Search

Background: To present abdominal multi-slice computed tomography (MSCT) results following transplantation in pediatric patients with a liver transplantation (LT), and to create awareness of early (<3 months) and late (>3 months) complications that may occur., Methods: This retrospective study included 119 children with an LT performed in our hospital from 2014 to 2017. The descriptive statistics relating to patients' age, gender, transplantation indications, transplantation technique, and MSCT findings were calculated, and are presented as numbers and percentages. The complications were divided into 4 groups: vascular, biliary, parenchymal, and extraparenchymal., Results: The LT procedures were performed with organs from living donors for 83 patients, and from deceased donors for 36 patients. Hepatic artery and portal vein complications were mostly seen in the early period (n = 18), and hepatic vein complications were also observed in the late period (n = 6). The most commonly encountered biliary complications were stenosis/stricture (n = 13) and bile leak/ bilioma (n = 9). Stenosis/stricture frequently occurred in the late period. The most common parenchymal complications were ischemic infarct (n = 8) in the early period, and abscess (n = 4) and recurrent hepatoblastoma (n = 2) in the late period. Hematoma (n = 7), intestinal perforation (n = 3), and focal spleen infarct (n = 3) were among the most commonly observed extraparenchymal abdominal complications., Conclusion: The complications occurring after pediatric LT varied according to the time after surgery and the transplantation technique used. Using MSCT, different abdominal complications can be assessed simultaneously, greatly contributing to diagnosis and treatment.

A 58-year-old woman with a previous clam ileocystoplasty was referred to the urology department for the investigation of haematuria. CT urogram showed a large left-sided soft tissue mass arising from the bladder. Histological analysis of the shavings from transurethral resection revealed a G3pT2 transitional cell carcinoma and T4N1Mx adenocarcinoma. The patient was referred to oncology for the discussion of palliative chemotherapy; however, in the interim she deteriorated and was admitted to hospital with a post-renal acute kidney injury. A right-sided nephrostomy was inserted relieving her obstruction and she subsequently made a good recovery. This case report illustrates the difficulties in the long-term follow-up of patients having undergone what is now a rarely performed procedure. In the absence of regular cystoscopic follow-up post ileocystoplasty, malignancy may present late and with complications from advanced disease., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: To analyze the effectiveness of fat and fibrin glue to prevent postoperative cerebrospinal fluid (CSF) leak in pituitary surgery., Material and Methods: Two hundred and eleven patients affected by pituitary adenoma entered this study. Patients that underwent a microscopic transsphenoidal approach between January 2013 and April 2019 were included. All the patients that developed intraoperative CSF leak were treated with fat and fibrin glue. The presence or absence of postoperative CSF leak was considered as a parameter to test the effectiveness of the intraoperative reconstruction technique used., Results: Postoperative CSF leak was observed in 5 patients (2.4%). Among patients with an intraoperative low- grade CSF leak (1 or 2), 97.9% did not develop a postoperative CSF leak. In contrast, those who presented an intraoperative CSF leak of grade 3, had a worse prognosis., Conclusion: Fat and fibrin glue is currently an effective method in the treatment of low-grade intraoperative CSF leak. In case of intraoperative CSF leak of grade 3, it should be used combined with the nasoseptal flap technique to obtain a safer reconstruction.

Purpose: The purpose of the study was to determine the change in the graft bending angles at the femoral and tibial tunnel aperture in single-bundle posterior cruciate ligament (PCL) reconstruction. It was hypothesized that different knee flexion and different tunnel directions may affect changes of the femoral and tibial graft bending angle., Methods: The right knees of 12 male subjects were scanned with a high-resolution computed tomography scanner at 4 different knee flexion angles (0°, 45°, 90° and 135°). To begin with, the 3D knee models were created and manipulated with the use of several modeling programs. Single-bundle PCL reconstruction was then virtually conducted in a 90° flexion model: The femoral and tibial graft bending angle, according to the various knee flexion angles, was calculated using a special software program., Results: The femoral graft bending angle significantly decreased as the knee flexion increased between 0° and 135° (all p < 0.001). The femoral graft bending angle of the AL graft showed the most obtuse angles among the three types of the graft beyond 45° of knee flexion. For the tibial graft bending angle, the anteromedial tunnel group showed significantly more acute tibial graft bending angle than the anterolateral tunnel group in all three types of the graft at all flexion angles (all p < 0.001)., Conclusion: Changes in the femoral graft bending angle were generally affected by different knee flexion angles. The effect of tibial tunnel direction on the tibial graft bending angle was found to be significant. The clinical relevance is that a mostly obtuse femoral graft bending angle was shown by the AL graft among three types of the graft.

Background: Ex vivo lung perfusion (EVLP) permits extended evaluation of donor lungs for transplant. However, the optimal EVLP duration of Lund protocol is unclear. Using human lungs rejected for clinical transplant, we sought to compare the results of 1 versus 2 h of EVLP using the Lund protocol., Methods: Twenty-five pairs of human lungs rejected for clinical transplant were perfused with the Lund EVLP protocol. Blood gas analysis, lung compliance, bronchoscopy assessment, and perfusate cytokine analysis were performed at both 1 and 2 h. Recruitment was performed at both time points. Donor lung transplant suitability was determined at both time points., Results: All cases were divided into four groups based on transplant suitability assessment at 1 h and 2 h of EVLP. In group A (n = 10), lungs were judged suitable for transplant at both 1 and 2 h of EVLP. In group B (n = 6), lungs were suitable at 1 h but nonsuitable at 2 h. In group C (n = 2), lungs were nonsuitable at 1 h but suitable at 2 h. Finally, in group D (n = 7), lungs were nonsuitable for transplant at both time points. In both groups B and C (n = 8), the transplant suitability assessment changed between 1 and 2 h of EVLP., Conclusions: In human lungs rejected for transplant, transplant suitability differed at 1 versus 2 h of EVLP in 32% of lungs studied. Evaluation of lungs with Lund protocol EVLP beyond 1 h may improve donor organ assessment., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Computed tomography (CT) volumetry and magnetic resonance cholangiopancreatography (MRCP) are mandatory steps for the evaluation of potential donors in living donor liver transplantation. The aim of this study is to compare the preoperative CT volumetry and biliary orifices of the donor graft to the actual operative findings., Methods: Between December 2013 and December 2017, 45 donors (27 men and 18 women) with a mean age of 27.3 years (range, 19-41 years) were evaluated preoperatively by CT volumetry and MRCP at the National Hepatology and Tropical Medicine Research Institute in Cairo, Egypt. Of the donors, 43 out of 45 underwent intraoperative cholangiography before and after bile duct division. The right hepatectomies for all donors, as well as the actual weight and apparent biliary orifices in the graft, were documented., Results: The mean estimated graft volume (EGV) preoperatively by CT volumetry was 894.9 ± 184.2 mL (range, 480-1687 mL), whereas the actual graft weight (AGW) intraoperatively after washout was 862.6 ± 124.4 g (range, 676-1110 g). The correlation coefficient between the EGV and AGW was significantly linear (Y = 0.96X, r 2  = 0.72, slope: 0.96, P < .001). The accuracy of the MRCP in preoperative biliary mapping was 76.7% whereas the accuracy of the MRCP in predicting the number of graft biliary orifices was 74.4% compared with the intraoperative cholangiography (IOC), which was 95.3% (P < .001)., Conclusion: The weight of the right lobe of the liver graft in living donor liver transplants (LDLTs) can be accurately predicted preoperatively by multiplying the EGV by 0.96. Also, the IOC is an essential technique for LDLT., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Despite improvement in short-term outcome of kidney transplants, the long-term survival of kidney transplants has not changed over past decades. Kidney biopsy is the gold standard of transplant pathology but it's invasive. Quantification of transplant blood flow could provide a novel non-invasive method to evaluate transplant pathology. The aim of this retrospective cross-sectional pilot study was to evaluate positron emission tomography (PET) as a method to measure kidney transplant perfusion and find out if there is correlation between transplant perfusion and histopathology., Methods: Renal cortical perfusion of 19 kidney transplantation patients [average time from transplantation 33 (17-54) months; eGFR 55 (47-69) ml/min] and 10 healthy controls were studied by [ 15 O]H 2 O PET. Perfusion and Doppler resistance index (RI) of transplants were compared with histology of one-year protocol transplant biopsy., Results: Renal cortical perfusion of healthy control subjects and transplant patients were 2.7 (2.4-4.0) ml min - 1  g - 1 and 2.2 (2.0-3.0) ml min - 1  g - 1 , respectively (p = 0.1). Renal vascular resistance (RVR) of the patients was 47.0 (36.7-51.4) mmHg mL - 1 min - 1 g - 1 and that of the healthy 32.4 (24.6-39.6) mmHg mL - 1 min -1 g -1 (p = 0.01). There was a statistically significant correlation between Doppler RI and perfusion of transplants (r = - 0.51, p = 0.026). Transplant Doppler RI of the group of mild fibrotic changes [0.73 (0.70-0.76)] and the group of no fibrotic changes [0.66 (0.61-0.72)] differed statistically significantly (p = 0.03). No statistically significant correlation was found between cortical perfusion and fibrosis of transplants (p = 0.56)., Conclusions: [ 15 O]H 2 O PET showed its capability as a method in measuring perfusion of kidney transplants. RVR of transplant patients with stage 2-3 chronic kidney disease was higher than that of the healthy, although kidney perfusion values didn't differ between the groups. Doppler based RI correlated with perfusion and fibrosis of transplants.

