Scientific Programme

In Switzerland, surgical resident training has become increasingly difficult over the past decades for numerous reasons. While the number of surgical residents has doubled over twenty years, the average workweek dropped from 70 to 50 hours. At the same time, the surgical case-load increased only marginally as opposed to the  the proportion of administrative responsibilities,  resulting in a substantial decrease of intraoperative exposure in surgical residency training.   

To asses the surgical exposure of our residents.

This study is a review of all performed surgical procedures in the field of general, abdominal, thoracic, vascular and trauma surgery at a category-A Cantonal hospital in Switzerland, performed from September 1st 2021 to August, 31st 2023. The primary outcome was surgical exposure of residents as primary, secondary and assisting surgeons. Secondary outcomes were case-distribution during daytime workhours as opposed to on-call hours per resident.

The surgical exposure of a surgical resident at our cantonal hospital as primary and secondary surgeon was 41.19 and 39.06 minutes respectively per week. This surgical exposure as was paired with a total of  127.46 minutes as assisting surgeons per week. On average this results in 1.34 operations per week and 60.3 cases per year per surgical resident. 73.51% of these cases are performed during daytime work hours and 26.49% during on-call hours.

To fulfill the minimal number of 510 cases in the mandatory FMH surgical catalogue of becoming a general surgeon, a total residency period of 8.46 years would become necessary to take the exam based on the average number of operative cases in this category-A teaching hospital which is considerably longer compared to residency training 20 years ago. While surgical procedures and techniques continue to become more complex, the need to exploit ways to maintain a sufficient level of surgical exposure inside and outside the OR is eminent.

Day surgery procedures constitute an essential part of surgical practices in hospitals worldwide. However, outpatients may experience anxiety, fear, and stress negatively impacting patients' ability to follow the established ambulatory surgery pathway. While medications are generally administered to reduce perioperative stress, there are several measures to avoid their use. Music therapy (MT) can be used as a complementary, drug-free, safe, and cost-effective intervention.

The purpose of our study was to evaluate the impact of MT on perioperative stress and patient satisfaction in patients undergoing ambulatory surgery.

We conducted a randomized study in patients undergoing ambulatory surgery. The MT group listened to relaxing music for the whole hospital stay, while the control group received the standard treatment. Both groups were managed in the pre- and postoperative periods according to current clinical practice and ultimately received the Leiden Perioperative care Patient Satisfaction (LPPS) questionnaire before hospital discharge.

During the study period, 33 patients were included, 16 randomized to the MT arm and 17 to the control arm. The average age of the patients was 51.1±16.2 years, and 10 (31.2%) patients were women. The postoperative period was uneventful for almost all patients (95.8%), and we observed a high level of satisfaction. No patient required medication for anxiety treatment in the postoperative period. Pre- and postoperative vital signs were similar in both arms. A slightly higher LPPS score was noted in the MT group (179±8 vs. 171±20 pts, p=0.174).

Despite limitations, our study demonstrated that MT in patients undergoing ambulatory surgery might be advantageous in reducing perioperative stress, potentially increasing satisfaction, and enhancing patients' perception of being cared for in a multidisciplinary manner, without neglecting the emotional aspect.

Surgeons who carry out research in addition to clinical activities are referred to as «Surgeon-Scientists». While their value remains undisputed, numbers have been plunging. Reasons for this decline have been partially identified and countermeasures proposed, but actions taken have failed to mitigate this trend. 

This study aims to explore the perspective of future surgeon-scientists, and to call for urgent measures to save this breed from extinction.

We first completed a systematic literature review adhering to PRISMA guidelines covering all aspects of surgeon scientists’ decline. Second, we performed a comprehensive online survey targeting the academic surgical youth globally.

Reasons for decline both in the literature and survey responses included a foremost priority on clinical duties and a lack of structural support and recognition for research. The proposed requirements to achieve surgeon-scientist sustainability are summarized in Figure 1. Consequent measures failed to affect the academic surgeon pipeline, as they are hardly implemented in the real world (no mentorship: 33%; no protected time: 45%; no extramural funding: 72%; no structured curriculum: 37%).

Of 140 respondents (26 centers, 15 countries, 3 continents) 67% still identified as surgeon-scientist, and 93% agreed on the need to preserve this breed. Main motivational drivers were interest in research (78%) and career progression (63%), and 80% would do it again if given the chance.

This is the first report on global perspectives of future surgeon-scientists about measures to ensure their survival. Their status as «endangered species» is clear, yet the countermeasures are grossly not implemented. To rescue surgeon-scientists, consciousness beyond the academic world with a call for revolution in academic surgery to meet the demands of our time is needed. Thus, we propose major structural changes (Figure 2).

Sex- and gender-based medicine (SGBM) addresses differences between male/men and female/women with regard to clinical manifestation, diagnostics, treatment and outcomes of diseases. The implementation of SGBM in the medical curriculum varies and data on the knowledge and perception of lecturers and students in SGBM is scarce.

The purpose of this study is to assess the current state of SGBM at a Medical Faculty in Switzerland. Further, we aim to evaluate the self-perceived importance and knowledge of SGBM in lecturers and students.

All lecturers and students at a Medical Faculty in Switzerland were invited to participate in a survey. An adapted questionnaire was developed and quantitative assessment using a Likert Scale. Statistical analysis was performed with Kruskal-Wallis rank sum test.

114 (34.1%) lecturers and 903 (41.4%) students participated in the survey. In both the lecturers’ and students’ subgroups, women perceived the teaching of SGBM to be more important compared to men (lecturer women vs. men median 6.0 vs. 5.0, p = 0.025; student 6.0 vs. 5.0, p < 0.001) (Figure 1). No significant difference was found between genders regarding self-reported knowledge of SGBM (lecturer median 4.0 vs. 4.0, p = 0.710; students 3.0 vs. 4.0, p = 0.841). A significant difference between lecturers and students in the perception of the amount of incorporated information actively addressing SGBM in the current curriculum was found (59.4% vs 28.8%, p < 0.001).

Women lecturers and students consider teaching of SGBM during medical curriculum to be more important than men. Lecturers perceived the amount of SGBM taught to be higher compared to students. These different expectations and perceptions need to be taken into account when striving for change and implementing SGBM within the medical curriculum.

Eastern Democratic Republic of Congo is an endemic zone of giant goiters (Fig. 1) that are a significant public health challenge in that region. Political instability led to deterioration of surgical care and inaccessibility of safe anesthesia. Thyroidectomies were performed only occasionally, with a high complication rate. In 2012, the Swiss NGO 2^nd Chance initiated a training program for local surgeons and anesthesiologists.

The aim of the program was to reintroduce a safe practice of thyroid surgery and general anesthesia among local actors to respond to the needs of the local population.

We retrospectively assessed the outcomes of patients enrolled in the program between 2013 and 2023 in Eastern DRC. The progression of the participating surgeons was evaluated.

38 teaching missions were conducted between 2013 and 2023 in 8 different localities of Eastern DRC, during which 559 patients underwent thyroid surgery (Fig. 2). The short-term follow-up rate was nearly 100% and the long term 36%. The complications included: hematoma requiring reintervention (2.4%), recurrent nerve palsy (1.2%), wound infection (2.75%). Out of the initial cohort of 20 local surgeons enrolled in the program, 10 are now certified as independent operators and 3 have the status of trainers. Two participants organise goiter campaigns on their own, in different region of the DRC.

Although the interventions were performed in rural conditions with basic equipment (Fig. 3) and on giant goiters approaching 1.5-2 kg, the complication rates was acceptable. The thyroid teaching program helped to improve the surgical skills in the management of other pathologies. The missions permitted to create a network of independent endocrine surgeons. The skills are being diffused now autonomously by local actors, maintaining the surgical expertise in the long term. This project demonstrates the feasibility of performing and teaching a complex procedure in an unstable socio-economic context in a limited resources setting.

Surgery, while often lifesaving, inherently carries risks of errors. Therefore, Morbidity and Mortality conferences (MMCs) are crucial in hospitals, providing a space for discussion and allowing professionals to learn from past actions. MMCs cover various domains, including clinical knowledge and skills, reasoning, system knowledge and change, sharing experiences, as well as illustrating errors. However, the extent to which residents and medical students as learners benefit from MMCs remains unclear.

This research aimed to analyze if MMCs fulfill abovementioned goals for surgical trainees and medical students. We also seek to understand their MMCs’ perception.

This analysis involved three steps: First, observation of 18 MMCs in three surgical teaching hospitals between 02-07/2023. Second, field interviews of 32 volunteering participants in training (15 residents, 17 medical students). The developed semi-structured interview guide covered expectations from MMCs, learning experiences, MMCs’ role in surgical education, emotional reactions to complications, and need for emotional support. Third, software-aided qualitative data analysis, following Elo and Kyngäs’ process, which involves data familiarization, coding, and categorization. Field notes from the observation and interviews provided context and deepened the analysis. Regular research team meetings supported the rigorous process.

Participants perceived MMCs as a valuable platform to learn from errors, with most medical students being unfamiliar with MMCs prior to first participation. MMCs' formats and case selection criteria varied among the participating surgical departments. Participants wished increased discussion time and reduced superiors' monologues. Residents' silence despite a “no blame, no shame”-culture led to medical students expressing uncertainty about learners’ role. Participants valued MMCs' fact-based atmosphere for addressing emotionally-charged topics.

While explored MMCs met their goals, improvements are still needed from learners’ perspectives. MMCs’ settings vary across hospitals, leaving room for implementation of an (inter)national standard. Early thematization and increased interactivity could transform surgical trainees from spectators to actors, ultimately inspiring medical students.

Background

Virtual reality (VR) distraction techniques are promising adjuncts to reduce pain and anxiety. 

Aims

This study assessed the impact of VR distraction during bedside change of vacuum assisted closure (VAC) dressings.

Methods

In this non-blinded randomized superiority trial, patients scheduled for bedside change of a subcutaneous VAC dressing were allocated to receive distraction through VR masks in addition to a standardized pain protocol (intervention) or pain protocol alone (control). Primary endpoints were pain scores assessed by a visual analogue scale (VAS:0-10), secondary outcomes were anxiety (State Trait Anxiety Inventory (STAI-Y:20-80), VAS:0-10), hemodynamic parameters and satisfaction (VAS:0-10).

Results

Nineteen and twenty-one patients were randomized to receive intervention and control, respectively. Baseline characteristics were well balanced including age (61±11 vs. 62±17), sex (female: 9 vs. 13), American Society of Anesthesiologists (ASA) scores (≥3: 18 vs. 18, all non-significant). Pre- and postoperative pain levels were 2.2±2.2 vs. 2.0±2.1 (p=0.38) for the intervention group compared with 2.6±2.1 vs. 2.2±1.6 (p=0.26), with no significant difference between the groups (p=0.38). Similar findings for blood pressure and heart rates. Anxiety was reduced in both groups post VAC change in the intervention and control group: STAI 40±12 pre-VAC vs. 30±8 post VAC and 45±14 pre-VAC vs. 32±9 post VAC (both p<0.01), ∆VAS -2 (interquartile range IQR 0, -3) vs. -2 (IQR 0, -5), both p<0.01. Postinterventional satisfaction was 8.3±1.9 (intervention) vs. 7.5±2.4 (p=0.11).

Conclusion

In this study, pain and anxiety were well managed with a standardized pain protocol with or without adjunct VR distraction. Further studies will focus on patients with insufficient control of pain and anxiety with a standard protocol.

Background

Standardized outcome reporting is key for proper assessment of surgical procedures. A recent consensus conference recommended the Clavien-Dindo classification (CDC) and the Comprehensive Complication Index (CCI^®) for assessing postoperative morbidity. However, their use in randomized controlled trials (RCTs) has not been assessed, and several challenging scenarios for grading complications require consensus-based guidance.

Aims

The aim of this study was to assess the use of the CDC and CCI^® in RCTs and to provide guidance on their standardized and consistent application.

Methods

We identified all RCTs that used the CDC or CCI^® as a primary or secondary outcome.

In addition, we asked 163 international surgeons to independently grade complications of 20 clinical cases covering seven challenging scenarios. Finally, a core group of five experts used this information do develop consistent recommendations.

Results

Up to July 2023, 1424 RCTs used the CDC or CCI^® to assess postoperative morbidity. Annual use was steadily increasing with now over 200 new RCTs per year (Figure 1).

Eighty-nine (55%) surgeons completed the survey. Table 1 summarizes the seven difficult scenarios and recommendations on how to grade those complications. Complications requiring multiple interventions, complications of complications, complications occurring prior to referral, and expected and unrelated complications should all be counted as separate complications and included in the CCI^®. Invasive diagnostics without findings should not be considered as a complication since purely diagnostic.

