Long-term outcomes of kidney transplants with multiple renal arteries: a retrospective study

Objective

The aim of this study was to investigate whether kidney transplantations performed using grafts with multiple arteries negatively affected renal function or increased the risk of vascular or urologic complications.

Methods

Among 249 kidney transplant patient followed for at least 1 year between 2000 and 2005, we retrospectively evaluated their donor renal artery anatomy to compare postoperative vascular and urologic complications: creatinine clearance at 1, 2, and 5 years, as well as graft survival at 3 and 5 years.

Results

While 214 (85.9%) displayed a single artery (group 1), 35 (14.1%) showed multiple renal arteries (group 2). Thirty-one of the group 2 allografts had two, three donors had three, and one had four arteries. The postoperative vascular and urologic complications and the creatinine clearance values at 1, 2, and 5 years of both groups were similar. The 3- and 5-year graft survivals among group 1 were 95% and 90%, whereas those of group 2 were 94% and 91% respectively (P < .05).

Conclusion

Our study indicated that multiple renal arteries did not adversely affect postoperative urologic or vascular complications or kidney allograft or patient survival compared with single renal artery cases.     

Influence of Pretransplantation Bacterial and Fungal Culture Positivity on Outcome after Living Donor Liver Transplantation

Backgrounds

Bacterial and fungal infections are serious complications in patients with cirrhosis and are among the main causes of morbidity and mortality. The effects of pretransplantation infection on the outcome after orthotopic liver transplantation (OLT), however, have not been fully described.

Objective

To assess the influence of pretransplantation infection on OLT by analyzing the clinical profiles of liver recipients with preexisting bacterial or fungal infection.

Patients and Methods

We retrospectively reviewed the medical records of 223 adult patients who underwent living donor OLT between October 1, 2005, and September 30, 2006. In all patients, routine blood culture, was performed, and in patients with suspected bacterial or fungal infection; sputum, urine, and ascitic fluid cultures were performed.

Results

Of 223 patients, 37 (16.6%) had a positive culture in one or more samples. Culture-positive and culture-negative groups differed significantly in end-stage liver disease score but showed no differences in Child-Turcotte-Pugh score, existence of spontaneous bacterial peritonitis, hemodialysis, or duration of stay in the intensive care unit or hospital. Six of 37 patients with positive cultures (16.2%) and 4 (2.2%) of 186 patients with negative cultures (2.2%) died during the first 90 days after OLT (P = .007). The causes of death among culture-positive patients were brain edema (n = 2), brain hemorrhage (n = 1), hepatic dysfunction (n = 1), and sepsis (n = 2), whereas all 4 culture-negative patients died of infectious complications.

Conclusion

Prompt OLT accompanied by adequate antibiotic or antifungal therapy may be acceptable in patients with preexisting bacterial or fungal infection unless there are overt manifestations of active infection.     

A novel Czech kindred with familial medullary thyroid carcinoma and Hirschsprung's disease

Purpose

The RET proto-oncogene is involved in neural crest disorders. Activating germline mutations in the RET proto-oncogene cause the development of familial medullary thyroid carcinoma (FMTC) or medullary thyroid carcinoma (MTC) as a part of multiple endocrine neoplasia type 2 (MEN2) syndrome. Inactivating germline mutations in the RET proto-oncogene are detected in Hirschsprung's disease (HSCR). Only in a very small number of families are these 2 diseases expressed together.

Methods

This study presents a novel Czech kindred with FMTC-HSCR phenotype. Two family members (mother and daughter) were tested for RET germline mutations in exons 10, 11, 13, 14, 15, and 16.

Results

Direct fluorescent sequencing of genomic DNA revealed a heterozygous mutation in the RET proto-oncogene in exon 10 at codon C609Y in both persons tested. This family was reclassified, thanks to genetic screening from the apparently sporadic MTC-HSCR to FMTC-HSCR.

Conclusion

The germline mutation was detected because of the systematic genetic screening of the RET proto-oncogene, which is useful for genetic counseling of potential risk of HSCR and MTC in other family members. This family could be added to the small worldwide cohort of families with MEN2A/FMTC-HSCR.     

Is surgery necessary for incidentally discovered adrenal masses in children?

Background

There are no guidelines that exist to direct the management of incidental adrenal masses (IAM) in children. The aim of this study was to determine if there is a subset of IAMs that could be safely observed.

Methods

A retrospective analysis was conducted of all adrenal masses that were either resected or biopsied between 1990 and 2002 (n = 91) at the Hospital for Sick Children, Toronto. IAM was defined as a solitary adrenal mass discovered by either physical examination (n = 6; 23.1%) or diagnostic imaging for other indications (n = 20; 76.9%), without metastases or biochemical activity.

