 12 months' follow-up-a randomised controlled trial comparing robot-assisted versus conventional laparoscopic Nissen fundoplication

PURPOSE

The present randomised pilot trial was designed to compare robot-assisted (RALF) and conventional laparoscopic fundoplication (CLF) focussing on post-operative quality of life (QOL) and functional outcome. Any long-lasting advantages for patients in this regard could be a justification for the use of RALF for the treatment of gastroesophageal reflux disease (GERD).

METHODS

Forty patients with GERD were randomised to either RALF or to CLF. During a follow-up period of 12 months, patients' QOL and functional outcome were investigated using disease-specific questionnaires.

RESULTS

There were no significant differences in the mean QOL (1.3 versus 1.1; P = 0.374) and functional outcome (1.27 versus 1.3; P = 0.913) between both groups. Minor side effects such as bloating and persistent diarrhoea were present in four patients of each group.

CONCLUSION

The present study did not show any benefit for RALF over CLF regarding QOL and functional outcome at 12 months' follow-up.

Gas-chamber mediastinoscopy for dissection of the upper esophagus

AIM

Mediastinoscopy has the potential to bring under view the upper mediastinum, the area most difficult to dissect during transhiatal esophagectomy. The aim of the present study was to evaluate in an animal model the feasibility of the gas-chamber mediastinoscopy technique for dissection of the upper esophagus.

METHODS

Operations were performed in nine Landrace pigs using a 30 degrees laparoscope and conventional 35-cm laparoscopic instruments. Through a left collar incision a virtual space was created with sharp and blunt dissection around the cervical esophagus and insufflated with CO2 at a pressure of 5 mmHg. Using one 10-mm optical trocar and two 5-mm working trocars dissection advanced in the periesophageal space with the aim to reach at least to the tracheal bifurcation.

RESULTS

Performed under visual control, the procedure was accurate and safe, the level of tracheal bifurcation being reached in all cases. Anatomical structures such as trachea and its bifurcation, pleura, pericardium, arch of the azygos vein and periesophageal lymph nodes were visible during the operation. There were no major intraoperative incidents and blood loss was minimal.

CONCLUSIONS

The technique of gas-chamber mediastinoscopy is feasible. It allows a fair amount of freedom of movement for the working instruments and offers a good view on the operative field for a controlled and accurate dissection. Further evaluation in experimental and clinical studies is required to establish the role of this procedure in esophageal surgery.

Thymoglobulin and ischemia reperfusion injury in kidney and liver transplantation

Since the beginning of organ transplantation, graft preservation has been one of the most important concerns. Ischemia reperfusion injury (IRI), which plays an important role in the quality and function of the graft, is a major cause for increased length of hospitalization and decreased long term graft survival. Among numerous attempts which have been made to minimize graft damage associated with IRI, the use of Thymoglobulin (TG) seems to offer potential benefits. TG is a polyclonal antibody which blocks multiple antigens related to IRI, in addition to its better known T cell depleting effects. This review will focus on the use of TG in preventing IRI in kidney transplantation (KTx) and liver transplantation (LTx). Different studies in experimental and clinical transplantation have shown that TG protects renal and liver grafts from IRI. Improvement in early graft function and decreased delayed graft function (DGF) rates are some of the clinical benefits of TG. Additionally, it is used in patients with hepatorenal syndrome to support the recovery of kidney function after LTx, by allowing reduced exposure to nephrotoxic calcineurin inhibitors as well as improving liver graft function by minimizing IRI. TG can reduce acute rejection rates in kidney and liver transplant recipients, decrease the length of hospital stay, and hence reduce transplantation costs. TG can play an important role in expanding the donor pool in both KTx and LTx by improving long-term graft and patient survival rates which increases the possibility of using marginal donors. Although controversial, the development of post-transplant lymphoproliferative disorder is a potential side effect of TG. No single optimal immunosuppressive regimen has given consistent results in decreasing the graft damage following IRI; however, TG usage in KTx and LTx appears to have some benefits in reducing IRI.