Citations

Normothermic Regional Perfusion (NRP) is emerging as a game-changer in enhancing outcomes for Donation after Circulatory Determination of Death (DCDD). NRP maintains physiological conditions through perfusion with oxygenated blood, outperforming conventional super-rapid recovery techniques significantly improving outcomes and organ utilization. Despite its clinical benefits, widespread adoption of NRP is impeded by heterogeneous organizational, legal, and ethical frameworks. At the ESOT Bucharest Consensus Conference, leading experts in transplantation achieved consensus on 130 relevant NRP-related open issues to facilitate its implementation and guide global practice. Key recommendations include criteria for adoption of NRP, minimal requirements, procedures to be adopted before and during NRP, donor organ evaluation criteria and sequence of organ harvesting. Consensus extends to procedural components (including the configuration of perfusion parameters and strategic team coordination), ethical integrity of NRP in the context of the dead donor rule and key unmet needs for future developments. While significant strides were made in unifying practice, unresolved issues regarding maximum warm ischemic time and variability in legal standards indicate avenues for future research. This consensus underscores the imperative for global standardization in NRP application, promising to elevate the success rates of organ transplants and establish NRP as a foundational element in the evolution of DCDD.

Endometriosis is a common, chronic inflammatory condition characterized by the presence of endometrium-like tissue outside of the uterus that can impact fertility through multiple mechanisms. In this review, the diagnosis, classification, staging, and surgical management of endometriosis for fertility enhancement is discussed. Surgery for patients seeking to optimize fertility or for whom infertility is the only symptom is complex. In patients with superficial endometriosis, laparoscopy may enhance fertility for unassisted pregnancy, but current guidelines recommend against routine surgery prior to ART. In patients with deep endometriosis, surgical intervention depends on multiple factors, including patient age, ovarian reserve, fertility goals, and the presence of other infertility factors. While there may be potential improvements in fertility-related outcomes, this must be weighed against potential impacts to ovarian reserve. Surgical techniques that minimize damage to the ovaries, fallopian tubes, and uterus are essential when fertility is the goal. While there is increasing interest in regenerative therapies for treatment of endometriosis (e.g., stem-cell based therapies, platelet-rich plasma, or extracellular vesicles), these remain investigational and are not yet utilized clinically for fertility enhancement in patients with endometriosis.

Objective: To determine whether normothermic machine perfusion (NMP) mitigates the historical survival disadvantage of donation after circulatory death (DCD) liver transplantation compared with donation after brain death (DBD) livers. Summary Background Data: NMP has improved outcomes in DCD LT compared with static cold storage (SCS), but whether it eliminates the historical disparity relative to DBD transplantation remains uncertain. Methods: We performed a retrospective cohort study of adult LT at a high-volume US center between 2019 and 2024. Outcomes of DCD-NMP grafts were compared with DCD-SCS, DBD-SCS, and DBD-NMP grafts. Primary outcomes were 1-year graft and patient survival. Secondary outcomes included early allograft dysfunction (EAD), hepatic artery thrombosis (HAT), primary nonfunction (PNF), biliary anastomotic strictures (BAS), and ischemic cholangiopathy (IC). Results: Among 1338 liver transplants (DBD-SCS n=527; DBD-NMP n=142; DCD-SCS n=255; DCD-NMP n=414), DCD-NMP grafts had a significantly higher donor risk profile ( P <0.001) yet demonstrated survival comparable to DBD transplantation. One-year graft survival was 94% for DCD-NMP versus 93% for DBD grafts and 86% for DCD-SCS, and 1-year patient survival was 98% for DCD-NMP versus 94% to 95% for DBD grafts and 93% for DCD-SCS. In adjusted models, DCD-SCS was associated with increased hazards of graft loss (adjusted hazard ratio: 2.48; P <0.001) and death (adjusted hazard ratio: 2.39; P =0.004), whereas DBD groups did not differ from DCD-NMP. Incidence of EAD was lower with DCD-NMP (21.7%) than DCD-SCS (50.2%) and similar to DBD grafts (21.1%–26.4%); HAT and PNF were rare (≤1.3%). At 1 year, BAS occurred in 36% of DCD grafts versus 17% to 23% of DBD grafts. IC occurred in 7.7% of DCD-NMP compared with 22% of DCD-SCS and ≤1.5% of DBD grafts. Retransplantation due to IC was infrequent overall (1.3%), but more common in DCD-SCS (4.7%) than DCD-NMP (1.0%) and DBD grafts (≤0.4%). Conclusions: NMP enables safe utilization of DCD liver allografts and achieves graft and patient survival comparable to DBD LT, mitigating the historical disadvantage of DCD grafts. These findings support routine integration of NMP into clinical practice and efforts to standardize its implementation.

