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Abstract: Objective: Femoral neuropathy is a rare but disabling complication following renal transplantation and pelvic surgery in general. In a retrospective review, we analyzed the incidence, clinical presentation, and outcome of this complication after renal transplantation in our center. In addition, we conducted a literature search on this complication. Materials and Methods: Five cases of isolated femoral neuropathy after renal transplantation were encountered at our center, out of 3,448 renal transplantations performed over a 47-year period. Results: All of these patients presented with a weakness of hip flexion (iliopsoas muscle) and knee extension (quadriceps muscle) starting immediately after surgery. Atrophy of the quadriceps became apparent in severe and prolonged cases. In addition, numbness and paresthesia located in the anteromedial part of the thigh were present in 3 patients. Conclusion: Isolated neuropathy of the femoral nerve is a rare but disabling complication after renal transplantation. The etiology of isolated femoral neuropathy often results from direct compression of the femoral nerve or from indirect compression on the psoas muscle by application of self-retaining retractors placed during pelvic surgery. Other factors that can play a role in the pathogenesis are related to direct ischemia of the nerve by clamping of the iliac artery, thus interrupting the pelvic blood supply to the femoral nerve during the vascular anastomosis or vessel dissection, or by postoperative hematoma in the retroperitoneum or psoas muscle. Meticulous surgery and careful positioning of the self-retaining retractors during surgery are pivotal to avoid this complication which transplant surgeons should be aware of. [Copyright &y& Elsevier]

Evidence suggests that structured training programs for laparoscopic procedures can ensure a safe standard of skill acquisition prior to independent practice. Although minimally invasive esophagectomy (MIO) is technically demanding, no consensus on requirements for training for the MIO procedure exists. The aim of this study is to determine essential steps required for a structured training program in MIO using the Delphi consensus methodology. Eighteen MIO experts from 13 European hospitals were asked to participate in this study. The consensus process consisted of two structured meetings with the expert panel and two Delphi questionnaire rounds. A list of items required for training MIO were constructed for three key domains of MIO, including (1) requisite criteria for units wishing to be trained and (2) to proctor MIO and (3) a framework of a MIO training program. Items were rated by the experts on a scale 1-5, where 1 signified 'not important' and 5 represented 'very important.' Consensus for each domain was defined as achieving Cronbach alpha ⩾0.70. Items were considered as fundamental when ⩾75% of experts rated it important (4) or very important (5). Both Delphi rounds were completed by 16 (89%) of the 18 invited experts, with a median experience of 18 years with minimally invasive surgery. Consensus was achieved for all three key domains. Following two rounds of a 107-item questionnaire, 50 items were rated as essential for training MIO. A consensus among European MIO experts on essential items required for training MIO is presented. The identified items can serve as directive principles and core standards for creating a comprehensive training program for MIO. [ABSTRACT FROM AUTHOR]

The accepted importance of a positive circumferential resection margin (CRM) (defined as R1 in the TNM classification) is based on histopathology of the resection specimen obtained after primary surgery in esophageal cancer patients. The aim of this study is to look for the prognostic value of CRM after neoadjuvant chemoradiotherapy and to compare the clinical significance of a histologically CRM < 1 mm from the cut margin (Royal College of Pathologists definition of R1) to a positive cut margin (College of American Pathologists definition of R1) and to ≥1 mm margin (R0) resections in patients with ypT3-esophageal tumors after neoadjuvant chemoradiotherapy. Between 2000 and 2014, 458 patients who received esophagectomy after neoadjuvant chemoradiation therapy were selected. Overall (OS) and disease-free survival (DFS) were calculated by means of Kaplan-Meier curves and compared by Cox regression analysis. There were 163 (35.9%) patients who had a ypT3 tumor; in 118 (72.4%) resection was complete (R0). In 37 (22.7%) patients a CRM < 1 mm was found and 8 (4.9%) had a circumferential R1-resection. CRM involvement was inversely correlated with tumor regression grading, lymph node capsular involvement, and number of positive lymph nodes. On univariate analysis, no statistically significant difference was found between R0-resection and CRM < 1 mm (P = 0.103) for OS, but DFS showed a significant difference (P = 0.025). Circumferential R1-resections showed a significant difference compared to R0-resections for OS and DFS (both P = 0.002). In multivariate analysis, extracapsular lymph node involvement and circumferential R1-resection were withheld as independent prognosticators for OS, whereas extracapsular lymph node involvement, absence of regression on the primary tumor and circumferential R1-resection were withheld for DFS. After correcting for different variables in the multivariate model, CRM < 1 mm showed no statistical difference compared to R0-resections neither for OS nor for DFS. After neoadjuvant chemoradiotherapy, CRM is correlated with biological behavior of the tumor and with therapy response. Furthermore it is an independent prognosticator for OS and DFS. HoweverCRM<1mm itself is no independent prognosticator for OS nor DFS survival in multivariable analysis. These results suggest that the definition of R1-resection should be limited to true invasion of the section plane. [ABSTRACT FROM AUTHOR]