Purpose: The aim of this study is to determine the correlation between the predonation computed tomography (CT)-based calculated kidney volume and post-transplant renal function in recipients of renal transplants and to compare two different CT techniques., Material and Methods: The study group is comprised of 55 paired living kidney donor-recipients transplants. The total parenchymal renal volumes were calculated by using two CT-based techniques (3-dimensional renal volume [3DRV] and voxel-based volume calculation). Post-transplant creatinine and estimated glomerular filtration rate (eGFR) levels for the recipients at hospital discharge and sixth month were obtained. We tested the association with eGFR and creatinine by adjusting the renal volume to body weight and body mass index. For the creatinine levels above 1.5 mg/dL at discharge, a threshold value for renal volume-to-weight ratio on receiver operating characteristic curve (ROC) analysis and odds ratio (OR) were calculated., Results: The renal volumes adjusted to weight were found to be moderately correlated with eGFR and creatinine levels at discharge (r = 0.51 and r = -0.54 for voxel-based calculation; r = 0.52 and r = -0.52 for 3DRV calculation, P < .001, respectively) and at sixth month (r = 0.55 and r = -0.58 for voxel-based calculation; r = 0.51 and r = -0.54 for 3DRV calculation, P < .001 respectively). A threshold value of 1.84 mL/kg was calculated for parenchymal volume-to-recipient weight ratio on ROC analysis (AUC±SE, 0.760 ± 0.078, P = .008). The likelihood of creatinine elevation above 1.5 mg/dL was found to be nine times greater for smaller renal volume-to-recipient weight ratios (OR = 9.6; 95% CI, 1.8-50.6) CONCLUSIONS: Predonation renal volume adjusted to recipient weight may estimate the renal function at discharge and 6 months after transplantation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aim of the Study: Liver transplantation is widely applied as a standard and effective management of end-stage liver diseases, hepatocellular carcinoma, and acute liver failure. Investigation of morphologic and functional changes in the transplanted graft, gastrointestinal system, and spleen after transplantation is an important ground for assessment of post-transplantation results, early changes related to complications, and evaluation of response to treatment modalities. The aim of this study was to investigate the dynamics of changes in elastography of the liver graft and spleen after living-related liver transplantation., Material and Methods: The study included 14 cirrhotic patients after living-related liver graft transplantation. Stiffness of the spleen and liver was evaluated before transplantation and at 1, 3, and 6 months after transplantation with a Supersonic Aixplorer Multi Wave device. Each procedure consisted of measuring the density in 10 points (spots) of the organ. The final result was calculated as the mean value of successful measurements (must have been > 60% of all measurements) and expressed in kilopascals., Results: The mean value of the liver and spleen stiffness before transplantation was 27 kPa (14-31 kPa) and 51 kPa (38-92 kPa), respectively. The stiffness of the spleen gradually reduced after transplantation to 40.3, 35.4, and 24.1 kPa (P = .001) at 1, 3, and 6 months. The stiffness of the liver graft in patients without complications was stable at 4-5 kPa, whereas the same value in patients with complications was increased (≥ 7.5 kPa). In 5 patients, endoscopic investigation confirmed the significant reduction of varicose veins after surgery., Conclusion: Elastography of the liver graft and spleen after liver transplantation can be recommended as a useful-for-patient 1-off method of investigation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Estimation of graft volume is critical in living donor liver transplantation (LDLT). In this study, we aimed to evaluate the accuracy of software-aided automated computer tomography (CT) volumetry in the preoperative assessment of graft size for LDLT and to compare this method with manual volumetry., Materials and Methods: Forty-one donors (27 men; 14 women) with a mean age in years ± standard deviation (28.4 ± 6.6) underwent contrast-enhanced CT prior to graft removal for LDLT. A liver transplant surgeon determined the weights of liver grafts using automated 3-dimensional volumetry software, and an abdominal radiologist specializing in liver imaging independently and blindly used the commercial interactive volumetry-assisted software on a viewing workstation to determine the liver volume on CT images. Both results were then compared to the weights of actual grafts obtained during surgery. Intraclass correlation coefficients were used to assess the consistency of numerical measurements and Pearson correlation coefficients were calculated to detect a linear relationship between numerical variables. To compare correlation coefficients, z scores were used., Results: Regarding the right and left lobe graft volume estimation by the surgeon, there was a positive correlation between the results and actual graft weight (r = 0.834; P = .001; and r = 0.587; P = .001, respectively). Likewise, graft volume estimation by the radiologist for the right and left lobe was also positively correlated with the actual graft weight (r = 0.819; P = .001 and r = 0.626, P = .001, respectively). There was no significant difference between correlation coefficients (P = .836)., Conclusion: Volumetric measurement of donor graft using 3-dimensional software provides comparable results to manual CT calculation of liver volume., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Venous outflow reconstruction of modified right-lobe liver grafts has been shown to prevent the occurrence of graft congestion and subsequent complications, including graft loss. In the present study, we aimed to investigate the safety and efficacy of Dacron grafts for venous reconstruction in living donor liver transplantation (LDLT)., Methods: Between January 2016 and January 2018, Dacron grafts were used in 148 liver transplants. Of these, 104 patients who had a follow-up computerized tomography (CT) scan were enrolled into the study. A total of 179 outflow hepatic veins including V5, V8, partial middle hepatic vein, and accessory inferior right hepatic veins (IRHV) were reconstructed using synthetic Dacron grafts. Graft patency was evaluated with both intraoperative Doppler ultrasonography following reconstruction, and a follow-up CT was performed on the postoperative day 7 (±1). Retrospective data collection included demographics, parameters for small-for-size (laboratory tests [bilirubin, International Normalized Ratio] and ascites) syndrome, postoperative morbidity, and mortality., Results: Follow-up CT revealed graft patency in 155 out of 179 (86.6%) vascular grafts. Postoperative seventh-day patency rates for each reconstructed vein were as follows: V5, 87.5% (70/80); V8, 87.7% (50/57); partial middle hepatic vein, 100% (11/11); and IRHV, 77.4% (24/31). No major graft-related complications (early graft dysfunction, graft infection) or graft-related mortality were observed. None of the recipients developed small-for-size syndrome based on laboratory tests and clinical findings., Conclusions: Dacron vascular grafts appear as an advantageous and useful alternative for venous outflow reconstruction in LDLT., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Accurate assessment of steatosis in procured livers is crucial to reduce the poor outcome associated with high-grade steatosis and to optimize the utilization of donor grafts. Clinical examination and digital image analysis (DIA) have been used for steatosis evaluation, but the validity of these methods is debated. This study aimed to compare these methods with standard histology for assessment of steatosis severity in human livers and to evaluate a revised classification system for automated fat measurement., Methods: Clinical assessment of liver steatosis at time of retrieval and automated measurement were compared with standard histology in paraffinized and hematoxylin and eosin-stained slides, using a 4-grade scale for ordinal data and percentages for numerical values., Results: Analysis of 42 human livers that were retrieved but not transplanted showed that clinical examination was not reliable for assigning steatosis grades (κ w , 0.12; 95% CI, -0.06 to 0.30), overestimated steatosis severity, and had an accuracy of 67% for discriminating low- and high-grade steatosis. Digital image analysis had a substantial agreement on absolute fat percentage (intraclass correlation coefficient, 0.76; 95% CI, 0.63-0.84) and steatosis grades (κ w , 0.70; 95% CI, 0.57-0.82), with 88% accuracy using the revised classification system., Conclusions: Clinical assessment of steatosis is inaccurate, and relying on this method alone could result in unnecessary discard of livers. Digital image analysis is feasible with higher accuracy and reliability, but further clinical studies are required to evaluate its clinical validity., (Copyright © 2019 Elsevier Inc. All rights reserved.)

