Laparoscopic radical prostatectomy: decreasing the learning curve using a mentor initiated approach

PURPOSE: Laparoscopic radical prostatectomy is being evaluated at several centers in the United States as a treatment option for localized prostate cancer. It is a technically difficult operation to perform with a steep learning curve. It has been stated that 50 procedures are necessary to satisfy the learning curve. To expedite performance and evaluation of laparoscopic radical prostatectomy a surgeon (mentor) who had performed 200 cases was invited to instruct a fellowship trained laparoscopist (trainee). MATERIALS AND METHODS: From March 2001 through September 2001 we performed 30 laparoscopic radical prostatectomies. The mentor performed the first 12 procedures with the trainee acting as assistant (group 1). The subsequent 18 procedures were performed by the trainee with the mentor acting as assistant (group 2). A final set of 20 procedures was performed by the trainee alone using 1 of 3 urological residents as the assistant (group 3). The transperitoneal approach was used and all suturing was intracorporeal. Preoperative data included prostate specific antigen, clinical stage, Gleason grade and median patient age. Intraoperative data included operative time, the blood loss/transfusion rate and intraoperative complications. Postoperative data included pathological stage, prostate specific antigen, the positive margin rate, catheter dwell time and hospital stay. When applicable, statistical significance was determined using the standard paired t test. RESULTS: There was no statistical difference in median operative time in groups 1 and 2 (248 and 258 minutes, respectively, p = 0.15). Similarly there was no difference in groups 2 (trainee and mentor assistant) and 3 (trainee alone) (p = 0.26). There was a difference in operative time in groups 1 and 3 (p = 0.04). Mean estimated blood loss was comparable in groups 1 to 3 and not statistically different (150, 250 and 250 cc, respectively, p = 0.15). Mean organ weight was also comparable (64, 59 and 55 gm., respectively). Hospital stay was 3 days in all groups. Catheter time decreased as confidence was gained with the procedure (range 6 to 33 days). Final pathological stage was compared among the 3 groups. There was an overall increase in positive margins in groups 1 to 3 (16%, 22% and 30%, respectively, p not significant). However, the positive margin rate for stage pT2 disease was similar at 15.5% for groups 1 and 2, and 14% for group 3. CONCLUSIONS: Laparoscopic radical prostatectomy is a technically challenging operation that is in the early stages of evolution and evaluation. We present an intensive, mentor initiated approach to decrease the learning curve and maintain outcomes.     

Transplantation of liver grafts from older donors: impact on recipients with hepatitis C virus infection

INTRODUCTION: Older donor allografts are being accepted for liver transplantation (LTx) due to shortage of organs. Hepatitis C virus (HCV) infection-related disease is presently the most common indication of LT in the United States. We studied the impact of donor age on patient and graft survivals in patients with HCV infection. PATIENTS AND METHODS: One hundred fifty four consecutive HCV(+) LTx recipients (117 men, 37 women) were studied. The mean follow-up period was 41.0 +/- 30.2 months. The population was divided into four groups according to donor age: group I (< or =20 years); group II (21 to 40 years); group III (41 to 60 years); group IV (>60 years). RESULTS: Thirty-two (20.8%) patients died during follow-up and 16 patients (10.4%) required retransplantation. The actuarial 7-year patient survivals for groups I, II, III, and IV were 87.1%, 73.7%, 69.3%, and 68.5%, respectively (P = .4). Patient survivals for donor age groups III + IV (n = 95) and groups I + II (n = 59) were 68.9% and 77.2%, respectively (P = .19). The 7-year graft survivals for groups I, II, III, and IV were 82.7%, 71.8%, 65.8%, and 62.5%, respectively (P = .17). Graft survivals for groups III + IV and groups I + II were 58.4% and 76.2%, respectively (P = .03). CONCLUSION: Patient and graft survivals for HCV-positive liver transplant recipients in this study decreased progressively as the donor age increased. Patient and graft survivals were best for group I recipients. There were significant differences in graft survivals when recipients were grouped with a cutoff donor age of 40 years.     