Recurrent disease after esophagectomy bears an infaust prognosis, especially when multiple recurrences are present. But little is known about survival in patients with limited recurrence (solitary locoregional recurrence or solid organ metastasis). Herein, we report our experience with these subgroups. We analyzed 1754 consecutive patients surgically treated with curative resection for esophageal cancer and cancer of the gastroesophageal junction between 1990 and 2012. Seven subgroups were defined according to the recurrence type (locoregional vs. organ metastasis), the site of recurrence (abdominal, thoracic, cervical for lymph nodes and lung, liver, adrenals and others for organ metastasis) and also the number of lesions (one vs. multiple lymph node stations or organ metastasis) Of these groups; clinical isolated locoregional recurrence (ciLR) was defined as solitary lymph-node recurrence confined to one compartment (cervical, thoracic or abdominal, within or outside surgical dissection-field) at clinical staging. Clinical solitary solid organ metastasis (csSOM) was defined as metastasis in a resectable solid organ, i.e. liver, lung, brain or adrenal. Salvage therapies were grouped in five categories. Kaplan-Meier curves were used to calculate survival. Recurrent disease was observed in 766 patients (43.7%) with overall 5-year survival of 4.5% after diagnosis of recurrence. Fifty-seven patients (7.4%) showed ciLR and 110 (14.4%) csSOM. Median timeto-recurrence was 16.8 months in ciLR and 9.9 months in csSOM (P=0.0074). Survival is significantly improved compared to supportive therapy when local therapy is possible (P<0.0001). In 25 (15%) of ciLR or csSOM patients, surgical therapy with or without systemic therapy, yielded a 5-year survival of 49.9% (median 54.8 months) after diagnosis of recurrence. When surgery was impossible or contraindicated, the combination of chemoradiotherapy appeared to be superior to chemotherapy alone (respectively 27.0% vs. 4.6% 5-year survival) or radiotherapy alone (no 5-year survival). Recurrent disease after esophagectomy is a common problem with poor overall survival. However prolonged survival could be obtained in selected patients if the recurrent disease is limited to ciLR or csSOM, if surgery (+/- systemic therapy) can be performed. If not a combination of chemoradiotherapy seems to offer the second best option. Patients presenting with a ciLR or csSOM should be discussed in a dedicated multidisciplinary team meeting as to evaluate and define the place of salvage treatment which in well selected cases could offer a perspective of prolonged survival. [ABSTRACT FROM AUTHOR]

Extended-criteria donors have been widely used to enlarge the donor pool. However, experience with lung transplantation (LTx) from older donors (≥ 70 years) is limited. This study aims to describe our experience with septuagenarian and octogenarian donors and compare short- and long-term outcome using a propensity-matched cohort of younger donors (< 70 years). All bilateral LTx between 2010 and 2020 were retrospectively analyzed. Matching was performed for donor (type, gender, smoking history, X-ray abnormalities, P/F ratio, time on ventilator) and recipient characteristics (age, gender, LTx indication, perioperative ECMO, CMV mismatch) resulting in a 1:1 matching. Primary graft dysfunction (PGD) grade 3 (within 72 hours), 5-year patient survival and chronic lung allograft dysfunction (CLAD)-free survival were analyzed. We performed 695 LTx, 69 with donors ≥ 70 years. Mean age in the older donor group (47 female/22 male) was 74 years (range 70-84 years) vs. 49 years (range 12-69 years) in the younger group (45 female/24 male). Overall acceptance rate for the lungs was 8.2% in the older group vs. 25.9% in the younger group. No significant differences were observed in length of ventilatory support, ICU or hospital stay. PGD 3 in the older cohort occurred in 26.1% similar to 29.0% for recipients of younger donors (P=0.85). Reoperation rate was comparable (29.0% vs. 15.9%, respectively; P=0.10). Follow-up bronchoscopy revealed no differences in rate of anastomotic complications (P=1.00). Patient 5-year survival was 73.6% vs. 73.1%, respectively (P=0.72). CLAD-free 3- and 5-year survival was 60.8% and 51.5% vs. 68.6% and 59.2%, respectively (P=0.41). LTx from selected donors ≥ 70 years is feasible and safe, yielding comparable short- and long-term outcome in a propensity-matched analysis with younger donors. Given this large potential, it is important to further analyze long-term outcome and processes of aging in this population. [ABSTRACT FROM AUTHOR]