There is a need for noninvasive, quantitative methods to characterize wound healing in the context of longitudinal investigations related to regenerative medicine. Such tools have the potential to inform the assessment of wound status and healing progression and aid the development of new treatments. We employed spatial frequency domain imaging (SFDI) to characterize the changes in optical properties of tissue during wound healing progression in a porcine model of split-thickness skin grafts and also in a model of burn wound healing with no graft intervention. Changes in the reduced scattering coefficient measured using SFDI correlated with structural changes reported by histology of biopsies taken concurrently. SFDI was able to measure spatial inhomogeneity in the wounds and predicted heterogeneous healing. In addition, we were able to visualize differences in healing rate, depending on whether a wound was debrided and grafted, versus not debrided and left to heal without intervention apart from topical burn wound care. Changes in the concentration of oxy- and deoxyhemoglobin were also quantified, giving insight into hemodynamic changes during healing.

Background: Few studies have evaluated the effect of chronic calcium-channel blocker therapy (CCB) on the angiographic and clinical outcome of radial artery (RA) grafts used for coronary bypass surgery., Objectives: The purpose of this study was to evaluate if CCB influences midterm clinical and angiographic outcomes of RA grafts., Methods: Patient-level data of 6 angiographic randomized trials evaluating RA graft status at midterm follow-up were joined in this observational analysis. Cox regression and propensity score methods were used to evaluate the effect of CCB on the incidence of a composite of major adverse cardiac events (MACE) (death, myocardial infarction, and repeat revascularization) and graft occlusion., Results: The study population included 732 patients (502 on CCB). The median clinical follow-up was 60 months. The cumulative incidence of MACE at 36, 72, and 108 months was 3.7% vs. 9.3%, 13.4% vs. 17.6%, and 16.8% vs. 20.5% in the CCB and no CCB groups, respectively (log-rank p = 0.003). Protocol-driven angiographic follow-up was available in 243 patients in the CCB group and 200 in the no CCB group. The median angiographic follow-up was 55 months. The cumulative incidence of RA occlusion at 36, 72, and 108 months was 0.9% vs. 8.6%, 9.6% vs. 21.4%, and 14.3% vs. 38.9% in the CCB and no CCB groups, respectively (log-rank p < 0.001). After controlling for known confounding, CCB therapy was found to be consistently associated with a significantly lower risk of MACE (multivariate Cox hazard ratio: 0.52; 95% confidence interval: 0.31 to 0.89; p = 0.02) and RA graft occlusion (multivariate Cox hazard ratio: 0.20; 95% confidence interval: 0.08 to 0.49; p < 0.001)., Conclusions: In patients with RA grafts CCB is associated with significantly better midterm clinical and angiographic RA outcomes., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Liver transplantation (LT) has been proposed as a curative treatment in hereditary hemorrhagic telangiectasia (HHT) with severe hepatic involvement. We provide a long-term evaluation of graft status after LT for HHT, with a focus on the risk of recurrence. The present study included all patients prospectively followed up after LT for HHT in the Lyon Liver Transplant Unit from 1993 to 2010, with a survival of more than 1 year. Protocol clinical, radiological, and histological examinations were performed at regular intervals. Fourteen patients were included (13 women and one man). Median age at LT was 52.5 years (range: 33.1-66.7). In eight patients (seven female), disease recurrence was diagnosed by abnormal radiological features, suggestive of microcirculatory disturbances. Typical vascular lesions, including telangiectasia, were demonstrated by liver biopsy in five of these patients. The median interval between LT and diagnosis of recurrence was 127 months (range: 74-184). The risk of recurrence increased over time; estimated cumulative risk was 47.9% at 15 years. Liver tissue analysis found the coexistence of an angiogenic process combined with endothelial microchimerism, as shown by the presence of vascular lining cells of recipient origin. Conclusion: The present data show that disease recurrence occurs, usually after a long delay, in a significant number of patients treated by LT for liver complications of HHT. This strongly supports the necessity of a lifelong follow-up and suggests that therapeutic strategy needs discussion and evaluation, especially of the role of potential adjuvant treatments to LT, such as antiangiogenic medications, when recurrent disease appears., (© 2018 by the American Association for the Study of Liver Diseases.)

Purpose: The purpose of this study was to evaluate the signal/noise quotient (SNQ) for graft maturation and the serial changes observed in the magnetic resonance imaging (MRI) findings after double-bundle (DB) anterior cruciate ligament (ACL) reconstruction using a hamstring tendon autograft at a minimum of 5 years after surgery., Methods: Forty-five patients who underwent DB ACL reconstruction between 2007 and 2010 were included in this prospective study. All participants underwent postoperative MRI at 3 weeks and 3, 6, 9 and 12, 18, 24, 36, 48 and 50 months. The signal intensity (SI) characteristics of the reconstructed graft were evaluated on oblique axial proton density-weighted MR imaging (PDWI) perpendicular to the grafts. The signal/noise quotient (SNQ) was calculated to quantitatively determine the normalized SI. The SNQ of the AMB and PLB was evaluated separately., Results: The mean SNQ of the AM bundle (AMB) continued to increase until 6 months after surgery (5.2 ± 1.2), and then gradually decreased and became well stabilized by 18 months (3.3 ± 0.5), after which it remained unchanged. On the other hand, the mean SNQ of the PL bundle (PLB) continued to increase until 9 months after surgery (6.2 ± 1.1), and then decreased incrementally and became well stabilized by 24 months (4.1 ± 0.5). The SI of PLB was significantly higher than that of AMB between 3 and 24 months (p = 0.04, 0.03, 0.01, 0.04, 0.02 and 0.03, respectively)., Conclusions: These results indicate that at least 18 months is needed after ACL reconstruction to sufficiently restore the SI of the AMB, while at least 24 months are needed to for the PLB. The SI of the PLB was significantly higher than that of the AMB at 3-24 months after surgery, indicating that the PLB showed inferior graft maturity to the AMB until 24 months after surgery. For clinical relevance, the correct understanding of serial changes in graft maturation may potentially be used in decision-making regarding a return to sports., Level of Evidence: Prospective case series, Level IV.

The anterior cruciate ligament (ACL) is an important stabiliser of the knee and is commonly torn in sports injuries. Common indications for imaging after ACL reconstruction include persistent symptoms, limitation of motion and re-injury. Important postoperative complications include graft failure, impingement, arthrofibrosis and graft degeneration. This article aimed to familiarise the radiologist with magnetic resonance (MR) imaging appearances of properly positioned intact ACL grafts and to provide a comprehensive review of MR imaging features of complications following ACL reconstruction., (Copyright: © Singapore Medical Association.)

Background: F18-fluorodeoxyglucose positron emission tomography/computed tomography (F18-FDG PET/CT) can be used to assess changes in the metabolism of an anterior cruciate ligament (ACL) graft as it is undergoing "ligamentization." Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is the preferred modality for noninvasive assessment of graft structure and graft vascularity., Purpose: To compare the use of F18-FDG PET/CT and DCE-MRI to assess ligamentization within the ACL graft and correlate the results with clinical tests., Study Design: Case series; Level of evidence, 4., Methods: Among 30 recruited patients, 27 patients (3 females and 24 males) completed 2 follow-up assessments at a mean of 125 ± 22 days and 259 ± 38 days after arthroscopic ACL reconstruction. At both assessments, anterior drawer test, Lachman test, and Lysholm scoring (LS) were conducted. Images from F18-FDG PET/CT and MRI were analyzed qualitatively and quantitatively (maximum standardized uptake value [SUVmax], SUVmax ratio to the contralateral side [SUVmax CL], normalized enhancement [NE]) in 3 zones: femoral, intra-articular (IA), and tibial. Of the 27 recruited patients, 1 patient had reinjury due to a fall. Therefore, 26 patients were considered for the final analysis., Results: A significant improvement ( P = .0001) was found in median LS, from 78.5 (range, 62-90) to 94.5 (range, 84-100), at the second follow-up. All grafts were found to be viable on PET/CT and vascularized on MRI. All grafts were seen as continuous on MRI, with exception of 1 graft at the second follow-up. Dynamic MRI identified single-vessel supply to all of the grafts at the first follow-up and multiple-vessel supply in 10 patients at the second follow-up. Reduction in the median SUVmax, SUVmax CL, and NE at second follow-up was seen in all 3 zones. Only SUVmax CL in the IA zone showed a significant reduction ( P = .032); patients with excellent LS at the second follow-up showed significantly higher reduction ( P = .005) than patients with good LS. NE in the IA zone was correlated (0.39; P = .048) with LS only at the first follow-up, whereas SUVmax CL (-0.52; P = .006) and SUVmax (-0.49, P = .010) in the IA zone negatively correlated with LS at the second follow-up only. No correlation was observed between PET/CT and MRI parameters., Conclusion: Glucose metabolism and vascularity in the graft tissue can be used to assess ligamentization of ACL graft. A viable and vascularized graft at first follow-up is associated with good to excellent final outcome, regardless of LS at this stage. Since no correlation was observed between PET/CT and MRI parameters, they may be assessing different domains of the same process. Higher NE in the IA zone at the first follow-up and lower SUVmax CL in the same region at second follow-up are associated with better outcome.