Effect of intraurethral captopril gel on the recurrence of urethral stricture after direct vision internal urethrotomy: Phase II clinical trial

OBJECTIVE: The purpose of this study is to evaluate the effect of intraurethral captopril gel as an antifibrotic agent on patients with urethral stricture. MATERIALS AND METHODS: In the first phase of clinical trial, 13 rabbits were included and local side-effects of captopril gel were evaluated. In the second phase, 56 patients were enrolled from April 2004 to January 2006. After internal urethrotomy the patients were classified into three patient groups: (i) received placebo gel (group I); (ii) received 0.1% captopril gel (group II); and (iii) instilled 0.5% captopril gel intraurethrally (group III). RESULTS: In phase I, no significant local side-effects were seen in the urethra of rabbits. In phase II, the mean age of the patients was 39.5 and the mean follow-up duration was 16 months. The most common etiology of the urethral stricture in the patients was iatrogenic (35.7%), most of their strictures had a depth of 0.5 cm or less (67.8%), and the length of most strictures was between 1 and 2 cm (41.1%). The patients' maximum urine flow increased more in groups II and III, than in group I (P < 0.04, P < 0.05, respectively). The recurrence rate was less in groups II and III than in group I (P < 0.05). In terms of the maximal urine flow and recurrence rate, no significant difference was seen between group II and group III (P = 0.13, P = 0.21, respectively). CONCLUSION: Captopril gel is a safe, effective and non-toxic agent for decreasing the recurrence rate of the urethral stricture after internal urethrotomy. However, more studies, including more cases and a longer follow up, are needed to prove the effect of captopril gel on patients' urethra.     

Histopathological outcome in 167 patients operated on with radical retropubic prostatectomy

OBJECTIVE: To evaluate the histopathological outcome in patients with prostate cancer operated on with radical retropubic prostatectomy. MATERIAL AND METHODS: A total of 167 patients with clinically organ-localized prostate cancer treated with open radical retropubic prostatectomy between 1996 and 2001 were divided into three equally sized consecutive cohorts (cohorts I-III). The prostatectomy specimens were re-examined by two pathologists with respect to pathological tumour stage, tumour grade and surgical tumour margins. RESULTS: The mean preoperative prostate-specific antigen (PSA) value was statistically significantly higher in cohort I compared to cohorts II and III: 13.2, 9.0 and 8.5 ng/ml, respectively (p<0.05). The incidence of locally advanced (pT3a-3b) tumours was 44% in cohort I and 20% in both cohorts II and III (p<0.05). The incidence of positive tumour margins was 58% in cohort I, compared to 30% in cohort II and 13% in cohort III (p<0.05). The incidence of positive intracapsular tumour margins was 55% in cohort I, compared to 25% in cohort II and 8.9% in cohort III (p<0.05). The incidence of positive tumour margins in the pT2 tumours in cohorts I-III was 57%, 26% and 8.9%, respectively (p<0.05). Cohort III had significantly more low-grade tumours (Gleason score 4-6; 58.9%) compared to cohorts I (31.5%) and II (34%). There was a higher incidence of Gleason score >or=7 in the pT3 tumours compared to the pT2 tumours (80% vs 46%) and in margin-positive compared to -negative tumours (69.6% vs 48.6%) (p<0.05). CONCLUSIONS: The decline in pT3 tumours and positive tumour margins between cohorts I-III is probably due to a gradually more strict selection of patients for radical retropubic prostatectomy. The successive reduction in positive intracapsular tumour margins is most likely due to an improved surgical technique.     