Results

Twenty-six (28.6%) IAMs were detected (mean age, 4.6 years [range, antenatal to 17 years]; 11 boys, 15 girls). Pathologic diagnoses included neuroblastoma (n = 7), ganglioneuroma (n = 6), adrenocortical adenoma (n = 4), adrenal cyst/pseudocyst (n = 3), adrenal hemorrhage (n = 3), ganglioneuroblastoma (n = 1), nodular cortical hyperplasia (n = 1), and teratoma (n = 1). Eight masses were malignant (30.8%). Two of the 5 masses discovered on antenatal ultrasound scan were neuroblastoma. In comparing the benign with malignant lesions, there was no significant difference in mean size (4.8 cm v 4.3 cm; P = .57), radiologic characteristics, or mode of presentation. Benign lesions occurred more frequently in older children (mean age, 6.5 years v 1.3 years; P = .03).

Conclusions

Clear guidelines cannot be established to predict benign IAM in children. Given the high proportion of malignant lesions, we recommend that all pediatric IAMs should be resected.     

Stealth surgery: subcutaneous endoscopic excision of benign lesions of the trunk and lower extremity

Background

Benign subcutaneous lesions of the trunk are typically excised through overlying skin incisions, which can result in permanent, potentially disfiguring scars. We previously reported our experience with transaxillary subcutaneous endoscopic approach for removal of benign lesions of the neck. Here we report a similar approach for removing benign lesions of the trunk and lower extremity.

Methods

A retrospective review was conducted on 4 consecutive subcutaneous endoscopic procedures for benign truncal and lower extremity lesions from November 2006 to October 2008. The lesions included an anterior chest wall epidermal inclusion cyst, anterior midsternal dermoid cyst, left posterior chest wall giant lipoma, and a lipoma extending from the right gluteal crease onto the thigh. Outcome measures included need for conversion, cosmetic outcome, and complications.

Results

All procedures were successfully completed using the endoscopic approach without conversion to open excision. There were no intraoperative complications. Postoperative complications included a 1 cm seroma at cyst site, axillary port site wound infection, and punctate dermal thinning secondary to adherent dermoid cyst, all resolved by 2 weeks postoperatively. All wounds healed with excellent cosmetic result at 1-month follow-up.

Conclusions

A subcutaneous endoscopic approach can be applied effectively to a variety of benign lesions of the trunk and lower extremities with adequate exposure for dissection and resulting in a quick recovery. Truncal and lower extremity scarring is absent, with small scars well hidden in either the axilla or the buttock, respectively.     

Staircase falls: High-risk groups and injury characteristics in 464 patients

Introduction

Few data are available about the epidemiology and injury characteristics in staircase falls. The available literature mainly concerns children and autopsy studies.

Objective

To describe the epidemiology and injury characteristics of staircase falls, and to identify high-risk groups for these falls.

Methods

All patients who reported to an academic Accident & Emergency (A&E) department in 2005 after a staircase fall were selected in the Dutch Injury Surveillance System These data were linked to the hospital Trauma Registry database.

Results

Four hundred and sixty-four patients (42% male, p = 0.001), with a median age of 35 years were included. Children under five suffered significantly more head injuries. Male patients showed significantly more thoracic injuries than female patients. Spinal column fractures were only seen in patients over 25 years of age. Older patients tended to accumulate more rib fractures and lower extremity fractures and were admitted more frequently than the younger patients. Sixty-one patients (13%) required admission. Two patients, both with severe traumatic brain injury (TBI), died. National data on staircase falls were comparable with our hospital data. However, in comparison to the national population data, senior citizens in this study had an incidence that was markedly higher than in the younger patients.

Conclusion

Injuries due to staircase falls occur in all age groups, however, children under five years are relatively over-represented with higher rates of head injury. Senior citizens showed a markedly higher incidence than younger patients. Most injuries occur to the distal extremities and are relatively mild.     

Prosthetic patches for congenital diaphragmatic hernia repair: Surgisis vs Gore-Tex

Purpose

The sequelae of congenital diaphragmatic hernia (CDH) continue well beyond the perinatal period. Up to 50% of these patients have subsequent recurrent herniation or small bowel obstruction (SBO). A recent trend has been toward the use of bioactive prosthetic materials. We reviewed different patch closure techniques used for CDH repair at our institution and their association with these sequelae.