Background Small-sized patients with cystic fibrosis usually face long waiting times for a suitable lung donor. Reduced-size lung transplantation (LTx) was promoted to shorten waiting times. We compared donor and recipient characteristics and outcome in lobar ([L]) versus full-size ([FS]) lung recipients. Methods Between July 1, 1991, and February 28, 2011, 535 isolated LTx were performed, including 74 in cystic fibrosis patients (8 L, 66 FS). Patients were followed up until September 2012. Results [L] recipients were younger, smaller, and lighter. Sex, waiting times, and donor data (age, sex, height, weight, PaO 2 /FiO 2 , and ventilation time) were comparable. Cardiopulmonary bypass was used more often in [L]; cold ischemia was comparable for first lung but longer in [L] for second lung; implantation times were comparable. In-hospital mortality rate was 0% in [L] versus 3% in [FS]. Both intensive care unit and hospital stay were longer in [L]. Grade 3 primary graft dysfunction was more pronounced in [L] at T0 and at T48. FEV 1 increased significantly in both groups from preoperative value. Bronchiolitis obliterans syndrome was absent in [L] and diagnosed in 18 patients in [FS], accounting for 6 of 15 late deaths. All [L] are still alive. No differences in survival were found between the groups. Conclusions Although hindered by a higher incidence of primary graft dysfunction, L-LTx is a viable option with excellent survival and pulmonary function comparable to FS-LTx. [ABSTRACT FROM AUTHOR]

Esophago-pleural fistula (EPF) is a rare surgical complication with important morbidity and mortality. Generally, EPFs present as a recurrent or chronic respiratory infection, empyema, or hemorrhage. Diverse diagnostic and multimodal treatment strategies can be considered including stenting, endoluminal clipping, as well as surgical repair. We present the diagnostic and therapeutic challenges of a unique case of EPF after bilateral lung transplantation (BLTx). A 62-year-old male with scleroderma and secondary pulmonary arterial hypertension underwent BLTx under VA-ECMO for acute deterioration of his underlying lung fibrosis. Early recovery was uncomplicated with weaning from ECMO on post-operative day (POD) 2, successful extubation on POD 3 and discharge to the ward on POD 13. However, 2 days later he developed acute respiratory distress due to a right-sided pneumothorax. Chest drainage did not suffice and on POD 18 a thoracoscopic exploration for empyema was performed. On POD 26, semi-digested food was seen in the chest tube. Esophagogastroscopy with methylene blue confirmed leakage and two separate EPFs. Nil per os policy was started. On POD 32 endoluminal clipping was attempted and esophagogastroscopy showed healing of the upper fistula, though persistence of the lower one. Additional clipping of the distal EPF was performed. Despite clinical improvement, a new esophagogastroscopy on POD 71 revealed a new fistula between the endoluminal clips. Ultimately, the EPF was primarily closed and covered with an intercostal muscle flap trough right-sided thoracotomy on POD 105. Nine days after surgical closure, a contrast esophagogram showed no residual leakage. The patient experienced a slow but gradual recovery and oral intake was started successfully. At 2.5 years post-BLTx, the patient has a normal oral intake and spirometry shows a good pulmonary function without signs of rejection or chronic lung allograft dysfunction. Post-operative EPF is a life-threatening situation, especially in immunocompromised patients. A low threshold of clinical suspicion and esophagogastroscopy are warranted to impede the diagnosis of EPF. In our experience, minimal invasive endoscopic strategies should be considered first, however, surgical treatment with primary suture and muscle coverage has the highest chance to be effective. [ABSTRACT FROM AUTHOR]

In countries with a legal framework for physician-assisted death, organ donation after euthanasia (DCD-V) can increase the donor pool. DCD-V grafts are characterized by absence of lung injury related to brain-death, intubation and a long agonal phase. We review our experience with LTx after DCD-V and compare outcome with DBD and DCD-III experience in the same era. Between 01/2007-09/2019, 797 LTx were performed, of which 158 from DCD donors, including 20 DCD-V {8M/12F; mean age (range): 50 (28-66y)} due to neuromuscular (8) / mental (9) disorder or untreatable pain (3). After the request for euthanasia was granted in accordance with legislation, an explicit wish for organ donation was expressed by the patient and approved by the Institutional Review Board. Euthanasia was carried out in-hospital (local: 4; remote: 16) adjacent to the operating room in absence of the retrieval team. Twenty patients {7M/13F; age: 53y (27-64)} underwent bilateral LTx for emphysema (n=10), pulmonary fibrosis (n=5), cystic fibrosis (n=3, liver transplant in 1) and bronchiolitis obliterans (n=2). Waiting time was 326d (34-662). Agonal phase was short: 3min (0-14). Warm ischemia time between circulatory arrest and flush was 12min (7-21). Intensive care unit and hospital stay were 6d (2-10) and 28d (16-44). Three patients died due to cardiac problem (3mo), haematological disorder (3mo) or aspergillosis (10y). Follow-up was 4y (2mo-10.5y), CLAD occurred in 4. Five-year patient survival for DCD-V was 89%, equaling the DBD {80% (p=0.68)} and DCD-III cohort {81% (p=0.78)}. CLAD-free survival was 66.7%, equal to DBD {68.2% (p=0.68)} and DCD-III {69.9% (p=0.91)}. Our series represents the largest LTx experience from DCD-V and demonstrates for the first time that long-term outcome is comparable with DBD and DCD-III. DCD-V can further expand the donor pool in nations with a legal framework for physician-assisted death. [ABSTRACT FROM AUTHOR]