Two-dose daclizumab regimen in simultaneous kidney-pancreas transplant recipients: primary endpoint analysis of a multicenter,randomized study

BACKGROUND: Controversy exists about the optimal immunosuppressive regimen in simultaneous kidney-pancreas transplant (SKPT) recipients. This study determined the safety and efficacy of two dosing regimens of daclizumab compared with no antibody induction in SKPT recipients receiving tacrolimus, mycophenolate mofetil, and steroids. METHODS: A total of 297 SKPT patients were enrolled in this prospective, multicenter, randomized, open-label study. The patients were randomized into three groups: daclizumab 1 mg/kg per dose every 14 days for five doses (group I, n=107), daclizumab 2 mg/kg per dose every 14 days for two doses (group II, n=112), and no antibody induction (group III, n=78). All patients received tacrolimus, mycophenolate mofetil, and steroids as maintenance immunosuppression. RESULTS: Demographic and transplant characteristics were similar among the groups. At 6 months, there were no differences in patient, kidney, and pancreas graft survival rates among the three groups. The probability of either kidney or pancreas allograft rejection at 6 months was 21%, 17%, and 32% in groups I, II, and III, respectively (P=0.042). The median time to first acute rejection of either the kidney or pancreas was 23 days in group I, 44 days in group II, and 20 days in group III (group I vs. II, P=0.078; group II vs. III, P=0.016). At 6 months, the actuarial event-free survival (no acute rejection, allograft loss, or death) rates were 66%, 77%, and 56% in groups I, II, and III, respectively (group I vs. III, P=0.119; group II vs. III, P=0.002). There were no differences in the incidence of serious adverse events including infectious complications among the groups. All three groups demonstrate excellent kidney and pancreas function at 6 months. CONCLUSIONS: Daclizumab is safe and effective in reducing the incidence of acute rejection in SKPT recipients compared with no antibody induction. Moreover, the two-dose regimen of daclizumab (2 mg/kg on days 0 and 14) compares favorably with the standard five-dose regimen.     

Serum albumin and survival in CAPD patients: the implications of concentration trends over time

HYPOTHESIS: Trends in serum albumin concentration over time provide a better prediction of clinical outcome in CAPD patients than a single mean value. METHODS: This was a retrospective review of outcome at 36 months in 225 adult CAPD patients. Mean serum albumin was determined for the first (SA1) and second (SA2) 6 months of treatment and patients grouped according to SA1 (group I, > 37; group II, 34-37; group III, < 34 g/l) and according to the change in serum albumin (delta SA) between the first and second 6 months (increased/static or decreased). Patient (PS) and technique (TS) survival were determined by Kaplan-Meier survival analysis. The effect of SA1 and delta SA on survival were determined in a multivariate Cox regression analysis model that included age and presence or absence of a systemic disease. RESULTS: By SA1 group, PS and TS survival at 36 months were 94 and 76% (group I), 64 and 53% (group II) and 70 and 52% (group III). If delta SA increased/remained static, then SA1 did not predict PS (group I, 100%; group II, 96%; group III, 74%; P = n.s.) or TS (group I, 72%; group II, 63%; group III, 65%; P = n.s.). If delta SA decreased, PS was worse in groups II and III, both as compared to group I (PS group I, 88%; group II, 52%; group III, 34%; P = 0.02) and as compared to the groups II and III when delta SA increased (PS group II, 74 vs 52%, P = 0.05; group III, 82 vs 34%, P = 0.005) The same trend was seen for TS. In the multivariate Cox regression model, age, direction of change in serum albumin, and presence of a multisystem disease were significant predictors of survival, whereas SA1 was not. CONCLUSION: Early hypoalbuminaemia in CAPD only predicts a worse patient and technique survival if mean serum albumin decreases further from the first to second 6 months of dialysis therapy. Change in serum albumin between the first and second 6 months of CAPD and the mean serum albumin over the first 6 months together offer better discrimination of outcome than either alone.      

Prevalence and prediction of renal artery stenosis in patients with coronary and supraaortic artery atherosclerotic disease.