Methods

A retrospective review was performed of 152 records for patients with CDH. Newborns that underwent patch repair for CDH and survived for at least 30 days were included in the analysis. Primary outcomes evaluated were recurrent herniation and SBO. Two types of prostheses were examined, Gore-Tex, an artificial material, and Surgisis, a bioactive material.

Results

Twelve (44%) of 27 patients who had Surgisis repair had recurrent herniation. Seventeen (38%) of 45 patients who had a Gore-Tex repair had recurrent herniation. Two additional patients in each group presented with SBO. No significant difference in recurrent herniation rates was observed (P > .5). The time to recurrence was similar in both groups (log-rank, P = .75), with most recurrences (92% Surgisis, 76% Gore-Tex) occurring in the first year.

Conclusion

The rates of recurrent herniation and SBO after neonatal prosthetic patch repair of CDH were similar regardless of the prosthetic material used (Surgisis or Gore-Tex).     

Expression of Pancreatic Endocrine Markers by Prolactin-Treated Rat Bone Marrow Mesenchymal Stem Cells

Background

Mesenchymal stem cells (MSCs) are an attractive source for generation of cells with β-cell properties. Previous studies have demonstrated the ability of prolactin to induce an increase in β-cell mass and maturation, which suggests beneficial effects of its use in MSC differentiation protocols.

Objective

To evaluate the expression of endocrine differentiation markers in rat MSCs treated in vitro with prolactin.

Methods

Mesenchymal stem cells from bone marrow of Wistar rats were isolated, expanded, and characterized. Differentiation of MSCs was induced in medium containing 23 mmol/L of glucose, and nicotinamide, 2-mercaptoethanol, and exendin-4, in the presence or absence of 500 ng/mL of rat recombinant prolactin. Expression of endocrine markers and prolactin receptor genes was evaluated using real-time polymerase chain reaction, and compared between culture stages and presence vs absence of prolactin in the culture medium. Expression of insulin, somatostatin, glucagon, and pancreatic and duodenal homeobox 1 was also evaluated at immunofluorescence microscopy.

Results

Isolated cells were mostly MSCs, as confirmed at fluorescent-activated cell sorting and cytochemistry. Pax6, Ngn-3, Isl1, NeuroD1, Nkx2.2, and Nkx6.1 exhibited varied expression during culture stages. The long form of the prolactin receptor messenger RNA was induced in prolactin-treated cultures (P < .05). The somatostatin gene was induced in early stages of differentiation (P < .05), and its expression was induced by prolactin, as confirmed using immunofluorescence.

Conclusion

Culture of rat bone marrow MSCs in differentiation medium induces expression of pancreatic endocrine-specific genes, and somatostatin and prolactin receptor expression was also induced by prolactin.     

The split abdominal wall muscle flap repair for large congenital diaphragmatic hernias on extracorporeal membrane oxygenation

Background

Numerous techniques exist for repairing large congenital diaphragmatic hernias (CDHs) including prosthetic patches, tissue-engineered grafts, and various muscle flaps. A split abdominal wall muscle flap is a simple, durable way to repair a large diaphragmatic hernia. This technique has not gained widespread use, and some have suggested that it would be inappropriate in the setting of extracorporeal membrane oxygenation (ECMO) because of bleeding risk. We present our series of diaphragmatic hernias with a focus on those repaired with the split abdominal wall technique while on ECMO.

Methods

A retrospective, single-institution chart review was performed on all patients who underwent surgical repair for CDH over 6 years beginning in August 2000.

Results

Seventy-five patients underwent repair. Sixteen were performed with patients on ECMO. Of these, 4 were closed primarily, 7 used a prosthetic patch, and 5 used a split abdominal wall muscle flap. Two patients in the prosthetic group developed a recurrent hernia, and 2 required reoperation for bleeding while on ECMO. No reoperations for bleeding were required in the abdominal muscle flap group.

Conclusions

The split abdominal wall muscle flap can be safely performed on anticoagulated patients. We believe it is a practical option for repairing large CDHs.     

Risk factors and prognosis of lower digestive tract haemorrhage in severe burns: a 12-year retrospective analysis

Objective

To explore the risk factors relating to lower digestive tract haemorrhage in severe burns and summarise the experience in clinical diagnosis and treatment.

Method

General data of 103 patients with severe extensive burns (EBs) admitted to our burn centre in Shanghai between 1997 and 2009 were reviewed retrospectively. The risk factors relating to EB-complicated lower digestive tract haemorrhage were analysed systematically with respect to the clinical features and experiences in treatment, and prognosis.

