Transplantation ethics: are we approaching the crossroads?

Ethical issues of organ transplantation are of extreme importance to involved physicians and to society. The basic principle is that the donor cannot be considered as a commodity; financial incentives must not occur. Regarding deceased-donor organ transplantations, ethical issues are related to the consent for donation, determination of death, and principles of organ allocation. Living donors should be healthy, giving free consent after being fully informed about the risks of the procedure. Transplant professionals have a double responsibility because they must remember about the rights of the organ recipient as well as of the donor. Because of the organ shortage we commonly use organ recovery from donors after cardiac arrest and extend the living-donor pool, practices that may influence some important ethical principles. A proper detailed determination of donor death is of utmost importance. The dead donor rule must be preserved. However category III non-heart-beating donors (so-called controlled cardiac arrest) raise doubts as to the time of the decision to transfer the dying (not yet dead) patient to the operating room to withhold supportive treatment. In certain centers, not quite healthy living donors are being used; they are called extended-criteria or complex donors. Although organ trade is condemned, some workers agree to use as complete strangers donors, obviously believing in pure altruistic motivation of such donors without the additional incentives. Finally, is the trend to consider utility in organ allocation justified? It seems that quite soon we may need a new transplantation ethics code that is not totally directed by transplant professionals exclusively to the needs of potential recipients.     

Structural fat grafts: the ideal filler?

In the search for injectable subcutaneous fillers, fat harvested, transferred, and placed in the manner previously described has most of the characteristics of an ideal filler. It is biocompatible, versatile, stable, long-lasting, and natural-appearing. The key to successful fat grafting lies in the technique. Harvesting, refinement, and transfer of subcutaneous tissue to provide pure, intact parcels of fat are essential for successful fat grafting. The surgeon also must infiltrate the refined fat parcels into the recipient site so that they survive predictably and uniformly, become integrated into the host tissues, and accomplish the desired structural alteration. The key to attaining these goals is the placement of minuscule amounts of fatty tissue with each withdrawal of the infiltrating cannula. This maneuver maximizes the surface area of contact between the newly transplanted tissues and the recipient tissues. Applying this technique to enact structural volume alteration of the face can result in subtle or striking improvements in the appearance of patients. The ideal substance for soft-tissue augmentation still eludes physicians, but fat grafting through a blunt cannula seems to be the safest of all of the fillers used; in the hands of an experienced surgeon, it can provide long-lasting, natural-appearing structural changes.     

Compression bandaging: are practitioners achieving the ideal sub-bandage pressures?

Compression bandaging is the mainstay of conservative management of patients with venous ulceration. But debate is growing over what levels of pressure to apply and how to balance this with what patients can tolerate.     

Immune privilege of the eye and fetus: parallel universes?

The eye is an extension of the brain and thus many of its tissues are incapable of regeneration. Ocular inflammation can produce extensive damage to innocent bystander cells leading to blindness. However, the eye possesses multiple strategies to control immune-mediated inflammation-a phenomenon known as immune privilege. The fetus of outbred mammals expresses paternal histocompatibility antigens and represents an allograft. However, the success of placental animals is a testament to the immune privilege of the allogeneic fetus. Extensive evidence suggests that the eye and the fetus employ similar strategies for establishing immune privilege for preserving vision and the unborn respectively.     

Video-assisted versus open pulmonary metastasectomy: the surgeon's finger or the radiologist's eye?

Objective: The use of VATS metastasectomy remains controversial because of doubt surrounding its ability to remove palpable but CT occult lesions. We aim to evaluate our policy of elective VATS and compare it with our results with open metastasectomy. Methods: Pulmonary metastasectomy was performed for metastatic colorectal adenocarcinoma in 52 patients: 27 open and 25 VATS over 8 years. The age and sex distribution was similar: median age was 66 for open and 69 years for VATS, p = 0.48, 70% male in open and 64% male in VATS, p = 0.31. Liver metastases were present in 37% in the open and 32% in the VATS group, p = 0.46. The choice of surgical approach was dependent on the distance of the lesion from the surface of the lung. We examined the survival using the Kaplan–Meier method and we tested for differences in the incidence of missed lesions, pulmonary disease progression and repeat metastasectomy. Results: There was no in-hospital mortality. There was no difference in the incidence of missed lesions (1 in VATS, none in open, p = 0.48), pulmonary disease progression (11 in open, 9 in VATS, p = 0.47) or recurrence in the same lobe (4 in open, 3 in VATS, p = 0.54). Median follow-up was 22 (1–70) months and there was no difference to the estimated actuarial survival. Mean survival for the open group was 47 months, SE 6 with 95% CI 36–59 months and mean survival for the VATS group 35.4 months, SE 3 with 95% CI 30–41.3 months. The estimated 1- and 2-year survival was 90% and 80% for open and 90% and 72% for VATS. Conclusions: The selective use of VATS therapeutic metastasectomy in conjunction with multi-detector CT is justified in metastatic colorectal adenocarcinoma. The insertion of the surgical digit is not mandatory. Trust the radiologist's eye.