Conclusion

We observed an extensive and steadily increasing use of CDC and CCI^® in RCTs, highlighting the importance of their consistent application. Provided by the original developers of the CDC and CCI^® and based on an international survey of their frequent users, the current consensus offers much-needed guidance for challenging scenarios. This will further improve the consistency and accuracy of complication reporting, leading to higher quality RCTs, improved cost estimations, and better quality control, ultimately benefiting all stakeholders.

Colon anastomosis leak is the most feared complication in colorectal surgery, with high morbidity and mortality. Despite the identification of correctible risk factors, its incidence has remained stable for the past 50 years. One of the risk factors is obesity, a systemic disease whose prevalence is continuously increasing worldwide. To understand the implicated mechanisms, and to develop therapeutic strategies, characterization of colon anastomosis healing in obese subjects is mandatory.

We aimed to describe the colon anastomotic healing process in obese mice, with a secondary aim to identify potential targets to decrease post-operative leaks.

Three groups of mice were fed different diets for 16 weeks: normal diet only (ND), high-fat diet reverted to normal diet on day of surgery (HF-ND), or high-fat diet only (HF-HF). Surgery consisted of left colon hemi-transection on the anti-mesenteric wall, and subsequent anastomosis with separate stitches. N=5 mice from each group were sacrificed at days 3, 5, 7, 10 and 14 after surgery.

HF-HF mice had diarrhea and lost weight up to day 10 after surgery, compared to day 1 for ND mice. Overall, abscess rate was 4% in ND and HF-ND, and 8% in HF-HF mice. Free leak rate was 0% in ND and HF-ND, and 16% in HF-HF mice (p=0.03). Angiogenesis was decreased in HF-HF mice at day 5 compared to ND mice (p=0.02).

Obese mice undergoing continued high-fat diet (HF-HF) globally demonstrated worst outcomes after colon anastomosis with increased leak rates, and decreased angiogenesis. Despite having similarly low angiogenesis, these results seem to be mitigated in high-fat diet fed mice reverting to normal diet on day of surgery (HF-ND), hinting towards an involvement of gut microbiota. Further analysis of gut microbiota and angiogenesis pathways are warranted in order to determine therapeutic strategies.

Autologous mesenchymal stem cells (MSC) from different origins, including adipose tissue, have been proposed for the treatment of anal incontinence with encouraging preclinical and clinical outcomes. Cell transplantation as tridimensional structures instead of individual cell suspension seems to increase cell viability and implantation. We previously developed a protocol for MSC isolation directly from haemorrhoidal tissue (he-MSC) in human and demonstrated that the isolated cells fulfil MSC criteria.

Evaluate the characteristics and secretome of he-MSC in both two-dimensional or tridimensional cultures.

Informed consent was obtained from all patients. Tissue samples were procured from haemorrhoidectomy specimens or liposuction waste product and processed and characterized according to previously reported methods. He-MSC were cultured as spheroids using the “hanging-drop technique” or agarose pits. Immunofluorescence was performed to assess the expression of mesenchymal proteins and cell viability. Conditioned media of tow-dimensional cultures or spheroids in suspension were generated using low serum culture medium and analysed with semi-quantitative cytokine arrays (120 cytokines) and ELISA assays.

Cultured cells demonstrated expression of vimentin and good viability, even as spheroids (2.6±2% cell death). Cytokine profile of he-MSC secretome was similar to that of adipose tissue-derived MSC (AT-MSC), with shared core cytokines (FGF-9, OPG, CCL2, CCL11, CCL13, IGFBP-4, IGFBP-6). Concentration of HGF measured by ELISA was higher in he-MSC conditioned medium than in AT- MSC conditioned medium (19613±3528 versus 179±84 pg/ml p<0.001) whereas VEGF concentration followed an opposite trend (7627±947pg/ml versus 181±74 pg/ml p<0.001). Production of mesenchymal proteins and growth factors was not affected by the spheroid configuration of cells.

We demonstrated that he-MSC exhibit a similar secretome profile compared to AT-MSC. Generation of spheroids did not compromise cell viability or their ability to produce structural proteins and growth factors, validating he-MSC spheroids use for further in vivo studies prior to clinical validation.

MicroRNAs secreted by tumour cells through exosomes or in non-encapsulated form, were shown to promote tumour growth and treatment resistance, underscoring their potential as cancer biomarkers.

Here, we compare miRNAs secreted by pleural mesothelioma (PM) primary cells with miRNAs secreted by non-PM cells, in order to identify diagnostic biomarkers of this devastating disease.

We established primary cell cultures from pleural effusion of 12 PM and 7 non-PM patients. Secreted miRNAs were profiled as: (1) total secreted miRNA in cell culture supernatant (Sup), and (2) exosomal (Exo) miRNAs. Exosomes were extracted using iZON qEV columns. RNA was extracted with mirVana PARIS kit. Sequencing libraries were prepared using the QIAseq miRNA Library Kit (Qiagen). Reads were mapped on the mature miRNA sequences (MirBaseDB), followed by DESeq2 differential expression analysis. MiRNA target genes were selected using MirDB and functionally annotated using DAVID.

We identified 309 and 84 deregulated miRNAs in PM-Exo and PM-Sup samples, respectively (p-value <0.05, Fig. 1A). Among the up-regulated miRNAs, we found let-7c-3p and miR-16-5p, which are known tumour suppressors, and miR-23a-3p and miR-30a-5p (Fig. 1B). Interestingly, miR-30a-5p belongs to the same family as miR-30e-5p, which together with miR-23a-3p was previously identified as part of the long survival signature in PM. Additionally, we identified 11 miRNAs that showed up-regulation in both PM-Exo and PM-Sup. Further analysis of these candidate miRNAs revealed that exosomal expression of miR-30a-5p was a significant predictor of patient survival (Fig. 1C). Finally, we identified potential target genes of the 11 up-regulated miRNAs - the target genes were significantly associated with transcriptional regulation and cell division (p-value <0.05).

Our comparative analysis of secreted miRNAs identified 11 candidate biomarkers for PM. Our findings emphasise the importance of the PM secretome in advancing our understanding of mesothelioma biology and discovering novel cell-free biomarkers. Further in-depth analyses are currently underway.

Abdominal surgeries are often live-saving procedures. However, surgical interventions in the peritoneal cavity can cause the formation of post-surgical adhesions. These irreversible scar bands can trigger severe complications, such as chronic pelvic pain, small bowel obstruction, and infertility in women. Unfortunately, no effective treatment options for adhesion patients exist. On a cellular level, mesothelium-derived mesenchymal myofibroblasts have been identified as key pro-fibrotic players in adhesion formation.

Our aim is to study the molecular mechanisms of mesothelial cell recruitment in serosal repair and scarring, and thereby to identify potential targets for specific pharmacological anti-adhesion treatments.

We used a mesothelial cell reporter mouse system (Wt1^CreERT2xRosa26^tdTomato) and experimental injury models to study the differences of mesothelial cell recruitment to sites of adhesion formation in comparison to wound sites healing scar-free. To answer how injury zones affect the accumulation of mesothelial cells, we used untargeted spatial transcriptomics, identifying candidate molecules that were i) upregulated in adhesion formation sites, ii) not highly expressed in scar-free wound sites, and iii) had the potential to interact with mesothelial cells.

We observed strong spatiotemporal correlation between accumulation of tdTomato⁺ cells and consecutive scarring. Spatial deconstruction of scar-specific signaling identified the candidate molecule Secreted phosphoprotein 1; an inflammatory zone-specific gene that encodes Osteopontin (OPN). After confirming increased OPN protein levels 7d post-surgery, we investigated its effect on adhesion formation using Spp1^-/- mice. Indeed, Spp1-deficient mice showed significantly lower adhesion scores compared to control mice. Mechanistically, recombinant OPN had no chemotactic effect on primary human mesothelial cells, however triggered the upregulation of transcription factors associated with mesothelial-to-mesenchymal transition.

Together, these findings suggest a pivotal role for OPN in linking inflammation at injury sites with mesothelial cell recruitment in post-surgical serosal scarring. Therefore, OPN represents a potential target for novel pharmacological strategies to specifically inhibit scarring without affecting normal wound repair.

Diabetic ulcers are characterized by local ischemia, usually without macroangiopathy. We have previously found that the combination of VEGF and PDGF-BB in a fibrin matrix is effective in stimulating arterial growth to diabetic wounds.

We developed modified forms of VEGF and PDGF-BB to bear super-affinity for the extracellular matrix (SA-VP), in order to decorate the wound tissue without the need for a biomaterial. We investigated the dose-dependent effects on local blood flow and wound healing, by applying the treatment either to the healthy tissue around the wound or to the damaged wound bed.

Full thickness wounds were created on the dorsal skin of diabetic (db/db) mice. SA-VP or saline were applied to the wound bed or divided into 4 injections around the wound edge. Wound closure and blood flow were measured on days 4 and 8 after treatment and tissues were harvested for histology on day 8. Data were analysed by Anova with Tukey’s post-hoc test for multiple comparisons

Wound healing was improved dose-dependently by SA-VP by both delivery routes. Histologically, angiogenic areas and total amount of angiogenesis were significantly increased by the highest SA-VP dose, again independent of delivery route (p= 0.034). However, the total amount of recruited arterioles was significantly increased only in the healthy tissue around the wound and only by intradermal injections of SA-VP(p= 0.008). In agreement with the arteriogenic effect, the blood flow at day 4 was significantly increased only by injections of the highest SA-VP dose around the wound (p= 0.018)

SA-VP treatment significantly accelerates wound healing in a diabetic murine model with a clear dose-dependent effect. Targeting the undamaged tissue around the wound by injections induces more effective arteriogenesis. However, direct treatment of the wound bed is equally effective for healing. These results support further development for a potential clinical use

Recurrence after hepatocellular carcinoma (HCC) treatment is a significant problem. It affects more than 70% of patients undergoing liver resection. Recurrence can arise from undetected micro metastasis or de novo cancer. Clinical and experimental studies suggest that liver regeneration ensuing surgical resection may activate occult micro-metastasis leading to regeneration induced tumor recurrence. However, in vivo patient-derived organoid (PDO) HCC models that are translatable to patient tumors are sparse.

Here, we aim to establish a new in vivo model to understand the impact of liver regeneration on HCC tumor growth.

PDOs were generated from HCC tissue obtained from patients undergoing liver resection at the Clarunis University Digestive Health and Care Center and transduced with firefly luciferase. Implantation was performed via laparotomy and orthotopic injection of the organoids in the right superior liver lobe. Tumor growth is monitored by in vivo bioluminescence imaging until the endpoint of the experiment. As a primary endpoint tumor growth two weeks after liver resection was defined. Experimental groups underwent either minor (30%) or major (65%) hepatectomy of tumor-free liver, whereas the control group received a re-laparotomy with subsequent closure of the abdomen. Normal liver and tumor tissue were characterized using immunohistochemistry.

Two HCC-PDO lines were successfully implanted. Compared to the control, after minor and major liver resection the mean weight increased significantly to 0.82% (p < 0.0001) respectively 0.99% (p < 0.0001). Preliminary data about the tumor volume have yet to be concluded. Histology and immunohistochemistry staining for HCC confirmed the origin of the PDOs from the original patient tumor.

The establishment of an orthotopic xenograft mouse model for HCC PDO was successful. Through liver resection, a regenerative environment could be achieved, to investigate the molecular behavior of HCC recurrence after surgery. This offers the basis to study potential new targets and mechanisms to improve HCC-treatment

Background

Hirschsprung`s Disease (HD) is a congenital intestinal disorder characterized by a variable length of distal colonic aganglionosis. It is caused by aberrant processes of the enteric neural crest-derived cells that could include proliferation, migration, differentiation, and survival. Enterocolitis is a potentially life-threatening complication. Aquaporin 1 (AQP1) is physiologically expressed in several parts of the intestine including mucosa, submucosal lamina, the capillary endothelial cells and in the enteric nervous system. Its function in each anatomical structure remains not clearly defined.

Aims

The aim of the study was to characterize the AQP1 expression in Hirschsprung`s Disease and correlate its expression with severity of disease including the risk for enterocolitis.

Methods

Tissue samples from 48 patients with Hirschsprung`s disease were examined by immunohistochemical and immunofluorescence staining and compared with control tissue. Co-staining against AQP1, β3 tubulin and AChE was carried out. Whole slide scanning was performed and AQP1, β3 tubulin and AChE expression was analysed visually regarding its anatomical expression pattern and by threshold image analysis.