Results

Of the 103 severe EBs, five developed lower digestive tract haemorrhage with an occurrence of 4.9%. Four of them were proved to have multiple mucosal erosions in caecum, colon and rectum, and the remaining one was proved rectal ulcerative haemorrhage. In comparison with upper digestive tract haemorrhage, lower digestive tract haemorrhage in the present group was characterised by a longer duration (median 4.0 days, interquartile range (IQR) 1.5-14.5 days vs. median 2.0 days (IQR 1.0-3.0 days), P < 0.05). Deep burns, especially fourth-degree burns, with complications of severe systemic infection, formed the main risk factors relating to lower digestive tract haemorrhage in severe EB patients.

Conclusion

Severe EB-complicated lower digestive tract haemorrhage is a critical condition in burns, which usually have deep wounds with severe infection surfaces that are difficult to deal with. Enteroscopic haemostasis in controlling lower digestive tract haemorrhage is usually ineffective. Clinical experiences indicate that early management of the wound with effective preventive and therapeutive measures for infection control may be a good choice in the prevention and treatment of lower digestive tract haemorrhage leading to improvement in its prognosis.     

Different pattern of matrix metalloproteinases expression in alveolar versus embryonal rhabdomyosarcoma

Background/purpose

The matrix metalloproteinases (MMPs), a family of enzymes that degrade the extracellular matrix (ECM), are important in neoplastic cell invasion and metastasis. Data for rhabdomyosarcoma (RMS), the most frequent soft tissue sarcoma of childhood, are lacking. The aim of this study was to assess their expression in this tumor and to evaluate the correlation with clinicopathologic parameters.

Methods

Immunohistochemical expression of MMP-1, MMP-2, MMP-3, MMP-7, MMP-9, TIMP-1, and TIMP-2 was investigated in 33 human RMSs, 12 alveolar, and 21 embryonal histologic subtypes (12 high risk and 9 low/standard risk). Evaluation of the results was based on the percent of positive neoplastic cells and on staining intensity (negative, moderate, and strong). In situ zymography was carried out on 4 frozen RMS samples (2 alveolar and 2 high-risk embryonal).

Results

Alveolar type showed a stronger MMP-1, -2 and -9 expression in comparison with embryonal (P = .006, P <.001, and P <.001, respectively). Intratumoral vessels and perivascular ECM were positive for MMP-9 in the majority of RMSs. Both TIMPs had negative results.

Conclusions

Gelatinases MMP-2 and MMP-9 and collagenase MMP-1 overexpression seem to contribute to the more aggressive phenotype of alveolar rhabdomyoblastic cells. Further characterization of the expression of MMPs and consequent utilization of their inhibitors in aggressive alveolar RMSs might lead to the development of novel anticancer therapies.     

Resectability and operative morbidity after chemotherapy in neuroblastoma patients with encasement of major visceral arteries

Background/Purpose

Image-defined vessel encasement is a significant risk factor for surgical complications and incomplete resection for intermediate-risk tumors. We sought to examine the impact of vessel encasement on complications or resectability in intermediate-risk or high-risk patients after neoadjuvant chemotherapy.

Methods

We retrospectively reviewed 207 consecutive patients with circumferential encasement of the renal vessels, celiac axis, and/or superior mesenteric artery (SMA) who underwent resection between 1991 and 2009. Specifically, we evaluated resection rates, complications, and outcome.

Results

Median age at diagnosis was 3.0 years, and 79% of patients had stage 4 disease. Of known MYCN status, 23.4% had MYCN amplification. Vessel encasement included renal vessels, celiac axis, or SMA alone in 107, 7, and 4 patients, respectively. Both the renal vessels and celiac axis were encased in 5 patients, renal vessels and SMA in 7 patients, and celiac axis and SMA in 14 patients. Sixty-three patients had all 3 vessels encased. The gross total resection (GTR) rate was 94%. No operative or postoperative deaths occurred. The overall complication rate was 34.8% (n = 72). Overall 5-year survival (±SEM) was 67.4% (±7.4%).

Conclusion

Encasement of major visceral arteries in patients with neuroblastoma who have received chemotherapy does not preclude gross total resection.     

Progression of Hepatocellular Carcinoma Before Liver Transplantation: Dropout or Liver Transplantation?

Background

Tumor progression before liver transplantation (OLT) is the main cause of dropout from the waiting list (WL) of patients with hepatocellular carcinoma (HCC). The aim of this study was to show a correlation between adopted dropout criteria and dropout/intention-to-treat survival rates of WL HCC patients.

