Calcium Microemboli and Microfilters in Valve Operations

Fatal microemboli occurred in 3 of 100 consecutive patients having aortic valve replacement; 2 occurred during perfusion before the microfilter era, and 1 occurred intraoperatively despite the use of in-line filters. In all 3 patients cerebral symptoms were present immediately postoperatively, and each died of severe brain damage. On postmortem examination cerebral calcium microemboli were verified in only 2 patients, although the brain of each patient contained minute infarctions. However, calcium particles were found in the kidneys of all 3 patients. Thus the kidneys proved to be the best place for detection of calcium emboli on postmortem examination. Although the microfilters currently available effectively prevent microemboli during extracorporeal circulation, the surgeon should be aware that embolization can also occur immediately after discontinuation of perfusion. The means of protecting the patient from this are discussed.     

Incidence of Infectious Disease and Malignancies After Rituximab Therapy in Kidney Transplant Recipients: Results From a Cohort in Germany

Background

Rituximab is frequently used in solid organ transplantation off-label, especially in patients with renal allografts. Few data are available on the safety aspects of solid organ transplant recipients receiving rituximab. There is a knowledge gap on long-term follow-up data, in particular on infectious complications.

Single-dose intrarectal metronidazole prophylaxis against wound infection after appendectomy

In a prospective, randomized, nonblind clinical trial, single-dose intrarectal metronidazole prophylaxis reduced significantly (p < 0.005) the rate of wound infection after appendectomy. A single 1 g metronidazole suppository was given 1 hour before operation. Metronidazole prophylaxis particularly prevented anaerobic infections caused by Bacteroides species, which were the most common bacteria recovered from the pus in the control group. No side effects attributable to the use of metronidazole could be detected.     

Quadriceps Snip in 321 Revision Total Knee Arthroplasties: A Safe Technique in a Matched Cohort Study

BackgroundQuadriceps snips (QSs) are commonly used to gain enhanced exposure during revision total knee arthroplasties (TKAs). The goals of this study were to evaluate the longer-term clinical outcomes and complications in a contemporary cohort of patients treated with QS and to compare them to a matched cohort treated with standard exposure during revision TKAs.MethodsWe retrospectively identified 3107 revision TKAs performed at our institution between 2002 and 2012. QS was performed in 321 of these knees. Each QS revision TKA was 1:1 matched to a control (standard exposure) based on age, gender, body mass index, surgery date, and reason for revision. Clinical outcomes studied included Knee Society Score, range of motion, and extensor lag. Other outcomes assessed were complications (especially extensor mechanism disruption) and survivorship. Mean follow-up was 5 years.ResultsThe mean Knee Society Score improvement was not significantly different between groups (P = .9). At latest follow-up, the mean range of motion was 93° in the QS group and was slightly higher at 100° in the control group (P = .002). Postoperative extensor lag of 10 degrees or more was present in 21 (6.7%) QS knees versus 19 (6.8%) control knees (P = .95). Complication rates were similar in both groups with extensor mechanism disruption occurring in 3 in the QS group (0.7% at 10 years) versus 4 in the control group (0.8% at 10 years; P = .91). Kaplan-Meier survivorships free of revision for aseptic loosening, free of any revision, and free of any reoperation were similar at 10 years (85%, 71%, and 61%, respectively, in the QS group vs 89%, 70% and 60%, respectively, in the control group).ConclusionThis matched cohort study is the largest to report the results of QS and also the largest to report results compared with patients treated with standard exposure. Building on the results of smaller historical series, this study demonstrates QS was a facile technique in complex revision TKAs allowing for safe exposure with few complications.Level of EvidenceIII (case-control study).     

Association Between Readmission After Liver Transplant and Adverse Immunosuppressant Reactions: A Prospective Cohort With a 1-Year Follow-up

Objective

To measure the association between readmission after liver transplantation and corresponding adverse drug reactions.

Cost of Care for Patients With Pre-Existing Comorbidities Undergoing Total Joint Arthroplasty: A Retrospective Cohort Study Evaluating Disease-Specific Perioperative Care

BackgroundInvestigations suggest a relationship between increased resource utilization with disease burden and advanced age. However, it remains unknown the degree increased resource utilization is associated with pre-existing conditions, before complications occur.MethodsThis retrospective study identified total hip/knee arthroplasty cases in the Premier Database from 2006 to 2016 (N = 1,613,744), with hospitalization cost as the primary outcome. With a variable combining the conditions and complication, generalized linear models measured associations between condition/complication interaction groups and hospitalization cost. Estimates of percent cost increase by variable were obtained.ResultsAcross all conditions, an increase in cost ranging from 0.38% to 4.28% was found in the absence of a complication. The “Condition = No, Complication = Yes” group was associated with a range of 11.50%-12.40% increase in average hospitalization cost, and the range was 14.43%-30.85% for the “Condition = Yes, Complication = Yes” group.ConclusionWe found that having a high-risk condition without a complication accounted only for a modest hospitalization cost increase.     

Antithymocyte globulins in renal transplantation—from lymphocyte depletion to lymphocyte activation: The doubled-edged sword

Compelling data suggest that lymphocyte depletion following T cell depleting therapy may induce prolonged CD4 T cell lymphopenia and trigger lymphocyte activation in some patients. These profound and non-reversible immune changes in T cell pool subsets are the consequence of both impaired thymic renewal and peripheral homeostatic proliferation. Chronic viral challenges by CMV play a major role in these immune alterations. Even when the consequences of CD4 T cell lymphopenia have been now well described, recent studies shed new light on the clinical consequences of immune activation. In this review, we will first focus on the mechanisms involved in T cell pool reconstitution after T cell depletion and further consider the clinical consequences of ATG-induced T cell activation and senescence in renal transplant recipients.     

Comparison of Kidney Transplantation Results From the Same Deceased Donor Between Patients With the First Transplantation and Retransplanted Patients

Background

It has been determined that there are about 25% patients with renal allograft failure on the waiting lists.

Prevention and management of lymphocele formation following kidney transplantation

Despite preventive methods, lymphoceles frequently form following kidney transplantation (KTx), with an incidence of 0.6%–51%. Here, we summarize the current strategies for preventing and managing this complication, and describe the approach used in our department. Rapid diagnosis and early treatment of lymphoceles through a well-defined approach can prevent or reduce the risk of organ loss. Diagnosis can be made by ultrasound, computed tomography, or magnetic resonance imaging and laparoscopic fenestration is the current therapy of choice when non-surgical methods fail. Preventive methods should be performed pre-, intra-, and post-operatively. A peritoneal fenestration at the end of KTx seems to be a reasonable method for preventing lymphocele formation.     

Objective Versus Subjective Assessment of Functional Status in Candidates for Liver Transplantation

Introduction

and aim. Poor functional status is associated with increased mortality in cirrhosis patients awaiting liver transplantation (LT); however, the optimal assessment of functional status remains unknown. This study sought to determine the relationship between 6-minute walk distance (6MWD) and Karnofsky Performance Status (KPS) and their association with waitlist mortality in LT candidates.