Results

An increase of AQP1 expression was recognized in the distal part of the affected colon tissue in Hirschsprung patients compared with control tissue in correlation with β3 tubulin and AChE expression. While AQP1 is known to be physiologically expressed in vascular endothelial cells and in ganglia of the enteric nervous system, in these patients this particular localization is missing, however we found an increased expression in the mucosa.

Conclusion

A distinct pattern of AQP1 expression could be observed in the colon of patients with Hirschsprung`s Disease, suggesting an imbalance in membrane water permeability, which might directly impact on development of enterocolitis, as well as hinting towards a regulatory role of AQP1 in the enteric nervous system.

Marginal grafts are increasingly considered for transplantation due to the widening gap of available donor grafts and waiting recipients. Graft assessment and repair prior to implantation are therefore essential to minimize the risk of failure. Normothermic perfusion has not been widely evaluated for kidney grafts, with existing perfusions limited to 2 days.

The aim of this study was to develop a long-term (>3 days) normothermic ex situ swine perfusion model in kidney grafts, while maintaining organ viability. We also wanted to investigate possible regenerative processes of the kidney during this period outside the donor animal.

Swine kidneys were retrieved with minimal injury. After cannulation, organs were perfused at 37°C for up to several days in a newly designed normothermic ex situ device with automated blood gas and glucose regulation, addition of nutrition, antibiotics, and vasodilators. Kidney biopsies, urine and perfusate samples were taken daily for analysis as well as markers of viability.

In total 17 kidneys were perfused. Four kidneys were perfused for 3 or more days. Viability was maintained up to 4 days without histological evidence of glomerular and minimal to moderate tubular necrosis. We observed upregulation of ki67 and pH3 in tubular cells with mean values of up to 14.2% and 2.2% respectively. This expression of ki67, a proliferation associated protein, correlated with the duration of ex situ perfusion.

This is the first report of normothermic kidney perfusion for up to 4 days with unprecedented observation of upregulated ki67 and pH3 after multiple days of perfusion. These preclinical results open the door for development of long-term perfusion protocols for discarded human grafts while also hinting at limitations and challenges.

Immune checkpoint inhibitors (ICI) represent a major breakthrough in cancer immunotherapy. Several molecules have shown efficacy in HCC and are increasingly used as a bridging therapy before liver transplantation. Initial reports have raised concern about severe rejections in patients following ICI therapy. 

This meta-analysis assesses the risk of neoadjuvant ICI therapy before liver transplantation.

We systematically searched MEDLINE, Web of Science and Embase for studies including all patients treated with ICI therapy before liver transplantation from a given center. A random-effects model was applied to pooled results with a priori determined subgroup analyses.

Eight studies published during the past three years fulfilled all inclusion criteria. All studies are noncomparative case series, one prospective and seven retrospective. Studies included 52 patients who received various PD1 inhibitors between 1 and 253 days prior to liver transplantation. Patients treated with an ICI ahead of transplantation demonstrated an overall relative risk (RR) of 2.5 [95% CI: 1.4-3.8] for an acute rejection event. Furthermore, a subgroup analysis showed that patients who received PD1 inhibitors up to 30 days (RR 7.2 [95% CI: 4.9-10.5]) or between 30 and 60 days (RR 7.2 [95% CI: 5.1-10.3]) prior to liver transplantation suffered a higher rejection risk than patients with a “washout period” beyond 60 days (RR 1.8 [95% CI: 0.6-4.9]). The ICI, age, and underlying etiology were insignificant for RR in their subgroup analysis.

PD1 inhibitors within two months of liver transplantation may significantly elevate rejection risk. This meta-analysis provides valuable insights to inform clinical decision-making. Nevertheless, future trials remain imperative to establish definitive guidelines.

Transjugular intrahepatic portosystemic shunt (TIPS) is used to mitigate the side effects of portal hypertension. However, its impact on hepatocellular carcinoma (HCC) remains unclear.

We aimed to evaluate its effect on HCC dynamics and patients survival.

We analysed 43’734 liver transplant candidates diagnosed with HCC from the prospective Scientific Registry of Transplant Recipients database (1985-2022). A total 7’404 patients with and without TIPS were propensity score matched 1:3. We assessed wait-list changes in total tumor volume, HCC count, and alpha-fetoprotein levels. We examined survival rates from time of listing and post-transplantation, as well as the incidence of HCC recurrence post-transplantation.

Pre-matching, TIPS patients exhibited poorer liver function and less advanced HCCs. Post-matching, TIPS correlated with a decrease in HCC nodules count (-0.24 vs 0.11, p = 0.008) over a median waiting period of 225 days (IQR 94; 441) and better overall survival rate from listing (93.0% vs 89.1% at one year, p = 0.0003). TIPS was not associated with altered changes in waitlist tumor volume (0.26 vs -0.07 cm3/month, p = 0.26) and AFP (14.62 vs 12.67 ng/mL, p = 0.79) compared to the non-TIPS group. Post-transplant survival rates (91.8% vs 91.7% at one year, p = 0.25) and HCC recurrence (5.2% vs 5.4% at 5 years, p = 0.73) were similar, with a median follow-up of 5.6 years (IQR 2.7; 9.6)

TIPS improved waitlist survival and is associated with decreased HCC nodule count, potentially due to a better efficacy in HCC treatment. However, TIPS did not have a measurable impact on HCC growth or aggressiveness.

Laparoscopic cholecystectomy is a very common procedure and while preoperative magnetic resonance cholangiopancreatography (pMRCP) is widely used for detection of choledocholithiasis and preoperative planning, the benefits in patients with normal preoperative cholestatic parameters remain unclear.

We aimed to investigate a large cohort of patients after laparoscopic cholecystectomy to analyse the impact of pMRCP on complication rates.

This retrospective cohort study consecutively includes all patients receiving elective or acute laparoscopic cholecystectomy between 2010 and 2020. Exclusion criteria were conversion to open cholecystectomy and preoperatively elevated cholestatic parameters. Complication rates were recorded and patients stratified depending on the use of pMRCP for preoperative planning.

3163 patients underwent laparoscopic cholecystectomy between 2010 and 2020, 2568 of which showed normal cholestatic parameters preoperatively. Of these patients, 684/2568 (27%) were male and 1884/2568 (73%) female. The most frequent indications for laparoscopic cholecystectomy were cholecystolithiasis in 72% (1845/2568) of cases, followed by cholecystitis in 18% (465/2568). The majority of patients (2267/2568, 88%) indeed received pMRCP, while the remaining 301/2568 patients did not. Postoperative complication rates did not significantly differ between the two groups (396/2267 (17%) in the pMRCP group and 58/301 (19%) without pMRCP, p=0.469). One case of pancreatitis occurred in the pMRCP group, versus two reported cases in the other group. Interestingly, the length of hospital stay after cholecystectomy was significantly shorter in the group with pMRCP versus without (4 days (range 1-61 days) versus 7 days (range 1 – 66 days), respectively, p = 0.023).

Preoperative MRCP seems to not prevent complications in laparoscopic cholecystectomy, since postoperative complication rates were comparable between the two patient groups with and without pMRCP. However, postoperative hospital stay was significantly shorter in patients undergoing pMRCP compared to patients without pMRCP.

Acute acalculous cholecystitis in healthy patients is relatively understudied. It is usually described in patients within the intensive care unit, where it is associated with high mortality rates reaching 30%-50% in the literature

To review patients who have developed AAC in outpatient or non-ICU settings, identify risk factors and clinical presentation, and compare these data with those in the literature

We first performed a literature review. We then determined the inclusion criteria: acalculous cholecystitis confirmed by either an ultrasound, or CT scan, at pathology and intraoperatively. We excluded all patients hospitalized within the ICU or who developed AAC because of multiorgan failure or patients without histopathological evidence. We performed a 5-year search in our institution’s database with the terms “cholecystitis” and “acalculous cholecystitis

23 patients were included in our study based on histopathology. The most frequent co-morbidities were cardiovascular and metabolic syndrome. The most common complaint was abdominal pain, ten patients (50%) presented to the emergency department with an increase of at least two of three biological markers (CRP, bilirubine and leucocytosis). We had no mortality reported at 30 days.

Epidemiologically, our population’s characteristics correspond to those of other studies, with most patients being male.The majority of patients were ASA III suggesting that this disease concerns more polymorbid patients despite a high percentage of healthy patients. Right upper quadrant pain, whether associated with leukocytosis or not, seems to be the main factor leading to further investigation. Abdominal US is considered the diagnostic technique of choice. However, most patients in our study underwent US and CT. We found that acalculous cholecystitis in outpatients, does not have the high mortality rate that was previously attributed to it, but is more frequent in polymorbid patients with cardiovascular risk factors.

Minimal invasive liver surgery (MILS) offers several benefits compared to open resections. For a safe introduction of MILS, formal training is required. However, definitions of learning curves vary greatly and are lacking international standardization.

The aim of this systematic review was to analyze the learning curves associated with both laparoscopic- (LLS) and robotic liver surgery (RLS).

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

62 articles with 13’005 patients and 102 learning curve analyses were included. The laparoscopic and robotic approach was evaluated in 70 and 18 analyses, while both approaches were assessed in 14 analyses. Sixty-one analyses (60%) based the learning curve on statistical calculations. The most often used parameters to define learning curves were operative time (n=64), blood loss (n=54), conversion (n=42) and postoperative complications (n=38). Overall, the number of procedures to surpass the first phase of the learning curve was 25 (10-106) for laparoscopic minor- compared to 19 (15-109) for robotic minor resections (p=0.903) and 19 (8-50) for laparoscopic major- compared to 40 (22–57) for robotic major resections (P=0.007). In a three-phase model (Figure 1), intraoperative parameters improved earlier (1st to 2nd phase: operating time –13%, blood loss –33%) whereas postoperative parameters improved later (2nd to 3rd phase: complications -29%, conversion rate –29%). Studies with larger sample sizes showed higher numbers of procedures needed to overcome the learning curve (rho=0.64, P< 0.001).

This study summarizes the best available evidence on learning curves in laparoscopic- and robotic liver surgery taking into account different definitions, analysis methods, and confounding factors. A standardized three-phase reporting of learning phases (competency, proficiency, mastery) is proposed and should be followed.

Minimally invasive pancreatic surgery (MIPS) is increasingly utilized in expert centers.

This study aims to assess short-term outcomes after MIPS during the learning curve in a tertiary referral university hospital.

From 2014 to 2023, all consecutive distal pancreatectomies treated at a single center in Switzerland were included. MIPS was compared to open surgery and propensity-score matching by the nearest-neighbor method was used to reduce confounding.

Ninety-nine patients were included, 28 had MIPS and 80 had open resections. After matching, 21 MIPS and 34 open resections were compared. There were no statistically significant differences in baseline characteristics. Most patients underwent resection for benign disease (14 patients (67%) in the MIPS and 24 patients (71%) in the open group). The robotic approach was used in 16 patients (76%) while 5 patients (24%) underwent laparoscopic MIPS. The operative time was not statistically significantly different (215 min (interquartile range [IQR] 181-300) and 212 (IQR 197-247), p = 0.960).

Major complications occurred in 18% (MIPS) and 10% of patients (p = 0.383), respectively. The mortality was zero. No grade C pancreatic fistula (POPF) occurred, 4 patients in the MIPS group (19%) and 13 in the open group (39%) developed grade B POPF. The number of intraabdominal infections was one after MIPS (5%) and 7 (24%) after open resections (p = 0.165). The median Comprehensive Complication Index was lower after MIPS compared to open surgery (0 [0, 20.9] and 20.9 [20.9, 29.6], p = 0.002) and the length of hospital stay was shorter (7 days [IQR 6-10] and 24 [IQR 15-30], p < 0.001). After conclusion of the learning curve and improvement of the robotic technique with Ligamentum Teres-Patch, the fistula rate was <10%.

Patient selection during the learning curve of MIPS results in a safe implementation with good short-term outcomes.

Extending the organ donor criteria to reduce the waitlists number and mortality with dual and pediatric en bloc kidney transplantation is not yet fully exploited.

To assess whether pediatric en bloc (PEB) and dual kidney transplants (DKT) have comparable results to living donor kidney transplants (LDKT).

The study was performed as a retrospective analysis of 39 LDKT compared to 13 DKT and 24 PEB transplantations all performed from 2011 to 2019 at the University of Virginia. The living donor kidney transplants were all performed in 2017 to provide 5-year outcome data. Primary outcomes were serum creatinine and glomerular filtration rate at 12 and 24 months postoperatively, whereas secondary outcomes were patient and graft survival.