BACKGROUND: Renal atherosclerosis is associated with increased cardiovascular mortality. This study aimed to determine the prevalence and predictors of renal artery stenosis (RAS) in patients with coronary artery disease (CAD) and supraaortic arteries (SA) stenosis. METHODS: Renal angiography was performed in 1193 (807 men) consecutive patients referred for coronary or SA angiography. Group I included 296 (136 men, 60.1 +/- 9.5 years) patients with no significant (< 50%) lesion in coronary arteries or SA; group II included 706 (526 men, 62.2 +/- 9.7 years) patients with stenosis > or = 50% within single arterial territory (coronary arteries or SA) and group III included 191 (145 men, 64.9 +/- 8.5 years) patients with stenosis > or = 50% in both territories. RESULTS: Some RAS was found in 55 (18.6%) patients in group I, 250 (35.4%) patients in group II and 115 (60.2%) patients in group III (P < 0.001). The proportion of patients with RAS > or = 50% in groups I, II and III was 3.3, 6.2 and 18.3%, respectively (P < 0.001). RAS prevalence increased with the number of stenosed coronary arteries (38.4% in 1-vessel, 42.1% in 2-vessel, 48.5% in 3-vessel CAD, P < 0.001). Independent predictors of RAS > or = 50% identified by logistic regression analysis were SA stenosis [relative risk (RR) = 3.28, P < 0.001], 2-3-vessel-CAD (RR = 2.04, P = 0.002), creatinine level > or = 1.07 mg/dl (RR = 2.95, P < 0.001), hypertension (RR = 2.97, P = 0.012) and body mass index < 25 kg/m(2) (RR = 1.42, P = 0.169). A calculated score for RAS > or = 50% prediction (based on the regression model) was reliable (coefficient of determination, R = 0.978) and showed a sensitivity of 77.5% and a specificity of 63.9%. CONCLUSIONS: RAS prevalence and severity increases with the number of arterial territories involved and CAD severity. The following independent predictors of RAS > or = 50% were identified: SA involvement, 2-3-vessel-CAD, serum creatinine level and hypertension.     

Use of different immunosuppressive strategies in recipients of kidneys from nonheart-beating donors

In nonheart-beating donor (NHBD) kidney transplants, immunosuppressive management is difficult mainly because of the high incidence of acute tubular necrosis. This has meant that since the start of our NHBD transplant program, several immunosuppression regimes have been used. The aim of this retrospective study was to evaluate the results obtained over 7 years using different treatment protocols. A total of 172 consecutive NHBD transplants performed between April 1996 and December 2002 were treated as follows: G-I (n = 21), cyclosporine (8 mg/kg/day) plus azathioprine plus steroids; G-II (n = 65), low-dose cyclosporine (5 mg/kg/day) plus mycophenolate plus steroids; G-III (n =17), low-dose tacrolimus (0.1 mg/kg/day) plus mycophenolate plus steroids; and G-IV (n = 69), daclizumab plus low-dose tacrolimus plus mycophenolate plus steroids. Delayed graft function rates were 76.2%, 72.3%, 76.5%, and 42%, respectively, for the four groups (P = 0.000). Rejection-free patient rates were 76.2%, 46.2%, 35.3%, and 71% (P < 0.001). Vascular rejection rates were 19%, 30.8%, 52.9%, and 18.8%, (P = 0.025). Two-year graft survival was 71.4% in group I, 95.4% in group II, 94.1 in group III, and 93.8% in group IV (P =0.004). Patient survival was worse in group I (75.2% in group I, 100% in group II, 100% in group III, and 96.7% in group IV at 2 years; P < 0.001). The use of daclizumab and low-dose tacrolimus could be effective at lowering the incidence of delayed graft function in NHBDT, with no negative repercussions on acute rejection.     