ABSTRACT Objectives Alar reconstruction is common, yet high‐quality outcomes data are limited. This review synthesizes the available literature to guide evidence‐informed reconstructive choices. Methods A systematic review identified 35 eligible studies reporting defect characteristics, techniques, and aesthetic, functional, and graft/flap outcomes. Single‐patient case reports, purely technical papers, and studies without outcome data were excluded. Results Full‐thickness skin grafts (FTSG), FTSG with cartilage, and composite grafts have been used with acceptable aesthetic outcomes for small defects. Local flaps are most common for small to intermediate defects, while regional flaps, particularly melolabial (MLF) and paramedian forehead flaps (PMFF), are the primary options for larger defects. PMFFs have higher reported cosmetic satisfaction but may require more secondary procedures. Conclusions Standard data and evidence reporting for alar subunit reconstruction is very limited, with a predominance of retrospective and technique‐driven studies and gestalt‐based outcomes. Standardized reporting of defect size, functional outcomes, and validated patient‐reported measures is needed. Until higher‐quality data is available, reconstructive decisions should be individualized.

ABSTRACT Background Multiple meta‐analyzes suggest that acne improvement with isotretinoin leads to improved mental health outcomes in adults, though isotretinoin‐related psychiatric data, including for suicidality, are limited for adolescents. Methods PubMed, MEDLINE, EmBase, PsychINFO, and the Cochrane Library databases were searched for papers published between 1982 and September 2024 that reported suicidality following isotretinoin treatment for acne vulgaris in adolescents aged 18 or younger. Results A total of 24 full text articles were reviewed. Despite numerous case reports describing suicidal ideation, suicide attempts, and completed suicides were rare. Databases suggest that adolescents taking isotretinoin are the group with the most suicide attempts, but epidemiological studies including matched controls suggest this could be a function of the number of prescriptions in this population. Observational, cohort, and case‐time‐control studies did not consistently report an increased risk of suicidality with isotretinoin. When compared with those prescribed antibiotics, isotretinoin‐prescribed adolescents had no increase in suicidality during treatment but had a higher prevalence of suicidal behavior in the year after treatment. If patients prescribed isotretinoin developed suicidal ideation, it was more likely to develop early in or following completion of treatment. Conclusion There exists a conventionally held belief in the association between isotretinoin use and suicidal ideation for adolescent patients, but this narrative review does not indicate a consistent relationship.

BACKGROUND Malignant peripheral nerve sheath tumors (MPNSTs) are malignant tumors that rarely demonstrate heterologous differentiation from angiosarcomatous components. These lesions can be hard to accurately diagnose. OBSERVATIONS A 25-year-old man with neurofibromatosis type 1 and a history of a left lumbar subcutaneous MPNST developed a lung metastasis of only the angiosarcoma component of the MPNST. Prior to H3K27me3 staining of the lung mass, there was no association of the angiosarcoma with the MPNST. Reinterpretation of the lumbar subcutaneous MPNST led to the identification of a previously unrecognized angiosarcomatous portion in that tumor as well. LESSONS This case highlights the importance of using H327me3 staining for accurate diagnosis of biopsies only capturing the heterologous components of MPNST. https://thejns.org/doi/10.3171/CASE251012

BACKGROUND Medication-refractory essential tremor (ET) patients who undergo MR-guided focused ultrasound or Gamma Knife thalamotomy may experience tremor recurrence, prompting rescue deep brain stimulation (DBS). Yet, the impact of prior ventral intermediate nucleus (VIM) lesioning on DBS targeting, microelectrode recording (MER), and stimulation programming remains uncertain. OBSERVATIONS The authors present 3 ET patients undergoing bilateral DBS for tremor recurrence after thalamotomy. Thalamotomy lesions showed depressed electrophysiological activity versus nonlesioned VIM on MER (p = 0.0397) and required smaller DBS charge density increases for tremor control, suggesting irreversible lesion effects despite tremor recurrence. Tremor recurrence correlated with lesion mislocation; specifically, ablations missed the central VIM (mean 1.8 mm) and decussating dentato-rubro-thalamic tract. For rescue DBS, ventral VIM stimulation yields the greatest tremor reduction, while central VIM stimulation balanced tremor control with adverse effects. LESSONS DBS is a safe, effective rescue treatment for failed thalamotomy without needing to retarget the prior lesion site. The authors advocate for prospective studies of initial DBS targeting 2 mm anterior to standard VIM coordinates, reducing intraoperative readjustment for central VIM stimulation; and initial thalamotomy targeting 1 mm anterior and 1.2–1.5 mm superior to standard coordinates for durable tremor control through ablation of both central and ventral VIM. https://thejns.org/doi/10.3171/CASE25955