The PEB group showed lower 1-year creatinine (mg/dl) levels (median 0.9, IQR 0.8-1.4) compared to the DKT (median 1.4, IQR 1.2-1.5) and LDKT (median 1.3, IQR 1.1-1.5) groups (p<0.001). Similarly, the 2-year creatinine levels were lower in the PEB group (median 0.8, IQR 0.7-1.08) compared to the DKT (median 1.3, IQR 1.1-1.5) and LDKT (median 1.3, IQR 1.0-1.5) groups (p<0.001). Glomerular filtration rates showed comparable outcomes. Graft survival rates at 1-, 3-, and 5-years were 100/100/90, 100/92/69, and 96/96/91 for LDKT, DKT, and PEB, respectively (p=0.27). Patient survival rates at 1-, 3-, and 5-years were 100/100/90, 100/100/88, and 100/100/95 for LDKT, DKT, and PEB, respectively (p=0.78).

Dual kidney and pediatric en bloc transplantation are two, not just alternative, but also safe techniques to expand the donor pool. Overall, the technically most demanding procedure of pediatric en bloc transplantation provides the best long term graft function.

During segmentectomy for early stage non-small cell lung cancer (NSCLC), the recommended distance between the tumour and the intersegmental plane is at least 1 cm and the recommended ratio between tumour and surgical margin (M/T) should be at least 1.

The aim of the study is to evaluate the association between surgical margin and the risk of recurrence, as well as overall survival, after pulmonary segmentectomy.

Single centre study of consecutive patients undergoing pulmonary segmentectomy for cT1N0M0 NSCLC from January 2017 to December 2022.

In total, 291 patients (median age: 69 years) underwent segmentectomy for cT1a (n=65), cT1b (n=152) and cT1c (n=74) cN0 NSCLC. Surgical approach was performed by video-assisted thoracic surgery in 99% and conversion thoracotomy was necessary in 2.4%. Single segmentectomy was performed in 183 patients (63%).The median number of dissected lymph nodes was 7 (IQR 4-12). The median size of tumour was 15 mm (IQR 11-20). The median surgical margin was 13mm (IQR 7-22) with 32% of patients had surgical margin of less than 10mm with only one patient with R1 resection. M/T ratio >1 was achieved in 49%. Nodal upstaging was found in 14 patients (5%). During the follow-up, 63 patients (21%) were lost and removed from analyses. Local recurrence was observed in only 3 patients (1%) and distant in 19 patients (8%). Recurrence free survival was significantly associated with PET FDG uptake > 3 (HR:4.89), pleural invasion (HR: 3.02) and nodal upstaging (HR: 3.79). However, surgical margin <10 mm or ratio < 1 were not correlated with increased recurrence (HR: 0.78; p=0.624) (HR: 0.69; p = 0.404) or poorer survival (HR: 1.14; p=0.806) (HR: 1.73; p= 0.309), respectively.

Our preliminary data indicates that local recurrence is infrequent after pulmonary segmentectomy for cT1N0 NSCLC, even with a limited surgical margin.

Background

Video-assisted segmentectomies are challenging operations and potentially associated with serious complications.

Aims

In this analysis, we investigated whether preoperative reconstructions of the lung anatomy with Visible Patient^TM 3D-reconstruction software based on HRCT-scans improve both surgical and postoperative outcomes.

Methods

We retrospectively collected data from 100 consecutive patients who signed the general research consent and received minimally invasive segmentectomies from 2019-2022. The operative outcomes (type of segmentectomy, conversion to thoracotomy, chest tube duration, intensive care unit stay) and complications of the surgeries planned with 3D-reconstructions were compared to the results of those performed without. The data was analyzed using propensity modelling and inverse probability of treatment weighting (IPTW).

Results

With 37 of the 100 patients included, surgical planning was performed with 3D-reconstruction. 3D-reconstructions enabled to successfully perform significantly more complex segmentectomies (p<0.001) in patients with a higher BMI. In this patient group, surgeries lasted longer (p=0.002), there were significantly fewer conversions to thoracotomy (p=0.003), and fewer major complications (Clavien-Dindo grade III or IV) (odds ratio 0.10 95% CI 0.01 to 0.87, p=0.037).  

In addition, planning surgery with 3D-reconstruction software leads to a reduction in the number of segments removed (1.7 ± 0.8 vs. 1.9 ± 1.0) (p = 0.402) and the average duration of the chest tube remaining from 3.0 days (2.0–4.0) to 2.0 days (1.0–3.0) (p=0.06). The stay in the intensive care unit/HDU also was shortened. See Table 1.

Conclusion

The planning of complex anatomical VATS segmentectomies with the 3D-reconstruction software Visible Patient^TM significantly reduces both, the need for conversions from minimally invasive to thoracotomy and the postoperative complications rates. Additionally, this proceeding allows safe performing of complex surgeries.

The indication for anatomic sublobar resection in solid or predominantly solid stage IA non-small cell lung cancer is still debated despite recently published prospective randomized trials.

Our aim was to evaluate the long-term oncologic outcome after these two surgical approaches and assess clinical and histopathologic parameters influencing overall mortality and recurrence rate.

Retrospective analysis of all patients who underwent uniportal anatomic segmentectomy or lobectomy for pathologic stage IA lung cancer (8th edition) from January 2015 to December 2021. Data up to December 31, 2023 were included for oncological follow-up. The primary endpoints were overall survival and recurrence. Univariate and multivariate logistic regression were used to predict indicators for mortality and recurrence.

A total of 232 consecutive patients were included in the analysis. A segmentectomy was performed in 160 patients and a lobectomy in 72 patients. The distribution of histological subtypes was comparable, with adenocarcinoma being the most common histology (67.6%).

The mean tumor size in the segmentectomy and lobectomy groups was 1.59 ± 0.63 and 1.71 ± 0.61, respectively. The mean number of resected lymph nodes was 10.38 ± 7.43 in 4.66 ±1.99 lymph node stations in the segmentectomy group and 14.07 ± 8.69 in 5.04 ± 1.58 lymph node stations in the lobectomy group. The 5-year overall survival rate were 76.9% in the segmentectomy group compared to 87.5% in the lobectomy group (Figure 1). A statistically non-significant difference. Multivariate analysis showed that men (OR = 3.21; CI: 1.33 to 7.75) and patients with lymphatic invasion (L) (OR = 4.60; CI: 1.27 to 16.66) had a higher risk of death (Table 1). The probability of recurrence was higher in patients with a larger number of removed lymph node stations (OR = 1.93; CI: 1.01 to 1.92).

Our results support anatomic sublobar resection as an acceptable alternative to lobectomy with comparable oncologic results.

The introduction of immunotherapy in the management of locally advanced non-small cell lung cancers (NSCLCs) has significantly improved patient outcomes. In 2017, our center evaluated immunotherapy for stage III NSCLC as follows: induction chemo- immunotherapy followed by surgery for potentially resectable and chemo-radiation therapy followed by immunotherapy for non-resectable NSCLCs.

We report and compare the outcomes of 75 stage III NSCLCs (51 single N2 and 24 bulky N2 or N3) managed by multimodal therapy including immunotherapy and surgery or radiation therapy.

Using our prospectively collected database, we reviewed all stage III NSCLC patients treated in our institution and in Valais Hospital between 2017 and 2023 with chemo- immunotherapy and surgery or radiation therapy. We recorded clinico-pathological characteristics, perioperative complications, and long-term outcomes. We compared groups using Stata®.

Thirty-nine patients (32 single N2 and 7 bulky N2/N3) underwent surgery and 36 (19 single N2 and 17 bulky N2/N3) underwent radiation therapy. Patients were significantly older (73 vs 63 years old, p<0.05) and had worst lung diffusion capacity (45% vs 76% of predicted value, p<0.05) in the radiation group. Tumor stages were equilibrated between both groups. All potentially resectable patients had surgery after induction chemo-immunotherapy. Pulmonary and cardiac morbidity were comparable between surgery and radiation groups (38% vs 33% and 18 vs 14%, p>0.05). No 30-day mortality occurred. Complete pathological response (CPR) occurred in 11 patients (10 of 32 single N2 and 1 of 7 bulky N2/N3). Overall survival was significantly higher in the surgery group and was the best in patients with CPR (Figure 1).

The inclusion of immunotherapy in neoadjuvant protocols has improved tumor response and allowed to consider potentially resectable bulky N2/N3 NSCLCs for surgery with good outcomes. Careful patient selection within multidisciplinary tumor boards remains mandatory and further studies are required.

Neoadjuvant immunotherapy has become an integral part of the multimodal treatment in advanced NSCLC. However, an increasing procedural complexity after neoadjuvant immunotherapy is described by many surgeons. We therefore aim to score the surgical complexity of anatomical resections after induction immunotherapy.

We aimed to score the surgical complexity of anatomical lung resections after induction immunotherapy.

We performed a single-institutional retrospective review of patients with clinical stage IIIA-IVB NSCLC who underwent anatomical lung resection and mediastinal lymphadenectomy after neoadjuvant immunotherapy. Surgical complexity and hilar fibrosis were scored according to the proposed scoring system by Rusch et al. (https://doi.org/10.1016/j.jtcvs.2022.10.007).

25 patients met the inclusion criteria, among which 4 (16%) were treated with neoadjuvant immunotherapy alone, 18 (72%) with neoadjuvant immunochemotherapy and 3 (12%) with neoadjuvant immunotherapy and chemoradiotherapy. Clinical UICC-stages were IIIA in 8 (32%), IIIB in 2 (8%), IVA in 9 (36%) and IVB in 6 patients (24%). Surgical access was primarily open in 13 (52%), RATS in 5 (20%) and VATS in 7 patients (28%). Resections included 15 lobectomies, 4 bilobectomies, 5 pneumonectomies and 1 segmentectomy. Conversion from minimally invasive to open approach was required in 5 patients (2 VATS and 3 RATS cases), all due to extensive hilar fibrosis. A hilar fibrosis score of 2 was present in 15 cases and a score of 0 was only seen in 4 patients. The presence of a high fibrosis score was not associated with an increased risk for perioperative complications (p=0.66), but patients with a fibrosis score of 2 showed a longer median length of hospital stay (9.4±3.9 versus 6.7±1.8 days), although not statistically significant (p=0.056).

Surgical complexity after neoadjuvant immunotherapy for advanced NSCLC can be objectified by a hilar fibrosis score. The prognostic relevance of the hilar fibrosis score for early outcomes such as perioperative complications and length of stay needs to be assessed in larger prospective cohorts.

The Timed Up and Go (TUG) test is an easy-to-administer tool measuring motor functions with prognostic value in elderly.

The aim of this study was to investigate the association between the TUG test and the short- and long-term outcomes after anatomical pulmonary resection.

We retrospectively reviewed records of patients who underwent anatomical pulmonary resection from 2021 to 2023. A TUG test taking more than 10 seconds was considered to be impaired. We compared cardiopulmonary complications at 30 days and long-term overall survival according to the TUG tests. Logistic regression was employed to analyze complications and the survival proportions were estimated using Kaplan-Meier curves. Hazard ratios were estimated using Cox proportional hazard models.

A total of 95 patients were included in the analysis, including 19% of patients with a TUG >10 seconds. Mean age was 68.9 ± 9.8 years. Lung cancer was the surgical indication in 81% of patients. A majority of patients underwent resection by VATS (90.5%), and a majority underwent segmentectomy (61.1%). The mean follow-up duration was 304 ± 124 days. An impaired TUG didn’t predict an increased risk of cardiopulmonary complications at 30 days. In the long term, an impaired TUG was associated with a shorter overall survival (P<0.001) (Figure). Multivariate analysis confirmed that an impaired TUG and age older than 80 years old were independent predictors of patient death in the long-term (hazard ratio, 11.7; P=0.030 and hazard ratio, 7.9; P=0.028, respectively).

An impaired TUG is associated with a shorter overall survival after anatomical pulmonary resection. It requires further investigation and whether interventions improving TUG such as rehabilitation could enhance long-term outcomes.

Chest wall resection may be necessary for various reasons. Reconstruction is warranted for large defects of the chest wall and sternum to prevent paradoxical, insufficient breathing, to protect underlying structures, and to offer a good functional result. Codubix^®Ribs (Tricomed) is a prothesis made of polyester and polypropylene yarn recently introduced for reconstruction.

Patients with resection of the chest wall and/or the sternum followed by reconstruction with Codubix^®Ribs were prospectively enrolled to assess chest wall integrity and pain.

