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Key Clinical Message The robotic modified Strong procedure is a safe and effective approach for surgical management of superior mesenteric artery syndrome in properly selected patients. Abstract Superior mesenteric artery syndrome is a rare syndrome of small bowel obstruction resulting from vascular compression of the duodenum. Here we present our modification of a robotic Strong procedure for the surgical management of SMA syndrome. This procedure is a safe and effective approach for management in properly selected patients.

IntroductionLeiomyosarcomas (LMS) involving the inferior vena cava (IVC) is a clinically rare entity, accounting for approximately 0.5% of all adult sarcomas.Case presentationA 67-year-old male presented to the emergency department with mild back and lower abdominal pain. During the workup, a computed tomography scan without contrast showed an area of decreased attenuation within the liver adjacent to the intrahepatic IVC. Magnetic resonance imaging confirmed the involvement of the retro-hepatic IVC; biopsy confirmed the diagnosis of LMS. Given the location of the involvement of the retro-hepatic IVC, liver explantation was deemed necessary for adequate tumor resection. The superior extension of the tumor toward the heart necessitated Cardio-Pulmonary (CPB). The patient successfully underwent a complex surgical procedure involving liver explantation with ex vivo back-table resection of the retro-hepatic LMS, replacement of the retro-hepatic vena cava with a ringed Gore-Tex graft, liver re-implantation, and hepatic vein-atrial reconstruction under cardiopulmonary bypass. There were no intraoperative or post-op complications.DiscussionThe role of vascular reconstruction of the IVC varies depending on the level and extent of the tumor, with options ranging from primary repair, ligation, or reconstruction dictated. Surgical resection with negative margins remains the treatment of choice due to the lack of efficacy of adjuvant therapies. Importantly, liver explantation offers a chance for complete surgical resection and reconstruction. Similarly, the complex nature of the tumor necessitated a pioneering approach involving direct hepato-atrial venous anastomosis.ConclusionTo the best of our knowledge, this is the first reported case in which the hepatic veins were anastomosed directly to the right atrium while also replacing the native vena cava with a separate graft.

Objective: To understand patient perceived acceptability of participating in a telehealth delivered group-based education and exercise-therapy program for knee osteoarthritis. Design: This qualitative study involved semi-structured, one-on-one interviews with knee osteoarthritis patients who have completed the Good Living with osteoArthritis from Denmark (GLA:D®) program via telehealth or in-person. Interviews were recorded, transcribed verbatim, coded, and analysed using an inductive content analysis approach, focusing on themes related to telehealth. Results: Nineteen participants [12 (63%) female, mean aged 62 years, range 49–72 years] were included. Eleven (58%) received GLA:D® via telehealth and 8 (42%) attended in-person sessions. Two overarching themes (6 sub-themes) related to telehealth perceived acceptability were identified: 1) Perceptions of telehealth acceptability was highly influenced by exposure. Individuals who had received telehealth considered it easy, convenient, and flexible, whereas telehealth was perceived to be inferior and misunderstood by those without exposure. 2) Telehealth participants reported similar program benefits to in-person participants, including reduced fear of pain and joint damage, changed beliefs in value of exercise, and stated improvements in pain and function. Conclusions: Telehealth delivery of group-based education and exercise-therapy for knee osteoarthritis was acceptable for people who had experienced it and provides similar benefits as in-person care for pain and beliefs about the safety and value of exercise. Wider implementation of telehealth group-based education and exercise-therapy may improve access to high value care for people with knee osteoarthritis.

BackgroundOrthotopic liver transplantation (OLT) is the best available option for early hepatocellular carcinoma (HCC), although its application is limited by stringent selection criteria, costs, and deceased donor graft shortage, particularly in Asia, where living donor liver transplant (LDLT) has been developed.MethodsThis article reviews the present standards for patient selection represented by size-and-number criteria with particular references to Milan Criteria and novel prediction models based on results achieved in patients exceeding those limits, with consideration of the expanded indication represented by the UCSF Criteria.ResultsThe expected outcomes after deceased donor liver transplant (DDLT) or LDLT are favorable if predetermined selection criteria are applied. However, selection bias, difference in waiting time, and ischemia-regeneration injuries of the graft among DDLT vs LDLT may influence long-term results. In the article, the differences between East and West in first-line treatments for HCC (resection vs transplantation), indications, and ethics for the donor, are summarized as well as possible novel predictors of tumor biology (especially DNA mutation and fractional allelic loss, FAI) to be considered for better outcome prediction.ConclusionsLiver transplantation remains the most promising product of modern surgery and represents a cornerstone in the management of patients with HCC.

Many glaciers on the Antarctic Peninsula have retreated and accelerated in recent decades. Here we show that there was a widespread, quasi-synchronous and sustained increase in grounding line discharge from glaciers on the west coast of the Antarctic Peninsula since 2018. Overall, west Antarctic Peninsula discharge trends increased by over a factor of three, from 0.5 Gt/y/decade during 2017 to 2020 up to 1.6 Gt/y/decade in the years following, leading to a grounding line discharge increase of 7 Gt/y (7.4%) since 2017. The acceleration in discharge was concentrated at glaciers connected to deep, cross-shelf troughs hosting warm ocean waters, and the acceleration occurred during a period of anomalously high subsurface water temperatures on the continental shelf. Given that many of the affected glaciers have retreated over the past several decades in response to ocean warming, thereby highlighting their sensitivity to ocean forcing, we argue that the recent period of anomalously warm water was likely a key driver of the observed acceleration. However, the acceleration also occurred during a time of anomalously high atmospheric temperatures and glacier surface runoff, which could have contributed to speed-up by directly increasing basal water pressure and, by invigorating near-glacier circulation, increasing submarine melt rates. The spatial pattern of glacier acceleration therefore provides an indication of glaciers that are exposed to warm ocean water at depth and/or have active surface-to-bed hydrological connections. Both atmospheric and ocean temperatures in this region and its surroundings are likely to increase further in the coming decades, suggesting that discharge increases may continue and become more widespread. [ABSTRACT FROM AUTHOR]