Background: Contrast enhanced ultrasonography (CEUS) assessment of kidney allografts mainly focuses on graft rejection. However, studies on delayed graft function (DGF) without acute rejection are still lacking. The aim of this study was to build a time-intensity curve (TIC) using CEUS in non-immunological DGF to understand the utility of CEUS in early transplantation., Methods: Twenty-eight patients in the short-term postoperative period (<14 days) were divided according to the need for dialysis (early graft function [EGF] and [DGF]) and 37 subjects with longer than 90 days follow-up were divided into creatinine tertiles. Time to peak [TTP] and rising time [RT were compared between groups., Results: EGF and DGF were similar, except for creatinine. In comparison to the late group, medullary TTP and RT were shorter in the early group as well as the delay regarding contrast arrival in the medulla (in relation to cortex) and reaching the medullary peak (in relation to artery and cortex). In the late group, patients with renal dysfunction showed shorter temporal difference to reach medullary peak in relation to artery and cortex., Conclusions: Although it was not possible to differentiate EGF and DGF using TIC, differences between early and late groups point to blood shunting in renal dysfunction.

Background: Hepatic steatosis (HS) can cause substantial problems for both donors and recipients in living donor liver transplantation. The controlled attenuation parameter (CAP) is a noninvasive method of measuring HS using a process based on transient elastography., Aim: To evaluate the accuracy of CAP in quantifying HS during living donor liver transplantation., Methods: A total of 54 liver donors who received CAP and intraoperative liver biopsy (LB) were enrolled in this study. The performance of CAP compared with LB for diagnosing HS was assessed using areas under receiver operating characteristic curves. HS was defined by the presence of steatosis in >5% of hepatocytes., Results: No HS was found in 47 donors, while the remaining 7 donors showed HS ranging from 10% to 30%. Using CAP, the area under receiver operating characteristic curve was 0.96 (95% CI, 0.91-1; P < .001) for HS; the optimal cutoff value for HS was 257 dB/m (sensitivity: 100%, specificity: 89.4%, positive predictive value: 58.3%, negative predictive value: 100%). Among the 42 candidates with CAP <257 dB/m, none had HS, while of the 12 candidates with CAP ≥257 dB/m, 7 had HS. In a multivariate linear regression analyses, body mass index (β = 0.71, P < .001) was found to be independently associated with CAP in those without HS., Conclusions: CAP might be a promising tool to exclude HS in East Asian living liver donors. Body mass index was found to be independently associated with CAP values in those without HS., (Copyright © 2018 The Author(s). Published by Elsevier Inc. All rights reserved.)

Transplantable kidneys are in very limited supply. Accurate viability assessment prior to transplantation could minimize organ discard. Rapid and accurate evaluation of intra-operative donor kidney biopsies is essential for determining which kidneys are eligible for transplantation. The criterion for accepting or rejecting donor kidneys relies heavily on pathologist determination of the percent of glomeruli (determined from a frozen section) that are normal and sclerotic. This percentage is a critical measurement that correlates with transplant outcome. Inter- and intra-observer variability in donor biopsy evaluation is, however, significant. An automated method for determination of percent global glomerulosclerosis could prove useful in decreasing evaluation variability, increasing throughput, and easing the burden on pathologists. Here, we describe the development of a deep learning model that identifies and classifies non-sclerosed and sclerosed glomeruli in whole-slide images of donor kidney frozen section biopsies. This model extends a convolutional neural network (CNN) pre-trained on a large database of digital images. The extended model, when trained on just 48 whole slide images, exhibits slide-level evaluation performance on par with expert renal pathologists. Encouragingly, the model's performance is robust to slide preparation artifacts associated with frozen section preparation. The model substantially outperforms a model trained on image patches of isolated glomeruli, in terms of both accuracy and speed. The methodology overcomes the technical challenge of applying a pretrained CNN bottleneck model to whole-slide image classification. The traditional patch-based approach, while exhibiting deceptively good performance classifying isolated patches, does not translate successfully to whole-slide image segmentation in this setting. As the first model reported that identifies and classifies normal and sclerotic glomeruli in frozen kidney sections, and thus the first model reported in the literature relevant to kidney transplantation, it may become an essential part of donor kidney biopsy evaluation in the clinical setting.

Background: Recent literature correlated anterior cruciate ligament (ACL) reconstruction failure to smaller diameter of the harvested hamstring (HS) autograft. However, this approach may be a simplification, as relation of graft size to native ACL size is not typically assessed and oversized grafts may impart their own complications., Purpose: To evaluate in vivo data to determine if the commonly used autografts reliably restore native ACL size., Study Design: Descriptive laboratory study., Methods: Intraoperative data of the tibial insertion area and HS graft diameter were collected and retrospectively evaluated for 46 patients who underwent ACL reconstruction with HS autografts. Magnetic resonance imaging measurements of the cross-sectional area (CSA) of the possible patellar tendon (PT) and quadriceps tendon (QT) autografts were also done for each patient. The percentages of tibial insertion site area restored by the 3 possible grafts were then calculated and compared for each individual., Results: The mean ACL tibial insertion area was 107.2 mm 2 (60.5-155.5 mm 2 ). The mean CSAs of PT, HS, and QT were 33.2, 55.3, and 71.4 mm 2 , respectively. When all grafts were evaluated, the percentage reconstruction of the insertion area varied from 16.2% to 123.1% on the tibial site and from 25.5% to 176.7% on the femoral site, differing significantly for each graft type ( P < .05). On average, 32.8% of the tibial insertion area would have been filled with PT, 53.6% by HS, and 69.5% by QT. Based on previous cadaveric studies indicating that graft size goal should be 50.2% ± 15% of the tibial insertion area, 82.7% of patients in the HS group were within this range (36.9%, QT; 30.5%, PT), while 65.2% in the PT group were below it and 60.9% in the QT group were above it., Conclusion: ACL insertion size and the CSAs of 3 commonly used grafts vary greatly for each patient and are not correlated with one another. Thus, if the reconstructed ACL size is determined by the harvested autograft size alone, native ACL size may not be adequately restored. PT grafts tended to undersize the native ACL, while QT might oversize it., Clinical Relevance: These results may help surgeons in preoperative planning, as magnetic resonance imaging measurements can be helpful in determining individualized graft choice to adequately restore the native ACL.

Solid-organ transplant is one of the most complex areas of modern medicine involving surgery. There are challenging opportunities in solid-organ transplant, specifically regarding the deficiencies in pathology workflow or gaps in pathology support, which may await alleviations or even de novo solutions, by means of point-of-care, or point-of-procedure optical biomarkers. Focusing the discussions of pathology workflow on donor liver assessment, we analyze the undermet need for intraoperative, real-time, and nondestructive assessment of the donor injuries (such as fibrosis, steatosis, and necrosis) that are the most significant predictors of post-transplant viability. We also identify an unmet need for real-time and nondestructive characterization of ischemia or irreversible injuries to the donor liver, earlier than appearing on morphological histology examined with light microscopy. Point-of-procedure laparoscopic optical biomarkers of liver injuries and tissue ischemia may also facilitate post-transplant management that is currently difficult for or devoid of pathological consultation due to lack of tools. The potential and pitfalls of point-of-procedure optical biomarkers for liver assessment are exemplified in breadth for steatosis. The more general and overarching challenges of point-of-procedure optical biomarkers for liver transplant pathology, including the shielding effect of the liver capsule that was quantitated only recently, are projected. The technological and presentational benchmarks that a candidate technology of point-of-procedure optical biomarkers for transplant pathology must demonstrate to motivate clinical translation are also foreseen., ((2018) COPYRIGHT Society of Photo-Optical Instrumentation Engineers (SPIE).)