Eleven patients (mean age 53 y ± 20.5, three female) who underwent thoracic wall reconstruction with Codubix^®Ribs were enrolled between 2019 and 2023. Pain was assessed by using a numeric rating scale (NRS, 0 no pain, 10 strongest pain). Functionality was measured by clinical examination, by assessment of upper extremity mobility (quickDASH questionnaire; 0 the best, 100 the worst), and by cine-magnetic resonance imaging (MRI).

Indication for resection consisted of tumors (n = 9) and osteomyelitis (n = 2) in an anterolateral (n = 10) and posterolateral (n = 1) location. The sternum was involved in three patients. Complication of the procedure was observed in one patient with dislocation of an undersized prothesis; following an uneventful reoperation. Functional assessment was performed in nine patients at a mean follow-up time of 23.3 ± 20.1 months. Chest wall was stable in all patients and dynamic MRI imaging showed symmetric movement of the chest wall in all but one patient, but without paradoxical motion. NRS pain score had a mean value of 1.7 ± 2.2 and the quickDASH score showed a median value of 6.8.

We observed excellent functional results using Codubix^®Ribs for chest wall reconstruction, suggesting high stability and low complication rates. However, further studies involving larger number of patients are required to confirm our initial results.

Simulation training has proved to be beneficial in many fields of professions including medicine and might be included already during medical school.

We evaluated if medical students rate their manual dexterity as good or above average and if this self-assessment (SA) correlates with the actual performance in a surgical simulation.

Basic surgical tasks have been performed by medical students in the 3rd and 4th year for a total of 4 rounds on 2 identical Lap-Sim® surgical simulators. Three questionnaires, before and after the simulation as well as follow up after 1 year had to be answered.
Descriptive statistics stratified by career goal (surgical/ undecided/ nonsurgical) for outcomes of simulation parameters are reported. Associations between surgical career goal and SA of manual dexterity with three performance parameters (tissue damage, time and path length) are estimated in linear regression models.

Out of 102 participating students 41 stated surgery as their career goal, 18 a nonsurgical field, and 43 were undecided. 87.8% of the surgical group rated their dexterity as good or above average (86.1% in the undecided group), 88.9% of the nonsurgical group as below average or good. An positive association of SA with tissue damage has been found statistically significant (p=0.033). The figure shows the influence of surgical simulation on SA of manual dexterity.
One year after the simulation (n=97) 13.4% changed their career goal from undecided to surgical, whereas 8.2% changed from undecided to non-surgical. 92.7% wanted to have simulation training integrated into the curriculum.
 

A correlation of self-assessed manual dexterity has been found in the surgical group for tissue damage, but not for time and path length. Simulation training might help students in decision making for a surgical field and therefore recruit future surgeons, which could be shown in the one year follow-up.

There is currently a lack of data on the indications for hardware removal (HR) following surgical stabilization of rib fracture (SSRF). Many of the symptoms are thought to be mostly a direct consequence of the blunt trauma itself.

To analyze the indications for HR and the long-term results in terms of improvement of the symptoms and satisfaction of the patients.

Single centre retrospective study with one prospective follow-up visit including 28 patients who underwent HR after SSRF between September 2017 and September 2023. A prospective follow-up visit was performed 29 (range 3-73) months after HR. Evolution of the symptoms and QoL were assessed in 82% of the patients by use of an adapted EQ-5D-5L questionnaire.

The mean age of the patients was 59 (range 29-83) years. The median number of fractures per patient was 10.5 (range 1-39) and the median number of implants used was 4 (1-11). Indications for HR after SSRF were persistent pain (36%), discomfort (25%), chest tightness (21%), dislocation of hardware (11%) and infection (7%). HR was performed after a mean time interval of 18 months (range 5 days-105 months) after initial SSRF. Patients with chest tightness showed the highest improvement rate of the symptoms (74%) followed by the group hardware infection (69%). In the 3 other indications groups, the improvement rate was 60%. All the patients with chest tightness, dislocation of hardware and hardware infection were satisfied and would undergo HR again.

Our preliminary results suggest that removal of hardware after rib stabilization leads to a significant relief of the symptoms and improvement of the quality of life in about two thirds of the patients. Consequently, HR might be more liberally performed and earlier if symptoms are disabling.

It is unclear if elderly patients treated with plate osteosynthesis for proximal humerus fractures benefit from cement augmentation.

This meta-analysis aims to compare cement augmentation to no augmentation regarding healing, complications, and functional results.

PubMed, Embase and Cochrane Central Register of Controlled Trials were searched for randomized clinical trials and observational studies. Effect estimates were pooled across studies using random effects models. The primary outcome is overall complication rate. Stratified analyses were performed for types of complication (implant related or systemic). Secondary outcomes include re-interventions, hospital stay, operation time, functional scores, and general quality of life.

Five observational studies and one randomized controlled trial with a total of 541 patients were included. The overall complication rate was significantly lower in the augmented group (15.6% versus 25.4%, OR 0.54 (95%CI 0.33–0.87)). This was caused by a reduction of implant related complications (10.4% vs 19.9%, OR 0.49 (95%CI 0.28, 0.88)). No difference in humeral head necrosis was found. Data on re-intervention, hospital stay, and operation time was limited but did not show significant differences. No impact on functional scores and general quality of life was detected.

This meta-analysis shows that cement augmentation may reduce overall complications, mainly by preventing implant related complications. No difference was detected regarding need for reintervention, functional scores, general quality of life and hospital stay. This is the first meta-analysis on this topic. It remains to be seen whether conclusions will hold when more and better-quality data becomes available.

The aim was to investigate whether operative treatment of displaced proximal humerus fractures is superior to nonoperative treatment.

The study design was prospective natural experiment (prospective cohort study) based on geographical randomization and clinical equipoise.  The setting was an international multicenter cohort study in the Netherlands and Switzerland. In total 226 patients with acute (<3 weeks) displaced proximal humerus fractures presenting from July 2020 until March 2022 were included after expert panel evaluation based on clinical equipoise. Patients were followed up for one year, and 191 (84%) had complete follow-up data. Operative treatment included plate fixation, intramedullary nailing and reverse shoulder arthroplasty at the discretion of the treating surgeon. Nonoperative treatment was sling immobilization. All patients received standardized outpatient rehabilitation and physiotherapy. The primary outcome was QuickDASH after one year. Secondary outcomes included QuickDASH at six weeks and EuroQoL5D (EQ5D), Subjective shoulder value (SSV), numeric rating scale for pain (NRS) at six weeks and one year.

No difference in QuickDASH score after one year (16.3 vs. 17.5, p=0.836) was found. At six weeks, operative treatment resulted in lower NRS (4.2 vs 3.0, p<0.001), higher EQ5D (0.59 vs. 0.68, p=0.015) and higher SSV (41.8 vs. 53.6, p=0.002). At one year operative treatment resulted in higher SSV (70.9 vs. 83.5, p<0.001). Increase in SSV was similar between groups (29.1 vs. 29.9, p=0.234) and EQ5D was comparable after one year (0.87 vs. 0.86, p=0.980).

No differences were observed in functional outcomes after one year. However, operative treatment resulted in lower NRS and higher EQ5D at six weeks. The SSV was better for the operative group at both six weeks and one year. Therefore, operative treatment might be beneficial in the short term for selected patients.

Minimal-invasive placement of a trans-sacral screw represents an increasingly popular method of fixation for Fragility Fractures of the Pelvis (FFP), with variable upper sacral anatomy representing the main challenge. Little is known about the variability of sacral anatomy in the geriatric population and the potential effect of osteoporosis on the upper sacral anatomy and thus S1 corridor morphology.

To examine the eligibility (>12 mm) of the S1 corridor for the trans-sacral screw placement in a geriatric population and to analyse what pelvic dysmorphism signs might serve as predictors for an ineligible S1 corridor.

We analysed S1 corridor in pelvic CT scans of 107 geriatric patients without history of fracture or other pelvic pathology. First, the eligibility for the trans-sacral screw placement was determined by measuring the width and the height of the central portion of the S1 corridor. Then, pelvises were examined for signs of dysmorphism. The correlation of these signs with the ineligible S1 corridor was analysed.

In our geriatric population with average age of 79,55 ± 8.79 years (male:female 0.88) 44% of S1 corridors were not eligible for a trans-sacral screw. In this ineligible group the height was shown to be a more significant limiting dimension (90,9%), compared to the width in 68,2% (p<0.05). Mamillary processes, not recessed sacrum and dysmorphic sacral foramina were present in 38,3%, 34,6%, and 26,2% respectively, with not recessed sacrum demonstrating a significant correlation with a too narrow S1 corridor (p<0.05).

The analysed geriatric population demonstrates a high prevalence of a too narrow S1 corridor, which makes a placement of a trans-sacral screw risky or even impossible. The height of the S1 corridor represents the main limiting factor with a dysmorphism sign of a not recessed sacrum being a significant predictor for the ineligible S1 corridor.

Percutaneous sacroiliac screw placement is a challenging procedure in patients with pelvic fractures. To overcome these challenges, navigated techniques have emerged as an alternative to conventional 2D fluoroscopy for guiding screw placement. However, it remains to be seen whether navigated techniques truly have a beneficial effect on accuracy, radiation exposure and occurrence of complications.

We performed a meta-analysis to investigate wheter navigated techniques are superior to conventional 2D fluoroscopy in percutaneous sacroiliac screw fixation. 

The electronic databases were searched for both randomized clinical trials and observational studies comparing percutaneous sacroiliac screw fixation with 2D fluoroscopy to new navigated techniques (2D or 3D fluoroscopic navigation with a c-arm, computer assisted ultrasound navigation, O-Arm navigation, mobile CT navigation, robotic navigation). Effects were pooled and presented as odds ratio, mean difference and standardized mean difference with corresponding 95% confidence interval.

In total 18 studies were included. New navigated techniques had a higher accuracy (81% versus 91% with MD 10%, 95% CI 5-14%). The greatest benefit in accuracy was found in studies with more advanced navigated techniques (O-Arm, mobile CT or robotic navigation). Also, fluoroscopy time (MD 72.13 seconds, 95% CI 7.73;92.91) and fluoroscopy frequency (MD 17.22 images in total, 95% CI 7.73;26.70) were lower for new navigated techniques. Radiation dose was higher for new navigated techniques (SMD 0.50, 95% CI 0.01;0.99). Surgery duration showed no significant difference. Similar results were found among in vitro studies. Complications were rare in both groups.

This meta-analysis demonstrated a higher accuracy of screw positioning, lower fluoroscopic frequency and time for navigated percutaneous sacroiliac screw fixation compared to conventional 2D fluoroscopy. Complications are acceptably low for both groups. Future studies should focus on which of the navigated techniques is the best and whether the implementation costs of a new technique outweigh its benefits.

While the inital assessment and the intial treatment of potentially life-threatening injuries is well-described, the surgical treatment strategy following initial resuscitation remains controversial. Timepoint of surgery and type of surgery still reamin topic of discussions. Various different strategies for optimal timing of fracture fixation in polytrauma patients exist.

This study tests the hypothesis that a concept of clearing patients for early definitive surgery that relies on anatomical and physiologic parameters is influenced by the injury distribution.

Polytrauma patients treated at a Level 1 trauma center (01.01.2016 - 31.12.2018). Inclusion: primary admission, injury severity score (ISS) ≥16points, requirement of surgical fixation of major extremity or a truncal injury. Exclusion: death <72h after admission, severe traumatic brain injury (TBI). Stratification according surgical fixation concept: Early total care (ETC, all surgeries <24 h), safe definitive surgery (SDS, staged surgeries <72h), and damage control orthopaedics (DCO, definitive care after stabilization). Endpoints: mortality, complication rates. Parameters of interest: Injury severity and distribution (ISS/AIS), pathophysiologic parameters of hemorrhagic shock, coagulopathy, hypothermia, soft tissue trauma.

527 patients, mean age 54.8 SD19.9 years, mean ISS 26.9 SD9.0 points, mortality 20.5%. Group ETC (n=21, 3.9%), Group SDS (n = 284, 53.9%), Group DCO (n = 222, 42.1%). Abdominal and spinal injuries associated with ETC (AIS Abdomen; OR 2.1, 95%CI 1.1 to 4.0, p =0.026: AIS Spine OR 2.0, 95%CI 1.2 to 3.4, p =0.007). Extremity and pelvic injuries associated with SDS (OR 1.8, 95%CI 1.1 to 2.8, p = 0.012 and OR 1.3, 95%CI 1.0 to 1.7, p = 0.036), head injuries associated with DCO (OR1.5, 95%CI 1.3 to 1.8, p <0.001). Head injuries were most relevant for mortality and were associated with patients undergoing DCO (29.7%) (ETC; 23.8%, SDS; 13.0%).

