Clinical experience with the silicone tracheal prosthesis

The superiority of using the patient's own tissue for tracheal reconstruction is acknowledged. When this is impossible an alternate method is mandatory. From 1970 to 1988, 62 patients with benign and malignant tracheal stenosis had airway continuity established with a silicone tube. A straight graft was used in 48 patients. Twenty-eight had strictures, two tracheoesophageal fistulas and strictures, five primary malacia, and 13 malignant tumors. In 20 with noncancerous tracheal obstruction the airway was resected and a graft interposed. Distal suture line granulomas developed in six of these patients. Two had subglottic granulomas. One had graft dehiscence after dissolution of absorbable suture material. This graft was replaced with a silicone T tube. Four patients with end-to-end anastomosis of the graft to the trachea died in 6 to 12 months. Six others were lost to follow-up. In 15 of the 48 with benign disease the stent was placed within the lumen. Six in this group died. Thirteen of the 48 patients had a malignant tumor. In six the tube was used for palliation; none are alive. Seven underwent resection; five are living 1 to 8 years after the operation, two died of their disease in 1 1/2 to 2 years, and two of the five living are undergoing irradiation for recurrent cancer. Fourteen individuals with tracheocarinal malignancy received a bifurcated graft. All six patients with a palliative intraluminal stent died. Among eight individuals, four died of disease in 1 to 4 years. Four are alive, but two have suture line granulomas and two are undergoing irradiation for residual carcinoma. Mediastinal infection, mucus encrustations of the intraluminal prosthesis, and impedence of pulmonary secretions across long tubular segments have not been manifest. These silicone tubes are well tolerated and function satisfactorily as an airway.     

Secondary membranous nephropathy--one center experience

INTRODUCTION: Secondary membranous nephropathy (MN) is most commonly seen in the setting of autoimmune disease, infection, and neoplasia, and with certain therapeutic agents. The aim of our study was to analyze the presenting features and outcome of the patients with secondary MN. PATIENTS AND METHODS: We retrospectively studied patients with secondary MN diagnosed between the years 1991-2002. In this period, we performed a total of 1874 renal biopsies. MN was diagnosed in 129 cases. RESULTS: In 40 patients (31%), an underlying primary cause was verified (70% women, 30% men, median age 49.5 years). In 18 patients (45%), the disease was drug induced, 11 patients (27.5%) had autoimmune disease, seven patients (17.5%) solid tumors, three patients (7.5%) hepatitis B, and one patient was diagnosed with both hepatitis B and prostate carcinoma. At presentation, median proteinuria was 4.09 g/24 h; 60% were nephrotic. Most of the patients had normal renal function with a median serum creatinine 79 micromol/L and a median GFR 1.285 ml/s. The patients were treated according to the underlying disease. At the end of the follow-up, the patients with drug-induced MN were in complete remission after the discontinuation of the drug. The patients with autoimmune disease were treated with immunosuppression, most of them with very good results. The outcome of the patients with neoplasia was much worse. CONCLUSION: A thorough and repeated exclusion of secondary forms of MN has significant prognostic and therapeutic implications, especially in drug-induced and autoimmune MN.     

Liver transplantation: experience at our center

Liver transplantation was pioneered by Starzl and his team in 1967. Since then, many difficulties have been overcome and this treatment modality has gained worldwide acceptance as the definitive treatment for end-stage liver disease. However, the current numbers of liver transplantations are still far below what is needed, the rising numbers on waiting lists have pushed transplant surgeons to search for new alternatives, and living related donors are considered one solution. At our center, the only living liver donors we accept are relatives and spouses of recipients. We have held the same policy for our kidney program from the beginning. In the past 3 years, we have increased the annual numbers of liver transplantations; our graft and patient survival rates for this period exceed 90%. Liver grafts donated by living related donors offer an extremely important, lifesaving alternative in urgent situations, such as acute liver failure, where there is limited time to wait for a deceased donor. Hepatocellular carcinoma is another important indication for living related liver transplantation. Availability of living donors allows us to perform transplantations even in recipients with advanced tumors who would not be accepted as appropriate transplant candidates according to widely used selection criteria. Liver transplantation is a lifesaving procedure that presents many challenges, and our experience has led us to develop an innovative technique for biliary reconstruction. We have used a method of "back-table guide-wire placement and intraoperative transhepatic biliary catheter insertion" in 44 patients since December 2004 to significantly decrease biliary complications and perform duct-to-duct anastomosis even in small pediatric recipients.     

