Abstract:Ischaemia Reperfusion (IR) injury is a major cause of post-operative morbidity, mortality and graft loss following Orthotopic Liver Trasnplantation (OLT). There is no current accepted treatment for IR injury. The recent drive to implant more marginal grafts, which are more susceptible to IR injury makes this clinical problem a key research goal. Remote Ischaemic Preconditioning (RIPC) has been shown to ameliorate hepatic IR injury in small animal models. Whether recipient RIPC can reduce IR injury in human liver transplant recipients has not previously been investigated. Methods:Forty patients with end stage liver disease undergoing liver transplantation were randomized to RIPC or a sham control group. RIPC was induced through three 5 minute cycles of alternate ischaemia and reperfusion using an orthopaedic tourniquet to the left lower limb under general anaesthesia prior to commencement of the abdominal procedure. The aim of the study was to determine the safety and feasibility of limb RIPC in patients with end stage cirrhosis. Data on clinical outcomes was collected prospectively (minimum 3 month follow up) and the function of the graft was also evaluated. Plasma cytokine levels were measured at baseline, 2 hours post reperfusion and at 24 hours post-operatively. Results:45 of 51 patients approached (88%) were willing to enroll in the study. 5 patients were then excluded and 40 patients were randomized of which 20 underwent RIPC.RIPC was able to be performed in all patients randomized to the RIPC group. There was no evidence of localized complications following RIPC. One patient died in the control group and 1 further graft was lost in the control group due to a non-IR related 3 issue. Median AST levels on the third post-operative day showed a slightly higher trend in the RIPC group than in the control group (221iU vs 149iU, p=1.00) but this was not statistically significant. Conclusions:RIPC is acceptable and can be carried out safely in patients with advanced liver disease. This pilot feasibility study has not demonstrated evidence of a reduction in IR injury or clinical benefit. A longer follow up, a larger study or an altered preconditioning protocol may be required. 4Liver transplantation is the treatment of choice for both acute and chronic end stage liver disease. As outcomes following transplantation have improved, the indications for liver transplantation have been widened and a shortage of suitable organ donors has developed. This has resulted in an increased use of grafts from marginal donors such as the elderly and those with a fatty liver from obesity (extended criteria donors) and especially the use of grafts from donors following cardiac death (DCD). The use of liver DCD grafts in the UK has increased from 6.9% in 2005 1 to 19.1% of grafts implanted in 2013 2 .Ischaemia Reperfusion (IR) injury is the damage that happens to an organ when its blood supply is interrupted and reconstituted. It is a major cause of morbidity and mortality following liver transplantation and is believed to acc...

Repair of inguinal hernia is the most commonly performed surgical procedure. Both open and laparoscopic methods are accepted modalities of surgical treatment. Transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) are the two types of laparoscopic repair of the inguineal hernia. The main advantages of laparoscopic repair, as compared to open repair, are a shorter hospital stay and a quicker recovery to normal activities. However, laparoscopic repairs are associated with a higher incidence of visceral and vascular injuries. One particular complication is the migration and erosion of mesh into the adjacent viscera. Although the total numbers of cases are small, compared to the total numbers of inguinal hernia repairs, they are important, as they often presented with a diagnostic dilemma. Most of the mesh migrations reported in the literature involves the urinary bladder. In this paper, we present a case of erosion of mesh into the caecum. The patient (a 66-year-old male) underwent TAPP repair of a right inguinal hernia in 1996 with polypropelene mesh. He also underwent an open appendicectomy in 1980. During the laparoscopic repair, he was found to have multiple intra-abdominal adhesions. He presented with intermittent diarrhea, for which he was investigated, and a benign caecal lesion was found. He was initially managed conservatively. However, his symptoms persisted and he underwent a right hemicolectomy in February 2006 in our hospital. The offending lesion was found to be the prolene mesh having eroded into the caecum.

Ischaemic reperfusion (IR) injury is a major cause of graft loss, morbidity and mortality following orthotopic liver transplantation (OLT). Demand for liver transplantation has resulted in increasing use of marginal grafts that are more prone to IR injury. Remote ischaemic preconditioning (RIPC) reduces IR injury in experimental models, but recipient RIPC has not been evaluated clinically.MethodsA single-centre double-blind randomized controlled trial (RCT) is planned to test the hypothesis that recipient RIPC will reduce IR injury. RIPC will be performed following recipient anaesthetic induction but prior to skin incision. The protocol involves 3 cycles of 5 min of lower limb occlusion with a pneumatic tourniquet inflated to 200 mmHg alternating with 5 min of reperfusion. In the control group, the sham will involve the cuff being placed on the thigh but without being inflated.The primary endpoint is ability to recruit patients to the trial and safety of RIPC. The key secondary endpoint is a reduction in serum aspartate transferase levels on the third post-operative day.DiscussionRIPC is a promising strategy to reduce IR injury in liver transplant recipients as there is a clear experimental basis, and the intervention is both inexpensive and easy to perform. This is the first trial to investigate RIPC in liver transplant recipients.Trial registrationClinicaltrials.gov NCT00796588Electronic supplementary materialThe online version of this article (doi:10.1186/s13737-016-0033-4) contains supplementary material, which is available to authorized users.

No abstract