The concept of staged early fixation for major extremity and axial injuries (SDS) was successfully applied in the majority of patients. Predominant head and abdominal injuries were associated with ETC or DCO. The injury distribution influences decision making towards surgical management that is associated with a low complication rate.

Intraoperative adverse events (iAEs) are common during surgical procedures. However, structured and comparable documentation often depends on the physician’s subjective assessment of each iAE.

The aim of this study was to validate the hypothesis that iAEs during surgical interventions are clearly associated with further postoperative complications and prolonged hospital stays.

We performed a retrospective analysis comparing surgical patients with and without any iAEs regarding postoperative outcomes during the hospitalization. We analyzed more than 100,000 patients with surgically treated injuries between January 2012 and December 2022 from over 70 institutions across Switzerland. Outcome parameters were further compared using a 1:1 case-control matching method, while controlling for same age, gender, main diagnosis and procedure.

Regarding outcomes, patients with iAEs had a significantly longer duration of surgery (131 vs. 77 minutes), a prolonged length of hospital stay (10 vs. 8 days), a significantly higher need for an intensive care unit (ICU) stay of more than one day (7% vs. 3%), and a significantly higher rate of postoperative and procedure-associated complications (28% vs. 7%) than those without iAEs. The prolonged duration of surgery, length of stay, and postoperative and procedure-associated complications in the iAE group were also confirmed in the matched-pair analysis to be associated with poorer patient outcomes while controlling for significant characteristics.

In line with the current literature, our data show a clear relevance of iAEs as crucial factors for patient outcomes, manifesting in significantly longer durations of surgery, prolonged lengths of stay, and more postoperative complications, in a broad spectrum of surgical trauma procedures. We propose the mandatory documentation of iAEs through a standardized classification system, such as ClassIntra, and in accordance with the Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) guidelines for clinical practice and surgical research.

Clinical assessment of the major trauma patient follows international validated guidelines without standardized trauma specific assessment of the lower extremities for injuries.

This study aimed to validate a novel clinical test for lower extremity evaluation during trauma resuscitation phase.

This diagnostic, prognostic observational cohort study was performed on major trauma patient treated at one Level I trauma center between Mar 2022 and Mar 2023. The Straight-Leg-Evaluation-Trauma (SILENT) test follows three steps during the primary survey: inspection for obvious fractures (e.g. open fracture), active elevation of the leg, gentle elevation of the lower extremity from the heel. SILENT considered positive when obvisous fracture were present, painfull or pathological mobility was observed. The SILENT test was compared with standardized radiographs (CT scan or X-ray) as the reference test for fractures. Statistical analysis included sensitivity, specificity and receiver-operating characteristic testing.

Inclusion of 403 trauma bay patients, mean age 51.6 ( standard deviation SD 21.2) years with 83 fractures of the lower extremity and 27 pelvic/acetabular fractures. Overall sensitivity 75% (95% CI 64 to 84%), overall specificity 99% (95% confidence interval CI 97 to 100%). Highest sensitivity was for detection of tibia fractures (93%, 95%CI 77 to 99%). Sensitivity of SILENT was higher in the unconscious patient (96%, 95%CI 78 to 100%) with a near 100% specificity. Area Under Curve was highest for tibia fractures (0.96, 95%CI 0.92 to 1.0) followed by femur fractures (0.92, 95%CI 0.84 to 0.99).

The SILENT test is a clinical applicable and feasible rule out test for relevant injuries of the lower extremity. A negative SILENT test of the femur or the tibia might reduce the requirement of additional radiological imaging.

Concomitant ulnar styloid process (USP) fractures are present in 40-65% of distal radius fractures. USP base fractures are most common and may cause distal radioulnar joint instability due to rupture of the triangular fibrocartilage complex. Currently there is no consensus whether fixation of concomitant USP base fractures is necessary after fixation of the distal radius. 

The aim of this systematic review and meta-analysis is to compare operative versus non-operative treatment of concomitant ulnar styloid base fractures in patients with surgically treated distal radius fractures regarding wrist function, USP union, grip strength, range of motion, pain scores and complications.

A comprehensive search of the PubMed/Medline/Embase/CENTRAL databases was conducted, identifying randomised controlled trials and comparative observational studies. Critical appraisal was performed with the NEXT-tool. Effect estimates were extracted and pooled analyses were performed using random effect models to account for heterogeneity across studies. Results were presented as (standardized) mean differences (SMD or MD) or odds ratios (OR) and their corresponding 95% confidence intervals (95% CI).

Two RCT's (161 patients) and three observational studies (175 patients) were included. Non-operatively treated patients had better wrist function at six months (SMD 0.57; 95% CI 0.3 – 0.9; I² = 0%), fig 1. Operatively treated patients had higher bony union rates (OR 0.08; 95% CI 0.04 – 0.18; I² = 0%), fig 2, but also suffered more complications (OR 14.3; 95% CI 1.08 – 188.39; I² = 89%), fig 3. The most common complication was hardware irritation (56.5%). No other significant differences were present.

Operative treatment of the USP results in higher union rates, but also more complications. Conservative treatment results in better function at six months. Based on these results, routinely performing surgery for ulnar styloid base fractures should be avoided, although surgery must remain an option for specific cases such as persistent DRUJ instability. 

Recently, a new generation of superior clavicle plates was developed featuring the variable-angle locking technology for enhanced screw positioning and optimized plate-to-bone fit design. On the other hand, mini-fragment plates used in dual plating mode have demonstrated promising clinical results. However, these two bone-implant constructs have not been investigated biomechanically in a human cadaveric model.

To compare the biomechanical competence of single superior plating using the new generation plate versus dual plating with low-profile mini-fragment plates.

Sixteen paired human cadaveric clavicles were assigned pairwise to two groups for instrumentation with either a 2.7 mm Variable Angle Locking Compression Plate placed superiorly (Group 1), or with one 2.5 mm anterior plate combined with one 2.0 mm superior matrix mandible plate (Group 2). An unstable clavicle shaft fracture AO/OTA15.2C was simulated by means of a 5 mm osteotomy gap. All specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with bidirectional torsion around the shaft axis and monitored via motion tracking.

Initial stiffness was significantly higher in Group 2 (9.28±4.40 N/mm) compared to Group 1 (3.68±1.08 N/mm), p=0.003. The amplitudes of interfragmentary motions in terms of craniocaudal and shear displacement, fracture gap opening and torsion were significantly bigger over the course of 12500 cycles in Group 1 compared to Group 2; p≤0.038. Cycles to 2 mm shear displacement were significantly lower in Group 1 (22792±4346) compared to Group 2 (27437±1877), p=0.047.

From a biomechanical perspective, low-profile 2.5/2.0 dual plates demonstrated significantly higher initial stiffness, less interfragmentary movements, and higher resistance to failure compared to 2.7 single superior variable-angle locking plates and can therefore be considered as a useful alternative for diaphyseal clavicle fracture fixation especially in unstable fracture configurations.

Background

Due to advances in devices and techniques, the endovascular approach using fenestrated or branched endografts has emerged as a valid and safe alternative for patients with complex aortic aneurysms, especially if considered at high risk for surgery. The use of inner branch devices (iBEVAR) combining benefits of fenestrations and outer branches could offer an ideal configuration in this context.

Aims

The aim of our study was to report our monocentric experience with iBEVAR in the treatment of complex aortic aneurysms.

Methods

A retrospective analysis of prospective data retrieved from 1 center between January 2020 and January 2024 was done. Endpoints were immediate technical success, postoperative morbidity, rate of re-intervention and mortality.

Results

During this period, 72 patients with a mean age of 68.5 years (range 41-88) were identified. The maximum preoperative mean aortic diameter was 56 mm (44-71 mm). The majority of patients was asymptomatic. For diffuse thoraco-abdominal aortic aneurysms, a 2-steps procedure was used. There were 34 off-the-shelf E-nside (47%) and the remaining 38 patients were treated with a custom-made Extra-Design graft (53%). Despite successful endograft deployment in all patients and branch catheterization in 69/72 cases (96%), the technical success was 94% due to an additional open conversion for ilio-mesenteric bypass. The 30-days mortality was 5.5%.

During the post-operative period, 19% of patients presented complications with 1 case of mesenteric ischaemia requiring a visceral resection and 2 cases of paralytic ileus, treated conservatively. 5 cases (6.9) of spinal cord ischemia were observed. During the median follow-up, 22 patients (31%) had a re-intervention, for endoleaks, bridging-stent events or limbs problems. The overall target vessel patency was 94%.

Conclusion

The use of iBEVAR appears to be safe and effective for the treatment of complex aortic aneurysms with an acceptable rate of complications. Strict follow-up is mandatory and about one-third of patients required a re-intervention. Further patients and longer follow-up are needed.

Endovascular techniques have provided new options in the treatment of arch pathologies. Multiple studies have reported good results after endovascular treatment of aortic arch aneurysms and it has developed to be a considerable approach, especially in patients who are unfit for open surgery. In treatment of progressing distal pathologies after open ascending aorta and/or aortic arch replacement, the endovascular arch repair has shown promising results.

Aim of study was to investigate the outcomes of endovascular arch repair (b-TEVAR) with a custom-made double or triple branched arch endograft in patients with distal anastomotic aneurysms after open repair of the ascending aorta or proximal arch replacement (Figure 1).

Retrospective analysis was conducted of all consecutive patients with anastomotic aneurysms after open surgical repair involving the ascending aorta and/or aortic arch treated with b-TEVAR. All patients were treated with a custom-made double or triple inner-branched arch endograft. Study endpoints were technical success, 30-day and follow up mortality/ morbidity and re-interventions.

Between 2018 and 2022, ten patients were treated with custom-made double or triple branched TEVAR due to anastomotic aneurysms after open ascending aorta and/or proximal aortic arch replacement. Eight patients received a triple and two a double arch branched endograft. Eight cases were performed electively and two urgently for contained rupture. Technical success was achieved in nine cases (90%). All elective patients survived. Two patients treated due to contained ruptures expired. Within 30 postoperative days, one transient ischemic attack occurred. No early endograft-related re-interventions were necessary. Median follow-up was 20 months. One patient died two months after discharge due to sepsis caused by pneumonia. No further deaths or endograft-related re-interventions were observed.

Endovascular aortic arch repair with double or triple inner-branched arch endograft for anastomotic aneurysms after open ascending and/or proximal arch replacement is technically feasible and a promising alternative in a patient cohort unfit for surgery.

Ruptured iliac aneurysms (rIA) are rare. The endovascular sealing is technically more demanding than in ruptured aortic aneurysms. Preserving the hypogastric artery (HA) should also be the goal in these anatomies.

The objective of this study was to analyze the endovascular procedures and outcomes of rIA in a single center.

From January 2016 until December 2023 122 patients underwent iliac aneurysm repair. All patients were treated endovascularly. Out of these, we identified all rIA. Treatment and anesthesia modalities, anatomies, hemodynamic stability, technical success rate, 30-day mortality and long-term outcome were analyzed.

Seven patients (6%) with rIA were identified. Three ruptured HA aneurysms (42%) could be treated by iliac branched stentgraft, four common iliac aneurysms were sealed by a tube stentgraft. In two of them an additional coiling of the HA was performed, two patients presented with already occluded HA.

Four patients could be treated in local anesthesia, one in general anesthesia, two had to be converted to general anesthesia for a laparotomy to relieve an abdominal compartment syndrome.

Three patients showed systolic blood pressure <60 millimeter mercury during surgery, two of them needed an occlusion of the HA.  

The technical success rate was 100%. One patient died 18 days after rupture, therefore 30-day mortality was 14%.

The mean follow up was 3.2 years (range 0-92 months) with a mean iliac diameter shrinkage of 13mm (0-32mm). One type III endoleak occurred and was sealed with a new bridging stentgraft (reintervention rate 14%).

Ruptured iliac aneurysms can safely be treated endovascularly. There seem to be some factors that determine the possibility of HA preservation as anatomies, aneurysm localization and hemodynamic stability. The good long-term outcome after endovascular sealed rIA is promising.

Complex endovascular aortic repair is widely used in treating thoracoabdominal, pararenal, juxtarenal aortic or iliac artery aneurysms. In these procedures, the aortic branches must be connected with bridging stent grafts (BS). A few BS are available, but none are approved as BS and generally in off-label use. 

The aim was to evaluate the efficacy of iCover stent grafts (iCover-SG) used as bridging stents (BS) in complex endovascular aortic or iliac repair procedures (EVAR/ EVIR). 