Objectives/hypothesis: Current techniques for airway characterization include endoscopic or radiographic measurements that produce static, two-dimensional descriptions. As pathology can be multilevel, irregularly shaped, and dynamic, minimal luminal area (MLA) may not provide the most comprehensive description or diagnostic metric. Our aim was to examine the utilization of computational fluid dynamics (CFD) for the purpose of defining airway stenosis using an ovine model of tissue-engineered tracheal graft (TETG) implantation., Study Design: Animal research model., Methods: TETGs were implanted into sheep, and MLA was quantified with imaging and endoscopic measurements. Graft stenosis was managed with endoscopic dilation and stenting when indicated. Geometries of the TETG were reconstructed from three-dimensional fluoroscopic images. CFD simulations were used to calculate peak flow velocity (PFV) and peak wall shear stress (PWSS). These metrics were compared to values derived from a quantitative respiratory symptom score., Results: Elevated PFV and PWSS derived from CFD modeling correlated with increased respiratory symptoms. Immediate pre- and postimplantation CFD metrics were similar, and implanted sheep were asymptomatic. Respiratory symptoms improved with stenting, which maintained graft architecture similar to dilation procedures. With stenting, baseline PFV (0.33 m/s) and PWSS (0.006 Pa) were sustained for the remainder of the study. MLA measurements collected via bronchoscopy were also correlated with respiratory symptoms. PFV and PWSS found via CFD were correlated (R 2  = 0.92 and 0.99, respectively) with respiratory symptoms compared to MLA (R 2  = 0.61)., Conclusions: CFD is valid for informed interventions based on multilevel, complex airflow and airway characteristics. Furthermore, CFD may be used to evaluate TETG functionality., Level of Evidence: NA. Laryngoscope, E272-E279, 2018., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To evaluate the long-term outcomes of asymptomatic stones ≤4 mm that are left in situ during renal transplantation (RT)., Materials and Methods: Between 2009 and 2017, 31 patients who received stone-bearing (≤4 mm) kidneys were analyzed. At their last follow-up, the patients were evaluated with computerized tomography (CT) imaging and the results were compared to the initial CT findings obtained during donor evaluation., Results: The mean stone size was 2.9 mm (range 1-4.3). The mean follow-up period after RT was 43.1 months (range 12-97). According to the CT findings of the last follow-up, the stone had passed spontaneously in 26 patients (83.9%). Three patients (9.6%) with a stone size of 4 mm required surgical intervention because the stone became symptomatic within the first year after transplantation. In the remaining 2 patients (6.4%), the stone remained in situ, without a change in its size. In terms of spontaneous passage rate, there was no significant difference between lower and midupper pole stones (P = .948). De novo stone formation was observed in 2 patients (6.4%)., Conclusion: Asymptomatic stones <4 mm that are detected on donor evaluation may safely be left in situ during RT. Regardless of their localization in the kidney, these stones have high spontaneous passage rates after RT, and the long-term recurrence rates are also considerably low., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Despite an increasing utilization of kidneys procured from expanded-criteria donors, little is known about the effects of particular expanded-criteria donors definition components, that is, hypertension, increased creatinine prior to procurement, and cerebrovascular cause of death on the kidney graft Doppler parameters measured shortly after transplantation, whose increased values are associated with unfavorable outcomes. Hence, we analyzed the relationship between expanded-criteria donors components and resistance index values measured within 2 to 3 days post-transplant., Material and Methods: The initial post-transplant resistance index value was measured in 676 consecutive successful first cadaveric kidney graft recipients without delayed graft function or early acute rejection episode. We analyzed resistance index values in 460 patients transplanted with organs from donors <50 years and in 216 recipients with organs from donors >50 years old., Results: In general, expanded-criteria donors status did not influence the initial resistance index values in the whole study group. Unexpectedly, in older donor groups, both the occurrence of donor hypertension and cerebrovascular cause of death resulted in significantly lower resistance index values in kidney graft recipients (0.73 ± 0.10 vs 0.76 ± 0.11 in the non-hypertension group, P = .013 and 0.74 ± 0.11 vs 0.78 ± 0.10 in the non-cerebrovascular cause of death group, P = .015, respectively). In the Cox proportional regression model for graft survival, cerebrovascular cause of death was increasing the risk of graft loss by 55%, while recipient's age had the opposite effect, decreasing the risk of graft loss by 2% per year., Conclusions: Regardless of the limited influence of expanded-criteria donor status on first post-transplant resistance index value, the long-term observation shows moderate but significantly worse kidney graft survival, mostly as a result of the cerebrovascular cause of donor's death., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Vascularized bone grafts (VBGs) are described as having superior osteogenicity, osteoconductivity, and osteoinductivity compared with other graft types and have been used in high-risk patients to augment arthrodesis. Pedicled VBGs are rotated on an intact vascular pedicle and therefore maintain all the benefits of VBGs but avoid many of the challenges and additional morbidity of free-tissue transfer. This study describes a novel surgical technique for rotating vascularized spinous process into the posterolateral space for augmenting arthrodesis in patients undergoing posterolateral fusion (PLF)., Methods: A technique is described for rotating the spinous process into the posterolateral space on an intact vascular pedicle of paraspinal muscle. Early clinical and radiographic outcomes are reported for 4 patients who have undergone this procedure., Results: Four patients were treated with a single or 2-level PLF combined with posterior, anterior, or lateral interbody fusion and vascularized spinous process graft. Three-month postoperative computed tomography scans demonstrated a dislodged graft in 1 patient and successful arthrodesis in 3 patients. Additional operative time taken for graft harvest and implantation ranged from 22 minutes for the first patient to 6 minutes for the fourth patient., Conclusions: Rotation of vascularized spinous process graft for augmentation of posterolateral arthrodesis in the lumbar spine is a potentially safe, effective surgical technique that results in successful arthrodesis in as little as 3 months but requires further study. This technique is expected to add little additional time or morbidity to the traditional lumbar PLF because it requires no separate incision or additional bone removal., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Differentiation of human pluripotent stem cells to small brain-like structures known as brain organoids offers an unprecedented opportunity to model human brain development and disease. To provide a vascularized and functional in vivo model of brain organoids, we established a method for transplanting human brain organoids into the adult mouse brain. Organoid grafts showed progressive neuronal differentiation and maturation, gliogenesis, integration of microglia, and growth of axons to multiple regions of the host brain. In vivo two-photon imaging demonstrated functional neuronal networks and blood vessels in the grafts. Finally, in vivo extracellular recording combined with optogenetics revealed intragraft neuronal activity and suggested graft-to-host functional synaptic connectivity. This combination of human neural organoids and an in vivo physiological environment in the animal brain may facilitate disease modeling under physiological conditions.

Objective: To investigate the role and efficacy of fast imaging employing steady-state acquisition (FIESTA) imaging in distinguishing fat graft enhancement from residual or recurrent tumor after vestibular schwannoma (VS) surgery., Methods: A retrospective study of 33 patients who underwent VS resection via the retrosigmoid or translabyrinthine approach with fat graft reconstruction was performed. Magnetic resonance imaging (MRI) was collected at different time points: preoperative, immediate postoperative (24-48 hours), delayed postoperative (3-6 months after surgery), and yearly postoperative. The image sets contained T1, T2, fat-suppressed T1-weighted with gadolinium, and FIESTA. The radiographs were analyzed for tumor recurrence by the primary neurosurgeon and an independent blinded neuroradiologist. If fat-suppressed T1-weighted images demonstrated postoperative enhancement in the resection bed, a comparison was made with FIESTA imaging., Results: At 3-6 months postoperatively and at 1 year and beyond, 28 (84.8%) and 33 (100%) of patients, respectively, displayed delayed enhancement of the fat graft on postgadolinium fat-suppressed T1-weighted MRI. The enhancement seen on postgadolinium, fat-suppressed, T1-weighted MRI consistently correlated with the characteristic fat graft signal on FIESTA imaging and not tumor recurrence. FIESTA imaging was able to distinguish residual tumor from enhancing fat graft compared with postgadolinium, fat-suppressed, T1-weighted MRI (P < 0.0001) due to distinctive signaling patterns., Conclusions: FIESTA is an effective tool in discerning fat graft enhancement from residual or recurrent tumor on delayed postoperative imaging after VS resection. Fat graft used in reconstruction consistently enhances on delayed postoperative postgadolinium, fat-suppressed, T1-weighted imaging, which correlates with the fat graft signal seen on FIESTA images., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