Sirolimus conversion experience in a single center

OBJECTIVE: One major cause of graft loss is chronic allograft nephropathy (CAN), which may relate to calcineurin inhibitors (CNIs). We converted CAN cases from CNIs to sirolimus and observed the outcomes. METHOD: From January 2004 to August 2007, there were 28 kidney recipients in our center with creeping creatinine levels compatible with CAN. We started sirolimus at 2 mg/d and reduced the CNIs gradually. Sirolimus trough levels were kept between 5 and 8 ng/mL. Mycophenolic acid was cut in half; there was no adjustment on prednisolone dose. RESULTS: The mean switch time was 47.3 months after transplantation. One case discontinued sirolimus due to severe drug-induced pneumonitis. Twelve of the 27 (45%) patients showed improvements in graft function. The most frequent complications were anemia (13/28), hyperlipidemia (13/28), and pneumonitis (4/28). A baseline serum creatinine level less than 2.2 mg/dL seemed to forecast a response to sirolimus conversion. Most of the graft functional improvement occurred within 6 months after the switch. No graft or patient loss was encountered. CONCLUSION: Our experience suggested that 45% of patients with sirolimus conversion showed improved graft function. Among patients within 1 year after transplantation, those with a creatinine level less than 2.2 mg/dL, no proteinuria, and no hyperlipidemia seemed to be better candidates for Sirolimus conversion.     

Cost-effective laparoscopic pyeloplasty: Single center experience

OBJECTIVE: Laparoscopic pyeloplasty (LPP) is a minimally invasive treatment option for ureteropelvic junction (UPJ) obstruction. We report here our experience of performing cost-effective LPP on 24 patients at a single center. METHODS: Between October 1999 and March 2002, LPP was performed in 24 patients (17 male, seven female; age range 8-51 years) including two patients who had failed previous endourologic treatments. In two patients with concomitant renal stones, laparoscopic pyelolithotomy was also performed. LPP was conducted in a cost-reductive manner by both transperitoneal (n = 12) and retroperitoneal (n = 12) access. To reduce the cost, an indigenous balloon to create the retroperitoneal space, reusable ports, ordinary polyglactin suture and intracorporeal free-hand suturing were employed. To reduce operative time, antegrade stenting was also performed in some cases. RESULTS: Laparoscopic Anderson-Hynes pyeloplasty was performed in 16, Foley Y-V pyeloplasty in five and Fenger pyeloplasty in three patients. One patient required conversion to open surgery due to tension at the anastomosis site during Anderson-Hynes pyeloplasty. The mean operating time, blood loss, analgesic (pethidine) requirement, duration of drain and hospital stay for the retroperitoneal and transperitoneal groups were 170.3 and 187.6 min, 102.2 and 145.9 mL, 125 and 136.4 mg, 2.1 and 2.5 days, and 3.4 and 4.3 days, respectively. No significant complications were encountered apart from prolonged ileus in three patients in the transperitoneal group. The mean follow-up period was 10.8 months with a range of 2-24 months. Postoperative renal scan was performed at 3 months in 21 patients, and 1 year in 11 patients. There was evidence of equivocal obstruction in one patient, but there were no obstructions in the remaining patients. CONCLUSION: Although LPP is technically demanding, it is emerging as a viable, minimally invasive alternative to open pyeloplasty for UPJ obstruction with a success rate similar to that of open pyeloplasty. It allows the duplication of open surgery steps (unlike endoscopic procedures), thereby providing durable and sustained results. LPP can also be performed safely, effectively and efficiently in a cost-efficient manner.     

Nipple-sparing mastectomy--initial experience at a tertiary center

BACKGROUND: Nipple-sparing mastectomy (NSM) combines skin-sparing mastectomy with preservation of the nipple-areolar dermis and intraoperative pathologic assessment of the nipple core. We evaluated our initial experience with NSM in terms of clinical outcomes. METHODS: An Institutional Review Board-approved retrospective review of patients undergoing NSM between November 2005 and June 2007 was performed. RESULTS: Eighteen NSM and two areola-sparing mastectomies were performed. Indications for surgery were invasive cancer (n = 4), ductal carcinoma in situ (DCIS) (n = 5), pseudoangiomatous stromal hyperplasia (n = 3), and risk reduction (n = 8). The average distance of tumor from the nipple on imaging was 4.8 cm (range 4 to 5.7). Nipple cores were all benign, and 2 patients developed self-limited superficial desquamation of the nipple. At a mean follow up of 10.8 months, all nipple-areolar complexes were intact, and there were no local or systemic recurrences. CONCLUSIONS: NSM can be successfully achieved with low morbidity in appropriately selected patients.     

