Are we ready to utilize non-heart-beating donors for clinical allotransplantation in China?

The concept of brain death has not been accepted by the majority of Chinese. Importantly, it is not recognized as a legal entity. We have developed a non-heart-beating donation protocol based on literature searches (Medline, Ovid, and CNKI) and issues related to Chinese customs and ethics. The principles guiding protocol development included: separation of the decision to terminate life support from the donation decision, family-centered donation, freedom of conflict interest, and prohibition of organ sales. This protocol covers donation policy, potential donor identification and evaluation, family consent, determination of death, procurement, and special legal documents/organ distribution policy. A random survey was performed regarding donation. There have been several arguments about the development of this protocol. First, do donor family members have the right to make a decision to withdraw life support? Another issue is whether family members have the right to consent to donation without a will from the donor. Our survey found that over 96.1% of people do not have a will and have not discussed their interests in donation with family members. The last issue is whether the hospital can financially help for the funeral after donation. We have debated these issues nationwide with various opinions. We hope to find the right solutions through international debate. We believe that the use of non-heart-beating-donor organs has potential in China. We are hopeful that it will become a major organ source that is developed in such a way so as to be accepted internationally as well as in China.     

Are we ready for the use of intraoperative salvaged blood in metastatic spine tumour surgery?

Purpose

To evaluate the feasibility of using intraoperative cell salvage (IOCS) in combination with leucocyte depletion filter (LDF) in eliminating tumour cells from blood salvaged during metastatic spine tumour surgery (MSTS). This is with the view to pave the path for use of IOCS-LDF in MSTS and musculoskeletal oncological surgery.

Methods

Sixty consecutive patients with known primary epithelial tumour, who were offered surgery for metastatic spine disease at our university hospital, were recruited. Blood samples were collected at three different stages during surgery: from operative field prior to IOCS processing, after IOCS processing and after IOCS-LDF processing. Three separate samples (5 ml each) were taken at each stage. Samples were examined by cell block technique using immunohistochemical monoclonal antibodies to identify tumour cells of epithelial origin in the samples.

Results

Of 60 patients, ten were excluded for not fulfilling the inclusion criteria leaving 50 patients. Malignant tumour cells were detected in the samples from operative field prior to IOCS processing in 24 patients and in the samples from the transfusion bag post-IOCS processing in 4 patients. No viable malignant cells were detectable in any of the blood samples after passage through both IOCS and LDF.

Conclusions

The findings support the notion that IOCS-LDF combination works effectively in eliminating tumour cells from salvaged blood so this technique can possibly be applied in MSTS and even musculoskeletal oncological surgery. This concept can then be extended to other oncological surgeries in general with further appropriate clinical studies.

     

Are we ready for day-case partial nephrectomy?

Fast-track and day-case surgeries are gaining more and more importance. Their development was eased by the diffusion of minimal invasive surgical strategies and the consequential morbidity reduction. In the field of kidney cancer, seven cases of ambulatory radical nephrectomy were previously reported in the international literature. Regarding robotic partial nephrectomy (PN), short postoperative pathways resulting in patients’ discharge on postoperative day 1 were shown to be safe and feasible. We report our initial experience of robot-assisted PN discharged on postoperative day zero and discuss the criteria for adequate patient selection. Indeed, outpatient PN will obviously not be suitable for all patients, and careful selection will be mandatory. Both specific baseline patient’s factors and postoperative events will have to be recognized for the first ones and prevented for the second ones. Safety, patient satisfaction, cost efficiency, and reproducibility will be the key factors to assess and promote day-case PN.     

Are we ready for the clinical use of novel acute kidney injury biomarkers?

Acute kidney injury (AKI) is a common event in several neonatal populations, and those neonates with AKI have poor outcomes. Serum creatinine (SCr)-based definitions of AKI are not ideal and are additionally limited in neonates whose SCr reflects the maternal creatinine level at birth and normally drops over the first weeks of life dependent on gestational age. Recent studies show that urine and serum biomarkers may provide a better basis than SCr on which to diagnose AKI. In this month's issue of Pediatric Nephrology, Sarafidis et al. show that urine neutrophil gelatinase-associated lipocalin (uNGAL), serum NGAL (sNGAL), and urine cystatin c (uCysC) are highest in those neonates with asphyxia who have elevated SCr. Furthermore, those with asphyxia without a concomitant rise in SCr levels have elevated levels of biomarkers compared to controls, suggesting a dose response. Once the SCr level returns to normal, the levels of novel AKI biomarkers continue to be elevated. While these findings strengthen the argument for the clinical use of these AKI biomarkers, further work is needed before they can be implemented in clinical practice. Large-scale observational multi-center studies are needed to test these biomarkers against hard clinical endpoints. In addition, randomized intervention trials which use biomarkers to define AKI need to be performed.     

Diagnosis and follow-up in constipated children: should we use ultrasound?

Purpose

We investigated the efficacy of ultrasound in determining megarectum and fecal load and the response to treatment in constipation and tried to specify objective criteria in this study.

Methods

A total of 66 cases were queried and divided into 2 groups as constipated (n = 35; mean age, 6.8 ± 2.9 years) and control (n = 31; mean age, 8.4 ± 3.8 years) according to Rome III criteria. After the clinical evaluation, pelvic ultrasonography (US) was performed by 2 separate radiologists. The bladder capacity and the transverse rectal diameter were measured with a full bladder. Then the rectal diameter and rectal anterior wall thickness were measured, and the presence of fecal load in the rectum and sigmoid colon was recorded with an empty bladder. The examination and ultrasound were repeated after treatment for a month in these patients.

Results

Comparison of the US measurements of the 2 radiologists performing the US tests did not show any interobserver difference (r = 0.981; P < .001). We therefore believe our results are objective and reproducible. We found a positive correlation between the rectal diameters and the age, height, weight, and bladder capacity. The posturination mean rectal diameter was thicker in the constipated group (3.02 ± 1.04 cm) than in the control group (1.98 ± 0.64 cm) (P < .001). The cutoff point of rectal diameter for a diagnosis of constipation was determined as 2.44 cm (71% sensitive; 76% specific; area under curve, 0.825; P < .001). The rectal anterior wall thickness and fecal load were higher in the constipated patients (P < .001). There was a significant decrease in the constipation score and fecal load after treatment for a month (P < .001), but the rectal diameter had not reached normal limits yet despite the decrease (2.71 ± 0.77 cm) (P > .05).

Conclusion

The use of US helps in making a correct diagnosis and in the follow-up with objective criteria and also convinces the patient and the family that the treatment needs to be continued.     

Are you ready to become a robo-surgeon?

Robotic and minimally invasive surgery represents the future of modern surgical care. However, its role during the training of surgical residents has yet to be investigated. A previous study conducted by our group surveyed program directors at accredited general surgery training programs in the United States to determine the prevalence and application of robotics in their residency programs. This current study is a follow-up survey sent to residents across the United States to see whether they were being adequately trained and exposed to robotic surgery during their training. A survey was sent to 1800 general surgery residents, and their responses were tabulated and analyzed. Twenty-three per cent of the 1800 residents responded to our survey. An overwhelming 57 per cent of the responders indicated a high interest in robotic surgery. However, 80 per cent of the responders indicated not having a robotic training program. Robotic surgery has led to many promising advancements within the surgical subspecialties. With this emerging technology comes the need for a greater emphasis on the training of surgeons in robotics during their residency.