There is currently no method to quantify the quality of the harvested graft before anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to explore a method for measuring stiffness of the normal tendon of the semitendinosus muscle using shear wave elastography (SWE). Our investigation comprised two steps. First, we determined orientation of the semitendinosus tendon fibers in 20 lower legs of embalmed cadavers. Second, we investigated the feasibility of quantifying stiffness of the normal semitendinosus tendon by SWE in 24 subjects (48 legs: 24 male and 24 female subjects) in vivo. Measured values were compared between male and female subjects. The point at the intersection of the semitendinosus tendon with the axial section through the center of the patella mostly was the middle of the semitendinosus tendon in the cadavers. The SWE modulus in all of the subjects could be measured on this point in vivo. The SWE modulus of males and females were 474.0 ± 71.9 kPa and 396.9 ± 104.5 kPa, respectively. The SWE modulus of males was significantly larger than that of females (P < 0.01). This study demonstrates that stiffness of the tendon of the semitendinosus muscle can be measured by SWE. It also shows that tendon of the semitendinosus muscle in males is stiffer than in females. Clin. Anat. 31:404-408, 2018. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Background: Anterior cruciate ligament (ACL) reconstruction with a quadrupled semitendinosus (ST4) graft is an evolution of the standard technique with 2 hamstring tendons (semitendinosus + gracilis [STG]). However, there is no published comparison of how well these 2 types of hamstring grafts are incorporated into the bone tunnels. Because the ST4 graft is shorter, there is less graft material inside the tunnels., Purpose: To use magnetic resonance imaging (MRI) to compare graft incorporation in the tibial bone tunnels 1 year after ACL reconstruction with either an STG graft or ST4 graft., Study Design: Cohort study; Level of evidence, 2., Methods: Sixty-two patients who underwent ACL reconstruction were enrolled prospectively: 31 with an ST4 graft and 31 with an STG graft. The same surgical technique, fixation method, and postoperative protocol were used in both groups. Graft incorporation and ligamentization were evaluated with MRI after 1 year of follow-up. The following parameters were evaluated: signal-to-noise quotient (SNQ), tibial tunnel enlargement, signal intensity at the bone-graft interface, and graft signal according to the Howell scale. The number of participants needed to show that the mean SNQ did not differ between the 2 techniques was 31 in each group (with a 1-sided alpha of 2.5% and a 1-sided beta of 10.0%). The Student t test was used to compare the distribution of continuous secondary endpoints., Results: The mean SNQ was 5.2 ± 4.5 for the STG group and 5.9 ± 3.7 for the ST4 group ( P = .5100). The mean tibial tunnel widening was 93.7% ± 51.7% for the STG group versus 80.0% ± 42.9% for the ST4 group ( P = .2605). The groups did not differ in signal intensity at the bone-graft interface ( P = .7502) or in graft signal according to the Howell scale ( P = .4544)., Conclusion: At the 1-year postoperative follow-up, incorporation and ligamentization of the STG and ST4 grafts were the same based on MRI analysis. The results were at least as good with the ST4 technique as with the standard STG technique in terms of incorporation and ligamentization.

Background: Previous studies reported the strategy of in situ skeletonised right internal mammary artery (RIMA) grafting to the left anterior descending artery (LAD). However, few reports have focused on assessing RIMA graft patency rate after grafting to the LAD. This study aimed to assess mid-term graft patency of in situ skeletonised RIMA grafting to the LAD versus in situ skeletonised left internal mammary artery (LIMA) grafting to the LAD in a single-centre propensity-matched study., Materials and Methods: After propensity score matching, 185 pairs of patients who received first, scheduled, isolated off-pump coronary artery bypass grafting (OPCAB) surgery were assigned to either a RIMA group (patients who received retrosternal crossover in situ skeletonised RIMA-LAD grafting with additional conduits grafting) or a LIMA group (patients who received in situ skeletonised LIMA-LAD grafting with additional conduits grafting). The primary endpoint was mid-term internal mammary artery (IMA) graft failure after grafting to the LAD and was determined by coronary computed tomography angiography examination. The secondary endpoints were mid-term all-cause mortality and the composite mid-term clinical outcome., Results: The graft patency rate of in situ skeletonised RIMA-LAD graft was not inferior to in situ skeletonised LIMA-LAD graft during a follow-up period of 36.6 ± 12.1 months (97.2% vs. 96.6%, p = 0.752). Kaplan-Meier curves showed a similar cumulative IMA graft failure between the two groups (χ 2  = 0.092, Log-rank p = 0.762). And Cox regression analysis revealed that grouping was not an independent factor for follow-up IMA graft failure after grafting to the LAD (HR = 0.93, 95% CI: 0.68-2.13). Additionally, Kaplan-Meier curves showed similar cumulative survival free from adverse events between the two groups (χ 2  = 2.365, p = 0.124, respectively)., Conclusions: Revascularisation of the LAD using a skeletonised RIMA resulted in excellent mid-term graft patency and clinical outcomes., (Copyright © 2017. Published by Elsevier Ltd.)

Background: Reconstruction of ureteral defects and strictures remains problematic for urologists. We aimed to investigate the possibility of a tapered non-vascularized bladder graft as a novel substitute for ureteral reconstruction., Methods: This experimental study was conducted on nine beagles. Under general anesthesia, a full-thickness graft with 5-6 cm in length was disassociated from the anterior upper wall of the bladder, and tapered into 1/3 to 1/2 thickness, remaining the urothelial surface. After removal of 5 cm of right-sided mid-ureter, the tapered bladder graft was tubularized along the long axis and then respectively anastomosed to the upper and lower stumps of the ureter. A retrograde urography through a cystostomy was performed 8 weeks after the ureteral reconstruction. The animals were euthanized, and histopathologic examinations of the neoureters were performed., Results: There were no severe complications during postoperative follow-up. The urography indicated patent urine excretion and no fistula or stenosis. Histopathologic examinations of the neoureters showed open lumen with urothelial lining. Nutrient vessels were observed in healthy submucosa, lamina muscularis and peripheral connective tissue., Conclusions: Our study implied that ureteral reconstruction by a tapered non-vascularized bladder graft was anatomically possible in our animal model. Further studies are expected to confirm long-term and functional outcomes.

Background: Kidney transplantation (KT) is the treatment option for patients with end stage renal disease (ESRD) to prolong survival and improve quality of life. Although the use of potent immunosuppressive agents increases graft survival in kidney transplantation recipients (KTRs), it may lead to the development of malignancy, including transitional cell carcinoma (TCC). TCC developing in the pelvis of graft kidney is very rare in KTRs., Case Presentation: A 40-year-old male visited hospital with complaints of nausea, vomiting and gross hematuria. Eleven years ago, he was diagnosed ESRD of unknown origin, and received a living related KT from his father 1 year later. Radiologic findings showed a huge polypoid mass in the pelvis of graft kidney with pelvo-calyceal dilation and a 3.3 cm-sized nodule in aortocaval chain and a 2.5 cm-sized nodule in right iliac chain as TCC stage IV. Sonography-guided percutaneous needle biopsy of pelvis mass in the graft kidney revealed a low grade urothelial cell carcinoma. Radical graft nephroureterectomy was performed and histopathological diagnosis confirmed as a low grade urothelial carcinoma of graft pelvis and ureter lumen, which invaded to perirenal fat and renal parenchyma with lymphovascular presence (T3Nx). The patient started with adjuvant concurrent chemo-radiation therapy and returned to regular hemodialysis., Conclusions: We report a rare case of TCC in the pelvis of graft kidney with already advanced disease at diagnosis in a young KTR. For the early diagnosis of TCC in KTRs, exposure history to Chinese herb or analgesics should be investigated before KT and high risk population in KTRs should be tightly performed regular postoperative surveillance for TCC and considered of less calcineurin inhibitor-based immunosuppressant protocol.