A single center experience with extrahepatic cholangiocarcinomas

BACKGROUND: Few large Western series on cholangiocarcinoma have been reported in the literature. We reviewed 40 consecutive cases of extrahepatic cholangiocarcinomas referred to a single center. METHODS: From 1992 until 2000, 40 patients with extrahepatic cholangiocarcinomas were evaluated. The charts of all patients were reviewed to evaluate predictors of survival. Survival was calculated with the Kaplan-Meier method. RESULTS: Forty patients were referred for management of extrahepatic cholangiocarcinomas. Tumors were located in the distal common duct in 3 (7.5%), mid duct in 5 (12.5%), and at the bifurcation in 32 (80%). Surgical resection was attempted in 32 (80%) patients and was curative in 9 (22.5%), palliative in 11 (27.5%), and diagnostic in 12 (30%). Mean survival for all patients was 21.1 +/- 5.1 months and on the basis of tumor stage was 71.4 +/- 15.4, 39.7 +/- 10.6, 19.2 +/- 2.9, 3.9 +/- 1.8, and 6.9 +/- 1.3 months for stages I, II, III, IVA, and IVB, respectively. Mean survival was 51.1 +/- 13.5 months versus 10 +/- 1.8 months in those with curative and noncurative resections, respectively. The presence of a portal mass was associated with a reduction in mean survival from 28.4 +/- 7.2 months to 6.0 +/- 1.9 months. CONCLUSIONS: Extrahepatic cholangiocarcinoma remains a dismal disease with only a 22.5% chance of a curative surgical resection, achieving a 5-year survival rate of 44.4%. Only the absence of a portal mass was predictive of a possible curative resection and long-term survival.     

Primary tracheal tumors: experience with 14 resected patients.

OBJECTIVE: Primary tracheal tumors are rare. Management includes interventional endoscopy, surgery and radiotherapy. METHODS: Between 1987 and 1996, 14 patients treated by resection and reconstruction of the trachea and bifurcation for primary tracheal tumors were retrospectively analyzed. RESULTS: The most common histological finding was adenoid cystic carcinoma (n=7), followed by a squamous cell carcinoma (n=2), a mucoepidermoid carcinoma (n=2), a carcinoid tumor (n=1) and two benign tumors (xanthogranuloma, pleomorphic adenoma). Various reconstruction techniques were used and one prosthesis was implanted. Eight of the patients required preoperative Nd-YAG laser recanalisation. Six were treated by postoperative external beam radiotherapy, in three cases combined with endoluminal brachytherapy. Two major postoperative wound-healing impairment at the anastomosis occurred. Four minor wound-healing disorders were successfully treated by interventional endoscopy. Two patients died postoperatively with mediastinitis respectively with bilateral pneumonia. A local recurrence was observed in only two cases. At the last follow-up in January 1998, nine patients were still alive. We observed five long-term survivors (>6 years) with an adenoid cystic carcinoma or mucoepidermoid carcinoma. CONCLUSIONS: Extensive segmental resection of the trachea is the treatment of choice for primary malignant and occasionally for benign tracheal tumors. Interventional endoscopy is a part of modern tracheal surgery.     

Transmesocolic pyeloplasty: experience of a single center

PURPOSE: We present our experience with dismembered left-sided pyeloplasty using a transmesocolic technique as a way to reduce operative time and facilitate repair by avoiding colon displacement. PATIENTS AND METHODS: Between January 2004 and January 2006, a total of 11 transmesocolic laparoscopic pyeloplasties were performed by the same surgeon at our institution. The mean patient age was 41.6 years (range 14-65 years). Operative records and follow-up were reviewed. RESULTS: A dismembered Anderson-Hynes pyeloplasty was carried out in nine patients (82%), while a Y-V plasty (9%) and a Fengerplasty (9%) were done in one patient each. Crossing vessels were observed in 8 patients (73%). A ureteral stent was left in all patients. The mean operative time was 88.6 minutes (range 60-125 minutes), and blood loss was minimal. Compared with classic transperitoneal laparoscopic left pyeloplasties, transmesocolic cases showed a significant reduction in operative time (88.6 minutes v 117 minutes; P < 0.05). There were no intraoperative complications or open conversions. The mean hospital stay was 2.1 days (range 2-3 days). Only 1 patient (9%) demonstrated narrowing of the anastomosis, which occurred 12 months after a Fengerplasty. CONCLUSIONS: The transmesocolic approach to a dilated left pelvis enables a shorter operative time without increasing morbidity. More patients and longer follow-up are necessary to determine its effect on convalescence.     