A total of 32 patients underwent fenestrated or branched EVAR/ EVIR using iCover-SG between 08/2021-01/2023. The primary endpoint was to evaluate the iCover-SG-related target vessel instability, including intraprocedural complications, stent graft patency, endoleaks (EL), and additional interventions. Secondary endpoints were clinical outcomes, major adverse events and secondary reinterventions. Data obtained from routine clinical and radiological follow-up controls were included up to July 2023.

101 iCover-SG were implanted in 76 target vessels with a primary and secondary technical success rate of 97% and 99%. The primary and secondary patency rate was 99%. Throughout the median follow-up period of 8 (2,13) months, 3 type 1c EL and 3 type 3c EL were detected. 5 of them required reinterventions. No other BS-related reinterventions were performed. This results in an iCover-SG-related freedom of target vessel instability of 93%. Secondary endpoints included 9 major adverse events in 7 patients (acute renal failures n=4, spinal cord ischemia n=3, mesenteric ischemia n=1, and multi-organ failures n=2), leading to a 6% in-hospital mortality rate. The overall mortality was 13% (n=4), which was not BS- or aneurysm-related. 

These findings suggest that iCover-SG is an effective and reliable BS for complex EVAR/EVIR. The iCover-SG showed favourable technical success rates and low complication rates. However, further long-term studies are required to evaluate the durability and long-term outcomes of iCover-SG.

Ultrasound examination of the resistance index (RI) of both kidneys can provide evidence of renal artery stenosis. The extent to which the RI is changed after bridging stent-graft implantation due to altered flow characteristics is not known.

The aim of the study was to investigate the influence of renal bridging stent-grafts on the RI of the kidneys after fenestrated endovascular aortic repair (FEVAR).

Ultrasound examinations of the kidneys were conducted using a GE LOGIQ S7 XDclear ultrasound system (GE Medical Systems AG, Glattburg, Switzerland). The evaluation was performed according to SGUM 2D standard criteria. The RI was determined in all consecutive patients on the day before and after renal bridging stent-graft implantation. For this purpose, the kidneys were divided into 3 areas according to the standard protocol and 2 RI values were recorded per area by evaluating intrarenal arterial Doppler signals. Mean values were calculated and compared for each kidney.

For 64 kidneys in 32 consecutive patients (73.9±7.8 years, 4 female, 28 male) treated with FEVAR and renal bridging stent–graft implantation pre- and postinterventional examinations were carried out. Sonomorphologically, the kidneys examined were inconspicuous (pre: size at least 107.1x52.4 mm, parenchymal margin 18.3 mm versus post: size at least 107.9x52.9 mm, parenchymal margin 18.6 mm, p>0.4). The arborization of the renal perfusion was preserved pre and post implantation. The RI did not differ before and after implantation (0.66±0.06 versus 0.67±0.07; p=0.10). None of the patients experienced severe impairment of renal function.

After successful implantation of a bridging stent-graft in a non-stenosed renal artery, there is no relevant change in the RI of the kidney. The RI seems therefore to be suitable for assessing renal perfusion after complex endovascular aortic therapy.

In the realm of endovascular aortic repair (EVAR), various anatomical severity grading scores have been used to link the characteristics of aneurysms to intra- and postoperative outcomes. These scores typically rely on measurements of the proximal neck, aneurysm sac, and the iliac arteries.

This study introduces a novel iliac access score (IAS), designed as a straightforward tool to anticipate prolonged operation times and the requirement for supplementary resources when dealing with challenging iliac anatomy.

A retrospective review was conducted on patients undergoing EVAR between 2016 and 2022. Morphology, operation times, and iliac access maneuvers were analyzed.
The IAS was calculated (0 - 12) and correlated with operation times through regression analysis. Further subgroup analyses were performed. Patients with a follow-up of >2 years underwent assessment for iliac-related reinterventions.

119 patients were included, revealing a mean IAS of 4.3 and mean operation time of 97.9 minutes. A positive correlation was observed between operation time and IAS.
10.9% of cases required further maneuvers for challenging iliac access, with a mean operation time of 153.5 minutes and IAS of 7.1, compared to 91.1 minutes and IAS of 4.0 for the remaining patients (p < 0.001). Subgroup analysis (Score ≤4 vs. >4) revealed significant differences in mean operation times (82.8 vs. 119.6 minutes, p < 0.001).
63 Patients with a follow-up of >2 years were evaluated for iliac-related reinterventions, 11.1% underwent reintervention due to a type Ib endoleak, with no significant difference in IAS between those with and without reinterventions.

The proposed IAS effectively predicts operation time and need for additional access maneuvers, offering valuable insights for surgical planning. However, we did not establish a clear correlation between the IAS and long-term postoperative outcomes.

Various methods of open-surgical treatment of infected aortic and iliac pathologies are available. The use of surgeon-made bovine pericardium grafts in infected aortic/iliac context has been associated with a low re-infection rate as well as high feasibility. Prefabricated (factory pre-sewn) bovine pericardium prostheses have been available for a few years. Studies reporting clinical results are rare.

Present the perioperative and mid-term outcomes of a bifurcated and straight bovine pericardium prostheses (BioModiVasc®) in infected aortic and iliac pathologies.

Retrospective database analysis of all vascular surgery operations between 2021 and 2023 at our centre.

28 BioModiVasc® grafts were implanted in 27 patients due to INAA (40,7%), VGEI (51,9%), trauma (3,7%) or Leriche-Syndrome (3,7%). Patients were predominantly male (85,2%) and often presented arterial hypertension (88,9%). Significant risk factors were infection in a remote site (29,6%), emergency/urgent operations in the past 12 months (22,2%) and previous vascular procedures (44,4%). Elevated CRP (88,9%) and soreness at site (81,5%) were the most common findings at presentation. CT-scan showed infection-typical findings in 96,3%. Pathogen was isolated in 77,8% of the cases. Median operation time was 300 minutes. 88,9% of the operations were emergency/urgent ones. 96,3% of the reconstructions were orthotopic, access was mostly transperitoneal (59,3%). Median hospital/ICU days were 19 and 2 respectively. Infection a/o operation-associated 30-day mortality was 11,1%. 3-deaths occurred at follow-up (median 12 months), non infection a/o operation related. 1 patient required a re-do due to a duodenal erosion caused by the prosthetic anastomosis.

Open surgical treatment of aortic/iliac septic pathologies with the BioModiVasc® prosthesis yields good results, which are similar to the reported results of the use of surgeon-made bovine pericardial reconstructions.

There is no consensus regarding the terminology, definition, classification, diagnostic criteria, and algorithm, or reporting standards for the disease of infective native aortic aneurysm (INAA), previously known as mycotic aneurysm.

The aim of this study was to establish this by performing a consensus study.

The Delphi methodology was used. Thirty-seven international experts were invited via mail to participate. Four two week Delphi rounds were performed, using an online questionnaire, initially with 22 statements and nine reporting items. The panellists rated the statements on a five point Likert scale. Comments on statements were analysed, statements revised, and results presented in iterative rounds. Consensus was defined as ≥ 75% of the panel selecting "strongly agree" or "agree" on the Likert scale, and consensus on the final assessment was defined as Cronbach's alpha coefficient > .80.

All 38 panellists completed all four rounds, resulting in 100% participation and agreement that this study was necessary, and the term INAA was agreed to be optimal. Three more statements were added based on the results and comments of the panel, resulting in a final 25 statements and nine reporting items. All 25 statements reached an agreement of ≥ 87%, and all nine reporting items reached an agreement of 100%. The Cronbach's alpha increased for each consecutive round (round 1 = .84, round 2 = .87, round 3 = .90, and round 4 = .92). Thus, consensus was reached for all statements and reporting items.

This Delphi study established the first consensus document on INAA regarding terminology, definition, classification, diagnostic criteria, and algorithm, as well as reporting standards. The results of this study create essential conditions for scientific research on this disease. The presented consensus will need future amendments in accordance with newly acquired knowledge.

Evidence is lacking to guide the management of infective native aortic aneurysm (INAA).

The aim of this study was to establish expert consensus on surgical and antimicrobial treatment and follow up, and to define when an INAA is considered cured.

Delphi methodology was used. The principal investigators invited 47 international experts (specialists in infectious diseases, radiology, nuclear medicine, and vascular and cardiothoracic surgery) via email. Four Delphi rounds were performed, 3 weeks each, using an online questionnaire with initially 28 statements. The panelists rated the statements on a 5 point Likert scale. Comments on statements were analysed, statements were revised and added or deleted, and the results were presented in the iterative rounds. Consensus was defined as ≥ 75% of the panel rating a statement as strongly agree or agree on the Likert scale, and consensus on the final assessment was defined as Cronbach’s α > 0.80.

All 49 panelists fulfilled all four rounds, resulting in 100% participation. One statement was added based on the results and comments of the panel, resulting in 29 final statements: n = 3 on need for consensus, n = 20 on treatment, n = 5 on follow up, and n = 1 on definition of cure. All 29 statements reached agreement of ≥ 86%. Cronbach’s α increased for each consecutive round; round 1, 0.85; round 2, 0.90; round 3, 0.91; and round 4, 0.94. Thus, consensus was reached for all statements.

INAA is rare, and high level evidence is lacking to guide optimal management. This consensus document was established with the aim of helping clinicians manage these challenging patients, as a supplement to current guidelines. The presented consensus will need future amendments in accordance with newly acquired knowledge.

Dysregulated expression of microRNAs has been shown to contribute to response to chemotherapeutic agents in several cancers, including pleural mesothelioma (PM). In previous work, we found expression of several tissue-microRNAs to correlate with patient’s response to cisplatin-pemetrexed.

We want to understand how altering the expression of these microRNAs affects cell growth and chemoresponse.

PM cell lines MSTO-211H (biphasic), H28, Meso-1, Mero-82 (epithelioid) and non-malignant MeT-5A were reverse transfected with synthetic microRNA mimics for 15 candidates. Following transfection, cell growth, colony forming ability, and migratory potential were assessed using standard assays. Furthermore, transfected cells were exposed to increasing concentrations of cisplatin to evaluate sensitivity to these drugs.

Overexpression of seven candidate microRNAs resulted in growth inhibition in all investigated PM cell lines five days post transfection. The strongest effects were observed for miR-380-5p, miR-221-3p, miR-210, miR-625-3p, and miR-19b, which reduced cell growth to 30-60%. Growth of non-malignant MeT-5A cells remained largely unaffected (Fig. A). Overexpression of those microRNAs also resulted in a strong reduction of colony forming ability (Fig. B), while an effect on wound healing capacity (migration) could not be observed. Finally, we found that especially overexpression of miR-221-3p, miR-625-3p and miR-19b was able sensitise cells towards cisplatin, with the strongest effect observed in MSTO-211H for miR-221-3p (IC50 from 17.6µM to 2.7µM) and miR-19b (IC50 from 17.6µM to 0.7µM), and in Mero-82 for miR-625-3p (IC50 from 3.75µM to 0.8µM) (Fig. C).

We show that overexpression of several microRNAs has the potential to alter PM cell growth and colony forming ability. Furthermore, microRNA overexpression can sensitise cells towards cisplatin, although the degree of sensitisation varies between different cell lines. Current analyses focus on the response towards the cisplatin/pemetrexed doublet and on the effect on cell cycle and expression of associated genes.

Thoracic wall infiltration in pleural mesothelioma (PM) can be an important prognostic factor when determining the extent of resection. Currently, standardized imaging for restaging after neoadjuvant systemic therapy comprises contrast enhanced Computed Tomography (CT) or Positron Emission Tomography (PET/CT) scan. 

However, thoracic Magnetic Resonance Imaging (MRI) could be a better discriminator of chest wall infiltration prior to surgery. To increase the preoperative staging accuracy, we introduced a MRI protocol at our center.

A retrospective analysis of this prospective new imaging protocol was performed from 07/2018 to 08/2023, including descriptive analysis for patient`s sex, age, nicotine consumption, asbestos exposure, histological subtype, TNM-stage, RECIST criteria and number of neoadjuvant therapy cycles. Preoperative restaging included routine imaging and MRI. After histological diagnosis of PM, neoadjuvant therapy was conducted, followed by partial pleurectomy or extended pleurectomy/decortication, with intraoperative biopsies of suspicious chest wall lesions. The CT/MRI results were compared to the intraoperative biopsies. Sensitivity and specificity of both modalities were analyzed.

Twenty-five patients (mean age 65.4, 12% female) with possible chest wall infiltration were included out of the 35 patients with PM treated during the observation period. Of the 10 patients with actual chest wall infiltration, 9 (90%) had a T-Stage of 3 or higher, 9 (90%) had PM of epithelioid histologic subtype and 4 (40%) a R2-Resection. The mean overall survival of all patients was 18.88 months (8-58).