Methods

The study period was 2000 to 2007. The dropout criteria were macroscopic vascular invasion, metastases, or a poorly differentiated tumor. Adult patients with benign chronic liver disease enlisted for primary OLT in the same period represented the control group.

Results

Dropout probability of study (n = 128) versus control group (n = 377) subjects was similar: namely, 12% at 1 year in both groups (P = NS). Intention-to-treat survival curve of the HCC group overlapped that of the benign group (5-year survival rates were 73% and 71%, respectively; P = NS). At the time of listing, 103 study group patients were within the Milan criteria (MC): among these patients, 29 (28%) showed tumor progression beyond MC before OLT. Simulating the dropout of these 29 patients at the time of diagnosis of tumor progression, we compared the dropout probability of the 103 patients within MC with that of the control group. As a result, the 1- and 2-year dropout rates became 37% and 53%, respectively, in the study group, which were significantly higher than those in the controls (P < .01).

Conclusion

HCC patients on the WL showed a significantly greater dropout rate than subjects with benign cirrhosis when too restrictive radiologic dropout criteria were used. The adoption of criteria more related to biological aggressiveness of a tumor decreased the dropout risk for HCC patients without impairing their intention-to-treat survival rates.     

Comparison of bacteria isolated from urinary tract infections in patients on transplant versus urologic wards

Objective

Urinary tract infections (UTI) are the most common hospital infections. Complications include sepsis and shock. Immunosuppressed transplant surgery patients may experience loss of the graft due to UTI. The purpose of this study was to determine the main microorganisms responsible for UTIs among patients of transplant wards compared to urologic wards. Additionally, drug susceptibility profiles of the most frequent microorganisms were analyzed.

Materials and Methods

We analyzed the results of positive urine cultures from patients on 2 transplant versus 1 urologic ward in 2010.

Results

The most common pathogen in urine samples from all 3 wards was Escherichia coli. Often, other Gram-negative bacilli of the genus Klebsiella spp, were cultured as well as Gram-positive cocci (Enterococcus spp). Yeasts of the genus Candida were only found in urine of patients of transplant wards. The percentage of resistant bacteria was much higher among bacteria from transplant patients.

Conclusions

The high level of antimicrobial resistance of microorganisms isolated from the urine of transplant patients and the relatively high incidence of fungal infections, demand an especially quick, accurate microbiological diagnosis for this group of patients.     

Structural changes of smooth muscle in congenital ureteropelvic junction obstruction

Background/Purpose

Ureteropelvic junction (UPJ) obstruction is the most common cause of congenital hydronephrosis. Previous studies have reported that the excess amount of collagen restricting mobility and resiliency of the UPJ is the result of an impaired collagen production by anomalous smooth muscle cells (SMCs). Our purpose was to evaluate the role of SMC differentiation in the pathogenesis of UPJ obstruction.

Methods

Surgical specimens of UPJ from 21 patients (8 girls/13 boys) who were subjected to dismembered pyeloplasty were examined immunohistochemically using monoclonal antibodies against smooth muscle (SM) myosin heavy chain isoforms including SM1, SM2, and SMemb. The age ranged from 1 month to 13 years. Ureteropelvic walls taken from 14 forensic autopsy cases, with no urological abnormalities, served as age-matched control group.

Results

The immunohistochemical expression of SM1 and SM2 in UPJ obstruction was significantly increased when compared with controls (P < .05). In contrast, there was no statistical difference of expression of SMemb.

Conclusion

Our findings supported the hypothesis that the primary anomaly in UPJ obstruction may be attributed to a malfunction of SMCs in the ureter.     

Effect of systemic corticosteroids on elective left-sided colorectal resection with colorectal anastomosis

Background

The impact of systemic steroid therapy on surgical outcome after elective left-sided colorectal resection with rectal anastomosis is not well known.

Methods

We compared 606 consecutive patients including 53 patients who were on steroids and undergoing surgery between 1995 and 2005.

Results

Postoperative mortality and anastomotic leakage rates were equivalent. The postoperative complications rate, especially infections, was higher in steroid-treated patients than in non-steroid-treated patients: 38% (20 of 53 patients) versus 25% (139 of 553 patients), respectively (P = .046). In the steroid group, univariate analysis revealed 3 significant risk factors for postoperative complications: blood transfusion, preoperative anticoagulation, and chronic respiratory failure. In a multivariate analysis, blood transfusion and chronic respiratory failure remained independent factors for postoperative complications.

Conclusion

Patients on steroids have a higher incidence of postoperative complications after elective left-sided colorectal resection with rectal anastomosis.