The male breast carcinoma: a center experience

Male breast carcinoma represents a rare tumor entity and is not the focus of major research activities although an increasing incidence has to be noticed. Registry data on 67 males diagnosed and treated for breast carcinoma during the period 1985-2005 in the metropolitan area of Leipzig were retrospectively analyzed. The median age at diagnosis was 65 years (39-92 years) with an incidence peak in the age group 60-70 years. According to the TNM classification a carcinoma in situ was diagnosed in 8 % (n = 5) of the cases and an invasive carcinoma T1 in 39 % (n = 26 ), T2 in 38 % (n = 25), T3 (n = 0) and T4 in 15 % (n = 11). The lymphnode status presented in 56 % negative and in 44 % positive (N1 + N2) nodes. Solid organ metastasis was detected in only 6 % of the patients. The overall 5-year survival is 72 % and comparable with published data. Respective survival rates for patients diagnosed with UICC-stadium 1-4 are 81 %, 76 %, 65 % and 0 %. These rates are similar to those of female patients. Considering the low incidence of male breast carcinoma and the limited knowledge on this rare disease surgeons should apply diagnostic and therapeutic guidelines that are established for the treatment of female breast carcinoma unless powerful evidence based data will become available.     

Laparoscopic liver resections: A single center experience

Background Since the first report of laparoscopic liver resection, by Gagner et al. 1992, an increasing number of small prospective studies have been published. They have shown encouraging results for the feasibility and safety of the procedure. This paper prospectively evaluated the results of a single center’s experience with elective liver resections.Methods From January 1995 to January 2004 a prospective study of laparoscopic liver resections was undertaken in 31 patients with preoperative diagnosis of benign lesions (13 cases, 42.4%), hepatocellular carcinoma in absence of complicated cirrhosis (three cases, 9.1%), and liver metastases (15 cases, 45.5%). Mean tumor size was 34.9 mm (range 10–100 mm).Results The procedures included 11 (37.9%) major hepatectomies and 21 (62.1%) minor resections (one patient was submitted to repeat laparoscopic liver resection) . There were three conversions to open. Mean blood loss was 210 ml (range 0–700 ml). Mean operative time was 115 min (range 45–210 min). There were no deaths and no reoperations for complications. No port-site metastases occurred in patients with malignant lesions.Conclusions Laparoscopic liver resections, including major hepatectomies, are feasible and safe. Major and posterior resections are difficult, though, and conventional surgery remains an option.     

Osteoporosis after renal transplantation: single center experience

BACKGROUND: Osteoporosis is a major source of morbidity after renal transplantation. The aim of this retrospective study was to determine the independent influences of different parameters on bone mineral density (BMD) in various parts of the body after renal transplantation. METHODS: BMD was measured in 130 of 954 renal allograft recipients who underwent surgery between 1985 and 1999. RESULTS: Time since transplantation and cumulative prednisolone doses were significantly higher in patients who had osteoporosis of the lumbar vertebrae (P=0.06 and 0.034, respectively). Logistic regression analysis revealed that cumulative prednisolone dose was the only significant predictor of low vertebral BMD (P=0.02, r=0.33). For the neck of the femur, high blood urea nitrogen and low Mg levels were found to be the predictors of low bone density (P=0.002 and 0.04, respectively). Although parathyroid hormone levels were higher in femoral osteoporosis patients than in those not affected at this site, the difference was not statistically significant (P=0.294). Time since transplantation, cumulative prednisolone dose, and cyclosporine A dose were all found to have a major negative impact on BMD in the radius region (P=0.001, 0.000, 0.001, respectively). Regression analysis showed that cumulative prednisolone dose (P=0.0008, r=0.34), time since transplantation (P=0.005, r=0.27), body mass index (P=0.01, r=-0.21), male gender (P=0.02, r=-0.21), and age (P=0.04, r=0.16) all had major effects on radius BMD. In conclusion, the radius seems to be one of the major parts of the skeleton affected by factors introduced after renal transplantation.