Background: To demonstrate the use of 18 Fluorodeoxyglucose positron emission tomography (PET) and magnetic resonance imaging (MRI) in combination ( 18 FDG-PET) to assess the metabolic activity of ACL graft tissue and evaluate the utility of this technique for ligament imaging., Methods: Twenty-one knees with intact ACL grafts in 19 patients at multiple time points following ACL reconstruction were recruited to participate. PET-MRI imaging was performed using a custom device to place knees in the same position for both studies. Images were co-registered for quantification of 18 FDG-PET standardized uptake value (SUV) for the proximal, middle, and distal ACL was quantified. Signal in extra-articular muscle tissue in the index knee was also recorded as a control. Signal from each location was compared based on how far post-operative each knee was from ACL reconstruction (<6months, six to 12months, 12-24months, or >24months)., Results: Significant differences in 18 FDG PET SUV between the four time points were observed in the proximal (p=0.02), middle (p=0.004), and distal (p=0.007) portions of the ACL graft. The greater than 24months group was noted to be different from other groups in each case. No difference in PET 18 FDG SUV was noted in the extra-articular muscle in the index knee in each time group (p=0.61)., Conclusions: Metabolic activity was noted to be significantly lower in grafts imaged greater than two years post-reconstruction relative to those grafts that had been in place for shorter periods of time., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Duplex ultrasound and transcranial Doppler are valuable tools for post-operative monitoring of extracranial-intracranial cerebral bypass grafts. Here we describe our technique for the evaluation of both high-flow and low-flow cerebral bypass grafts over a nine year period. 186 bypass grafts were studied daily during the inpatient period between Jan 2005 and Dec 2014 after surgery for various cerebrovascular pathologies. There was a technical success rate of 97%. Duplex ultrasonographic flow measurements had excellent interobserver reliability with an intraclass correlation coefficient (ICC) of 0.89 (p=0.009). Technical nuances are highlighted and a brief discussion of pathology is undertaken., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Acoustic radiation force impulse (ARFI) imaging is a noninvasive imaging modality for quantitative assessment of tissue stiffness. This study utilized ARFI imaging to assess the stiffness of a transplant renal cortex within the first month after renal transplantation and to explore the correlation between the cortical stiffness and arterial resistance of the transplant kidney., Methods: Forty renal transplant recipients (male/female = 26/14; mean age: 45.3 years; deceased donor/living related donor = 27/13) were included in this study. ARFI imaging with virtual touch tissue imaging quantification was applied to assess the stiffness of the transplant renal cortex by using a linear ultrasound transducer. Arterial resistance was acquired by spectral Doppler examination of the main artery and intrarenal arteries of the transplant kidney using a curvilinear ultrasound transducer., Results: The stiffness of transplant renal cortex was expressed as shear wave velocity (m/s). The mean value of cortical stiffness was 3.19 ± 1.01 m/s (range: 1.55-5.54). The stiffness of transplant renal cortex was positively correlated with the resistance index of the main renal artery (r = 0.55, P = .001), segmental artery (r = 0.43, P = .005), and interlobar artery (r = 0.42, P = .006)., Conclusion: The stiffness of a transplant renal cortex is positively correlated with the arterial resistance of the renal transplant in the early post-transplant period. This result indicates that, in addition to renal fibrosis, the stiffness of the transplant renal cortex is also influenced by the hemodynamics of the transplant kidney., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: This report describes the need for a tailored approach for intracranial vascular occlusive disease and introduces the usefulness of the OA as a donor artery for interposition graft., Materials and Methods: A 65-year-old male patient suffered from repeated transient ischemic attack (TIA). Imaging studies revealed complete occlusion of the proximal left side of the internal carotid artery (ICA) and multiple infarction in the watershed zone. We planned superficial temporal artery-middle cerebral artery (STA-MCA) bypass to restore cerebral blood flow and to prevent the progression of infarction. However, the parietal branch of the STA was too small in diameter and not suitable as a single donor for the bypass in order to supply sufficient blood flow. Moreover, the frontal branch of the STA had collateral channels through the periorbital anastomosis into the cerebral cortex that could result in infarction during clamping for anastomosis., Results: We determined that tailored treatment planning was necessary for successful revascularization under these conditions. Thus, we performed a bypass between the parietal branch of the STA and a cortical branch of the MCA as an "insurance bypass." Then we performed another bypass between the frontal branch of the STA and a cortical branch of the MCA using an ipsilateral occipital artery (OA) interposition graft. The patient had no perioperative complications, and postoperative imaging confirmed the restoration of cerebral blood flow., Conclusion: When end-to-side anastomosis in single-branch bypass is not appropriate for cerebral revascularization, a tailored double-barrel "insurance bypass" with an OA interposed graft could be a good alternative treatment modality. In addition, an OA interposition graft is a useful option for double-barrel bypass surgery in such cases of intracranial vascular occlusive disease., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The objective of the study was to establish a right-lobe graft weight (GW) estimation formula for living donor liver transplantation (LDLT) from right-lobe graft volume without veins (GV w/o&#95;veins ), including portal vein and hepatic vein measured by computed tomographic (CT) volumetry, and to compare its estimation accuracy with those of existing formulas. Right-lobe GW estimation formulas established with the use of graft volume with veins (GV w&#95;veins ) sacrifice accuracy because GW measured intra-operatively excludes the weight of blood in the veins. Right-lobe GW estimation formulas have been established with the use of right-lobe GV w/o&#95;veins , but a more accurate formula must be developed., Methods: The present study developed right-lobe GW estimation formulas based on GV w/o&#95;veins as well as GV w&#95;veins , using 40 cases of Korean donors: GW = 29.1 + 0.943 × GV w/o&#95;veins (adjusted R 2  = 0.94) and GW = 74.7 + 0.773 × GV w&#95;veins (adjusted R 2  = 0.87). The proposed GW estimation formulas were compared with existing GV w&#95;veins - and GV w/o&#95;veins -based models, using 43 cases additionally obtained from two medical centers for cross-validation., Results: The GV w/o&#95;veins -based formula developed in the present study was most preferred (absolute error = 21.5 ± 16.5 g and percentage of absolute error = 3.0 ± 2.3%)., Conclusions: The GV w/o&#95;veins -based formula is preferred to the GV w&#95;veins -based formula in GW estimation. Accurate CT volumetry and alignment between planned and actual surgical cutting lines are crucial in the establishment of a better GW estimation formula., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to find the ideal femoral tunnel position in single-bundle anterior cruciate ligament (ACL) reconstruction using three-dimensional computed tomography (3D-CT) by comparing clinical scores, stability of the knee joint, and graft signal intensity on follow-up magnetic resonance imaging (MRI). We hypothesized that positioning the femoral tunnel near the anteromedial bundle or center would lead to better results in terms of clinical outcomes and graft signal intensity on follow-up MRI than would positioning the tunnel near the posterolateral bundle., Methods: Two hundred patients underwent arthroscopic single-bundle ACL reconstruction with a soft-tissue graft; all patients had the same surgeon, surgical technique (anteromedial transportal technique), and rehabilitation protocol. Each patient underwent 3D-CT within 1 week after the operation and MRI at 1 year after the operation. Outcomes were evaluated in terms of clinical scores and the stability of the knee joint. We classified patients into three groups based on the femoral tunnel position: the anteromedial position group, the posterolateral position group, and the center position group. We evaluated graft signal intensity on follow-up MRI., Results: This study included 77 patients: 25 patients in the anteromedial position group, 15 patients in the posterolateral position group, and 33 patients in the center position group. Four patients had an eccentric tunnel position and were excluded. The 3 groups did not differ significantly (p > 0.05) in preoperative demographic characteristics. There were no significant differences (p > 0.05) between groups in clinical outcomes. However, patients in the anteromedial position group and in the center position group had better graft signal intensity on follow-up MRI than those in the posterolateral position group., Conclusions: Positioning the femoral tunnel near the anteromedial bundle and center led to better graft signal intensity on follow-up MRI in anatomic single-bundle ACL reconstruction than did positioning the femoral tunnel near the posterolateral bundle. There were no differences in clinical scores or stability of the knee joint among the three groups., Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Aim: To present the results of PRP-adipose grafts implanatation., Material and Methods: The study included 25 patients after transplantation of autologous adipose tissue. Autotransplantation was performed to correct volume defects of breast and to restore lost volume after polyacrylamide gel removal in 4 patients; after mastectomy in 6 cases; after complicated replacement using silicone endoprostheses in 11 patients; after previous reduction in 2 cases; after augmentation mammoplasty in 2 cases. Mean age of patients was 42 years. Patients were divided into 2 groups. Group 1 included 12 patients in whom pure adipose tissue was transplanted. Group 2 consisted of 13 patients who received autologous fat with platelet-rich plasma (PRP)., Results: Dynamic ultrasonic monitoring showed early resorption processes (liponecrosis foci) after autologous fat injection. Locally increased vascular pattern of breast tissue is an inflammatory sign requiring anti-inflammatory therapy. PRP-adipose grafts have improved outcomes.

Preoperative prediction of hamstring tendon lengths and graft diameter for anterior cruciate ligament (ACL) reconstruction enables better preoperative planning. Presently, no study exists for Indian population where both derivation and verification of a mathematical equation for accurate prediction of hamstring graft dimensions have been done. This study was conducted in two phases: First phase ( derivation cohort): devoted to the study of correlation of length of hamstring tendons and graft diameter with various anthropometric measurements in 123 patients undergoing ACL reconstruction. Length of semitendinosus (ST) was observed to have a strong correlation with leg length ( r = 0.719), whereas that of gracilis (G) had a strong correlation with patient height ( r = 0.768). Quadrupled diameter (QD) had a strong correlation with patient height and thigh length ( r = 0.685 and 0.680, respectively). Using Pearson correlation coefficient, multiple stepwise linear regressions, and analysis of variance test, predictive equations were developed to predict the length of ST and G and QD. Second phase ( verification cohort): This was a blinded prospective study done on 300 patients to further authenticate and test the accuracy of equations developed. Here, a steady correlation was found between the observed and predicted values of length of ST, G and QD, with correlation coefficients being 0.838, 0.847, and 0.767, respectively. Thus, we can safely conclude that clinically measurable anthropometric variables can reliably predict hamstring graft dimensions. This is likely to prove useful in better preoperative planning of ligament reconstructions.