In our study, thoracic MRI showed a high sensitivity (90%) and specificity (100%) for the detection of chest wall infiltration, especially when compared to the CT scan (sensitivity of 10%). 

With the adjunctive use of thoracic MRI we demonstrated a higher sensitivity for detection of chest wall infiltration compared to conventional imaging prior to surgery. This may facilitate the preoperative assessment of the extent of resection. Nevertheless, larger studies are required to confirm these results.  

Prolonged air leakage (PAL) is a common problem after lung surgery. Localization of air leaks (AL) remains challenging in some cases especially in minimally invasive surgery. Ventilation-SPECT/Computertomography (vSPECT/CT) has been reported as potential aid to identify and localize AL.

To evaluate vSPECT/CT as potential aid for the localization of AL and explore its use as support for PAL management.

Retrospective analysis of a case series of seven patients with PAL after minimally invasive thoracic surgery at our institution in 2023 for which vSPECT/CT was applied.

Six patients underwent oncologic lung resections, one patient underwent thymectomy for a thymoma. In 5/7 cases an AL was spotted with vSPECT/CT (maximal AL ranged from 40-2000 ml/min). In the remaining two cases (with a maximal AL of 1900ml/min for 1 day, and 10 ml/min after more than 4 weeks and continuous clinical signs of PAL), the AL could neither be localized during revision surgery.

Nevertheless, the AL ceased in all patients after revision surgery. In two cases the detected AL supported the continuance of conservative treatment as it confirmed a leak within the prior resection site (maximal AL 40ml/min and 200ml/min). These results are depicted in the attached visual abstract.

The use of vSPECT/CT for localizing ALs proved to be precise in all instances where an imaging spot was observed (5/5 cases). Additionally, in the two cases where no spot was detected, no AL was found during subsequent revision surgery. These initial results are promising and support further prospective studies of a broader group of cases, reinforcing the role of vSPECT/CT as valuable aid in managing PAL.

Background

As the population ages and comorbidities increase, minimalinvasive anatomical segmentectomies are increasingly being performed. Complications are to be considered in this vulnerable population.

Aims

Our aim was to investigate the incidence and risk factors for prolonged air leak in patients undergoing minimally invasive single-port pulmonary segmentectomy at our institution.

Methods

Retrospective analysis of all patients undergoing uniportal segmentectomy in our department from March 2015 to August 2023. Prolonged air leak (PAL) was defined as an air leak that lasted longer than 5 days.

Results

575 segmentectomies were performed using uniportal video-assisted thoracoscopic surgery (uVATS). 374 complex segmentectomies (65.0%) and 405 (70.4%) single segmentectomies were performed (table 2). Prolonged air leak occurred in 88 patients (15.3%). Length of stay and duration of drainage were 8.6 (±4.86) and 10.6 (±8.12) days in the PAL subgroup, whereas they wer 3.6 (±2.25) and 2.0 (±1.3) days in the non-PAL group, both statistically significant. Patients with COPD GOLD II/III were significantly more common in the PAL group (table 1).
Using machine learning, two models were developed that predicted the occurrence of PAL with an accuracy of 70 %. The first model detected the following parameters as significant: removal of segment 2 or 8, diabetes, inhalers, squamous cell carcinoma. The second model recognized DLCO (%), pack-years, FEV1 (%) and operation time as parameters.
Furthermore, we used recursive partitioning to develop a decision tree that stratified PAL risk by answering 1-3 yes/no questions. Patients with >28 pack-years and DLCO < 71% had a 77% probability of developing prolonged air leak.

Conclusion

Severe COPD, low DLCO and FEV1, increased pack-years, inhalers, diabetes, and segment 2 or 8 surgery were identified as risk factors for prolonged air leak. These findings may help in the planning of surgery and the use of sealants at the end of surgery in high-risk patients.

Performing a postoperative chest X-ray (CXR) is routine practice following lung surgery. Despite studies indicating that CXRs may be unnecessary for most patients, no initiative has been taken to discontinue routine CXRs.

To improve quality of care, our initiative aims to eliminate routine CXR after lung resection and assess its safety.

We performed a single-centre, controlled, prospective cohort study. Patients who underwent lung resection between January 2022 and May 2023, excluding pneumonectomy and spontaneous pneumothorax, were included. Prior to implementation of the initiative, patients had routine CXRs immediately after surgery, after chest tube removal, and during outpatient consultation. After implementation, CXR were only ordered if there was a clinical need. We compared 30-day readmission rates before and after discontinuation of routine CXRs. Cardiopulmonary complications, length of hospital stay, and reoperation were also analyzed. We performed additional analyzes 8 months after the start of the initiative to monitor the evolution of our practices. 

A total of 128 patients (64 in each group) were included in this study. Among them, 46.1% underwent segmentectomy, 29.7% lobectomy, and 24.2% wedge resection. The total number of CXRs decreased by 56% after discontinuation of routine CXRs. 28.6% of patients did not receive any CXRs after the initiative. Moreover, 17/23 of the CXRs performed immediately after the operation and 9/14 during outpatient consultation were undertaken by mistake. There were no statistically significant differences in 30-day readmission rates between patients before and after the initiative (14.1% vs 4.8%, respectively, p=0.073) or in cardiopulmonary complications (28.1% vs 20.3%, respectively, p=0.302).  Eight months after the initiative was introduced, 86.4% of patients no longer received postoperative CXRs, and the 30-day readmission rate was reduced to 0%.  

Eliminating routine chest X-rays after lung resection is safe. The process of adapting to this practice and building confidence, however, takes time.

The combined influence of challenges in pinpointing the ideal timing for lung transplantation (Ltx) and the potential merging of graft scars contributes to an escalated demand for emergency transplantation (ELTx).

We aim to analyze the outcomes of our significantly high rate of ELTx over 10 years.

A retrospective analysis, excluding retransplanted and pediatric LTx, was performed between January 2010 and December 2022. Donor and recipient variables were collected, and univariate, multivariate, and survival analyses compared the two groups.

A total of 265 LTx were conducted, 219 being conventionally listed (81.5%) and 49 being ELTx (18.5%). Notably, 67.7% BLTx were bridging with extracorporeal membrane oxygenation (ECMO).

The overall characteristics of donors and recipients were similar, as detailed in Image 1. Although recipients undergoing ELTx tended to be slightly younger (49 vs. 54 years) and had a lower BMI (20 vs. 22, p 0.050). Furthermore, this group exhibited higher requirements for intra and postoperative ECMO support (76% vs. 52% and 31% vs. 20%), surgical reintervention (20% vs. 11%), and primary graft dysfunction (PGD 3) at 72 hours (29% vs. 11%, p 0.009). Whereas maintaining a slightly worse 5 years overall survival (51% vs 62.7% (IC 95%) p 0.043 (Imagen 2). Besides, multivariate analysis also revealed a greater risk of prolonged hospital stays (p-0.0002), 90-day mortality (p-0.0004), and one-year mortality (p-0.038). Imagen 2. Additionally, while the overall incidence of chronic lung allograft dysfunction (CLAD) was identical, time-free rejection was superior in the Non-BLTx group (810 vs. 522, p 0.0611[Opi1] ).

Despite a high incidence of emergency transplants in our center, the collaboration of a well-prepared multidisciplinary team and careful case selection has enabled us to achieve comparable and acceptable results.

Controlled organ donation after circulatory death (cDCD) was launched in Switzerland in 2012.

We aim to analyze the outcomes of lung transplantations (LTx) with cDCD after 10 years in our center.

Patients transplanted between January 2012 and December 2022 were included in this retrospective analysis, excluding re-LTx and pediatric LTx. Donor and recipient information was obtained from our database, and several prognostic factors for short- and long-term survival and CLAD incidence were included in uni- and multivariate analyses.

Of 268 LTx performed, 222 (82.8%) were DBD, and 46 were cDCD (17.%). Recipient characteristics are summarized in Table 1. Donor and recipient characteristics did not differ significantly between the two groups. COPD was the main indication for LTx in this cohort (33% vs. 37% in DBD and cDCD groups). Followed by Cystic fibrosis (24% both).

After a multivariate analysis, the DBD group was found to be correlated with a higher risk for prolonged ventilation (p=0.0054) and higher 90-day mortality (p=0.0016). Whereas cDCD groups were associated with an extended hospital stay (p 0.0017). Meanwhile, late transplant outcomes presented no statistically significant differences among groups; there was marginally superior 1-year mortality and early appearance of CLAD in the cDCD cohort (14% vs. 7% and 702 vs. 838 days p 0,33 and 0,651).

As the most extensive series of cDCD in Switzerland, our findings assert that the introduction of the cDCD program has established a secure and valuable source of high-quality organs for lung transplantation. Notably, outcomes are on par with conventional DBD methods.

Background

Even after minimally invasive anatomic lung resection, pain remains a burden for patients. Current guidelines recommend the surgical placement of intercostal catheters at the end of the surgery to promote faster recovery after lung surgery.

Aims

The aim of this trial was to investigate the analgesic efficacy of continuous loco-regional application of ropivacaine via an intercostal catheter and to establish this method as a possible standard of care in postoperative analgesia management.

Methods

Between December 2021 and October 2023, we evaluated the efficacy of surgically inserted intercostal catheters.  Patients were eligible when undergoing anatomic VATS lung resection under general anesthesia for confirmed or suspected stage I lung cancer (UICC, 8th edition). Patients received ropivacaine at a concentration of 2 mg/ml or a placebo through an elastomer pump, flow rate of 6-8 ml/h for 72 hours after surgery. The sample size was calculated to find an NRS (numerical rating scale) difference associated with a pain reduction of 1.5 points.

Results

14 patients were randomly included in the ropivacaine group and 18 in the placebo group. The patients’ characteristics and preoperative pain scores were similar in both groups.

Between the observed groups there was no statistically significant difference in postoperative pain scores and morphine consumption. The NRS score for cough 24 hours postoperatively was 4.9 (±2.2) in the ropivacaine group and 4.3 (±2.4); p=0.474 in the placebo group (Graph 1). In addition, we were unable to determine any influence of the pain management on the relative postoperative pulmonary function.

Conclusion

Our results suggest that the analgesic efficacy of continuous loco-regionally applied ropivacaine administered through a surgically placed intercostal catheter after surgery does not have a positive effect on postoperative pain scores or morphine requirements. Instead, local analgesia started at the beginning of the procedure and covering several intercostal spaces should be considered.

The pathophysiology underlying development of chronic thromboembolic pulmonary hypertension (CTEPH), including involved genes, is thus far only poorly understood.

Here we want to understand if and how changes in microRNA expression contributes to the development of CTEPH.

Levels of miR-939, miR-942, let-7b and let-7d were measured in a) 50 CTEPH pulmonary endarterectomy (PEA) specimens vs 49 pulmonary arteries (PAs) from explant lungs of transplant recipients (27 COPD, including 22 with pulmonary hypertension (PH)), and b) pre-operative plasma from 47 CTEPH patients and 21 lung transplant patients (12 COPD, including 3 with PH). Statistical analyses were performed by Spearman correlation, Kruskal-Wallis and Mann-Whitney test.

Expression levels in PEA-derived tissues correlated negatively for right-sided microRNAs let-7b and mPAP (n=43, R= -0.34, p=0.02), and miR-942 and 6-minute walk distance (6MWD) (n=46, R= -0.34, p=0.02), as well as left-sided let-7d and CRP (n=49, R= -0.296, p=0.04), and miR-939 and oxygen saturation (SpO₂) at peak 6MWD (n=47, R= -0.4, p=0.005). Positive correlation was found with SpO₂ before 6MWD for let-7b (n=41, R= 0.318, p=0.043). Jamieson left showed association with mean expression levels of let-7b (n=43, H=8.25, P=0.04) and left-sided let-7d (n=43, H=9.19, P=0.03). Plasma analysis showed positive correlations with SpO₂ after 6MWD and miR-939 (n=40, R= 0.35, p=0.026) and for let-7b with CRP (n=44, R= 0.30, p=0.048), and NYHA (n=45, H=16.56, P=0.0009).

Relative to the comparator groups, significance was reached in PAs for expression of let-7b (p <0.0001), and in plasma for miR-939 (p <0.0001).

Correlations and associations with clinical parameters suggest that miRNA expression is associated with disease severity, and that plasma microRNA levels might serve as circulating biomarkers. Furthermore, the significant elevation compared to comparator samples suggest that miRNA dysregulation might be involved in CTEPH development.