Primary central nervous system (CNS) lymphomas account for 13-20% of the posttransplant lymphoproliferative disorders (PTLD) and rank among the most aggressive conditions. Reduction of immunosuppressive therapy should be mandatory to treat PTLD, but this is rarely used as the only therapy option. Chemotherapy regimens for PTLD involving the CNS most commonly include high-dose rituximab and high-dose methotrexate and/or cytarabine. The efficiency only of discontinuation of immunosuppressive therapy for PTLD does not exceed 5-10%, but there are no literature data on its efficiency for PTLD involving the CNS. The paper describes a clinical case of achieving long-term remission in a female patient with Epstein-Barr virus (EBV)-positive diffuse large B-cell lymphoma involving the central nervous system, associated with immunosuppression after kidney transplantation from a related donor, in the absence of chemotherapy during immunosuppressive therapy discontinuation and transplantectomy.

Background: Patients with congenital or acquired deformities always need fat graft at least twice to remodel facial contour. The purpose of this study was to objectively evaluate the outcomes of the first and second fat grafts for Romberg syndrome by using three-dimensional (3D) volumetric analysis., Method: A retrospective study was conducted using the medical records of 13 patients with Romberg disease who were treated with fat graft twice for facial filling. Patient and surgeon satisfactions were evaluated by comparing the preoperative and postoperative two-dimensional (2D) photographs. The preoperative and postoperative 3D images were analyzed with professional analysis software to calculate the volume discrepancy between them., Result: According to the 2D photographs, both patients and the surgeon were more satisfied with the cosmetic results of the second fat graft. There was no significant statistical difference in the injection volumes between the two surgeries (p = 0.1); however, the survival rate of the second fat graft (75.1% ± 7.7%) was much higher than that of the first (43.3% ± 11.1%) with a significant difference (p < 0.01)., Conclusion: In this study, 3D images were used to objectively evaluate the survival rate of fat graft. The results showed that the second fat graft without any sophisticated procedures could acquire better cosmetic result and volume retention in Romberg syndrome. This study result could serve as a guide for clinical surgeons to forecast the outcome of sequential fat graft for patients with congenital or acquired deformities., (Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Breast augmentation with fat transfer does not bear the risks associated with silicone implantation. The method can potentially be especially useful in Asian women, who often reject augmentation mammoplasty with implants. This prospective clinical trial evaluated the effects of external breast expansion on breast density and vessel count using magnetic resonance imaging., Methods: Thirty-four enrolled patients were instructed to apply one of two devices, the conventional BRAVA device (used in the AESTES trial) or a novel external expansion device (EVERA) designed for Asian women, continuously for 8 h per day for 12 weeks. For external expansion, the pressure was set to 25 mmHg. Follow-up examinations were performed for 4 weeks after completion of the expansion. The ratio between the fibroglandular and adipose tissues of the breast was measured using T1-weighted MRI, and the number of vessels in the breast tissue was determined before and after the treatment by contrast MRI. Additionally, the volume of the breast was measured by laser scanning before, during, and after the device application. The obtained measurements were compared within and between the groups at different time points., Results: Six patients dropped out, while 28 completed the trial without major side effects or adverse events. External expansion significantly increased breast vessel count in both the EVERA and AESTES groups (p = 0.019, p = 0.022). However, it did not significantly change breast density in either group (p = 0.186, p = 0.638). No significant intergroup differences were noted in vessel count (p = 0.874) or density (p = 0.482). Breast volume increases after 12 weeks of application were statistically significant in both groups, with mean changes of 81 ± 22 cc (AESTES) and 98 ± 30 cc (EVERA) (p < 0.001 in both cases)., Conclusions: External expansion resulted in a marked increase in breast vessel count but did not affect breast density. The observed increase in breast volume can be considered substantial for Asian women., Level of Evidence: Level II, therapeutic study., (Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Hepatic regeneration is essential to meet the metabolic demands of partial liver grafts following living donor liver transplantation (LDLT). Hepatic regeneration is promoted by portal hyperperfusion of partial grafts, which produces shear stress on the sinusoidal endothelium. Hepatic regeneration is difficult to assess within the first 2 weeks after LDLT as the size of liver graft could be overestimated in the presence of postsurgical graft edema. In this study, we evaluated the effects of graft hyperperfusion on the rate of hepatic regeneration 2 weeks after LDLT by measuring hepatic hemodynamic parameters. Thirty-six patients undergoing LDLT were enrolled in this study. Hepatic hemodynamic parameters including peak portal venous flow velocity (PVV) were measured using spectral Doppler ultrasonography on postoperative day 1. Subsequently, we calculated the ratio of each velocity to 100 g of the initial graft weight (GW) obtained immediately after graft retrieval on the day of LDLT. Ratios of GW to recipient weight (GRWR) and to standard liver volume (GW/SLV) were also obtained. The hepatic regeneration rate was defined as the ratio of the regenerated volume measured using computed tomographic volumetry at postoperative week 2 to the initial GW. Correlations of the hemodynamic parameters, GRWR, and GW/SLV with the hepatic regeneration rate were assessed using a linear regression analysis. The liver grafts regenerated to approximately 1.7 times their initial GW (1.7 ± 0.3 [mean ± standard deviation]). PVV/100 g of GW (r = 0.224, β1 [slope coefficient] = 2.105, P = 0.004) and velocities of the hepatic artery and vein per 100 g of GW positively correlated with the hepatic regeneration rate, whereas GRWR (r = 0.407, β1 = -81.149, P < 0.001) and GW/SLV (r = 0.541, β1 = -2.184, P < 0.001) negatively correlated with the hepatic regeneration rate. Graft hyperperfusion demonstrated by increased hepatic vascular velocities and a small-sized graft in the early postoperative period contributes to hepatic regeneration 2 weeks after LDLT., Competing Interests: The authors have no conflicts of interest to disclose.

Background: Kidney transplant (KT) recipients have a higher incidence of malignancy than the general population. Smooth muscle tumors (SMT), including leiomyosarcoma, are rare in kidney transplant recipients, and most cases are associated with Epstein-Barr virus (EBV) infection., Case Report: A 57-year-old man received a deceased donor kidney transplant at the age of 53 years, with 5 human leukocyte antigen (HLA) mismatches. Before the transplantation, the patient was IgG positive for EBV viral capsid antigen (VCA), negative for IgM EBV VCA, and also negative for IgG EBV nuclear antigen (EBNA), suggesting a prior EBV infection. He received immunosuppressive induction with basiliximab, and maintenance with tacrolimus, mycophenolate mofetil, and prednisolone. Two years after transplantation, he had an acute cellular rejection episode treated with methylprednisolone. An increased graft size was found 4 years after transplantation. A computed tomographic scan showed 3 solid tumors involving the renal graft with extension to the perinephric fat; no secondary localizations were found. A nephrectomy of the graft was performed. The histologic diagnosis was a high-grade leiomyosarcoma. In situ hybridization for EBV was negative. Nine months after nephrectomy, local recurrence was diagnosed. The surgical approach was unsuccessful, and the patient died after a brief period., Conclusion: Kidney leiomyosarcoma is a very rare clinical condition. Most of these neoplasms that arise in transplanted recipients are associated with EBV in tumor tissue. Only one case of renal graft leiomyosarcoma without EBV RNA in the tumor has been previously reported., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: There are two primary surgical techniques to reconstruct the anterior cruciate ligament (ACL), transtibial (TT) technique and anteromedial portal (AMP) technique. Currently, there is no consensus which surgical technique elicits the best clinical and functional outcomes. MRI-derived measures of the signal intensity (SI) of the ACL graft have been described as an independent predictor of graft properties. The purpose of this study is to compare the MRI derived SI measurements of the ACL graft one year after ACL reconstruction, in order to compare the outcomes of both the AMP and TT ACL reconstruction technique., Methods/design: Thirty-six patients will be included in a randomized controlled trial. Patients who are admitted for primary unilateral ACL reconstruction will be included in the study. Exclusion criteria are a history of previous surgery on the ipsilateral knee, re-rupture of the ipsilateral ACL graft, associated ligamentous injuries or meniscal tear of the ipsilateral knee, unhealthy contralateral knee, contra-indications for MRI and a preference for one of the two surgical techniques and/or orthopaedic surgeon. Primary outcome is MRI Signal intensity ratio (SIR) of the ACL graft. Secondary outcome measures are the International Knee Documentation Committee (IKDC) Knee Examination Form,the Knee injury and Osteoarthritis Outcome Scores (KOOS) and the Anterior Cruciate Ligament OsteoArthritis Score (ACLOAS). Differences between MRI SIR assessment with the current MRI protocol (proton density weighted imaging protocol) and the additional T2*-weighted gradient-echo protocol will be assessed., Discussion: There is no consensus regarding the TT or AMP ACL reconstruction technique. SI measurements with MRI have been used in other clinical studies for evaluation of the ACL graft and maturation after ACL reconstruction compared to clinical and functional outcomes. This randomized controlled trial has been designed to compare the TT technique with the AMP technique with the use of MRI SI of the graft after ACL reconstruction., Trial Registration: Netherlands Trial Registry NTR5410 (registered on August 24, 2015).