Thirty years of cardiac transplantation at Stanford university

BACKGROUND: The experience with 30 years of cardiac transplantation at Stanford University Medical Center was reviewed. A total of 954 transplants were performed in 885 patients. Patients were divided into 3 groups based on immunosuppression received: group I, no cyclosporine (INN: ciclosporin) (n = 201) (January 1968-November 1980); group II, cyclosporine (n = 248) (December 1980-June 1987); and group III, cyclosporine + OKT3 (n = 436) (July 1987-March 1998). RESULTS:The 1-, 5-, and 10-year actuarial survivals were 68%, 41%, and 24% (group I); 80%, 57%, and 37% (group II); and 85%, 68%, and 46% (group III) (I vs II, P <.01; I vs III, P <.005; and II vs III, P <.005). The 1-, 5-, and 10-year actuarial death rates from rejection were 8%, 12%, and 14% (group I); 5%, 7%, and 7% (group II); and 2%, 5%, and 5% (group III) (I vs II, P = not significant; I vs III, P <.005; and II vs III, P <.005). The 1-, 5-, and 10-year actuarial death rates from infection were 25%, 43%, and 50% (group I); 8%, 17%, and 29% (group II); and 6%, 11%, and 16% (group III) (I vs II, P <.005; I vs III, P <.005; and II vs III, P <.05). The 1-, 5-, and 10-year actuarial death rates from graft coronary artery disease were 0%, 5%, and 13% (group I); 0%, 12%, and 19% (group II); and 1%, 6%, and 9% (group III) (I vs II, P <.01; I vs III, P <.005; and II vs III, P = not significant). There have been 69 retransplants in 67 patients with 1-, 5-, and 10-year actuarial survivals of 49%, 27%, and 15%, respectively. CONCLUSIONS: The evolution of 3 decades of experience with cardiac transplantation has resulted in improved overall survival. The incidence of rejection and of death from infection and graft coronary artery disease have decreased over time, primarily as a result of improvements in immunosuppression and in the prevention and treatment of infection. Continued advances in perioperative management and the development of more specific, less toxic immunosuppressive agents could further refine this initial experience and improve the survival and quality of life of patients after cardiac transplantation.     

Impact of an ultrasound-guided radiofrequency ablation training program on the outcomes in patients with hepatocellular carcinoma

PurposeThe aim of this study was to retrospectively evaluate the impact of a training program on the safety and efficacy of percutaneous ultrasound-guided radiofrequency ablation (RFA) for the treatment of hepatocellular carcinoma (HCC).Materials and methodsA total of 227 patients with 296 HCC nodules who underwent percutaneous RFA with or without transcatheter arterial chemoembolization at our institution were included. There were 163 men and 64 women with a mean age of 74.2 ± 8.3 (SD) years (range: 41–89 years). Percutaneous ultrasound-guided RFA was performed by three trainees (205 HCC nodules in 157 patients) or a mentor (91 HCC nodules in 70 patients) after preprocedural preparation including planning ultrasonography. We compared background-related, tumor-related, and treatment-related factors, and local recurrence and complication rates between the trainee group and the mentor group. Similarly, we compared these variables among the years 2015, 2016, and 2017 for trainee group.ResultsThe proportion of easy-to-treat tumors in the trainee group (109/205; 53.2%) was greater than that in the mentor group (33/91; 36.3%) (P = 0.020). No significant differences were observed in procedure difficulty among the years 2015, 2016, and 2017 for trainee group (easy-to-treat HCC nodules: 25/47; 53.2% vs. 39/79; 49.4% vs. 45/79; 57.0%. P = 0.775). The local recurrence rate in the trainee group was 8.8% (18/205 HCC nodules) which was equivalent to 7.7% in the mentor group (7/91 HCC nodules). No significant differences were observed in local recurrence rate (8.8% vs. 7.7%, respectively; P = 0.621) and major complication rate (1.3% vs. 1.4%, respectively; P = 0.999) between the trainee group and the mentor group. No significant differences were observed in local recurrence rates ([5/47; 10.6%] vs. [11/79; 13.9%] vs. [2/79; 2.5%]) (P = 0.109) and major complication rates ([1/36; 2.8%] vs. [1/62; 1.6%] vs. [0/59; 0%]) (P = 0.701) between the years 2015, 2016, and 2017 for trainee group.ConclusionA well supervised training program that includes planning ultrasonography fosters the efficacy and treatment quality of RFA for HCC.     

Randomized clinical trial comparing level II and level III axillary node dissection in addition to mastectomy for breast cancer

BACKGROUND: In addition to mastectomy, level II and level III axillary node dissection procedures are performed widely in Japan. A randomized clinical trial was performed to determine which procedure was more effective. METHODS: One group of women had resection of the pectoralis minor muscle and dissection of level I, II and III axillary lymph nodes (level III dissection). In a second group, the pectoralis minor muscle was left intact and level III axillary lymph node dissection was not performed (level II dissection). A total of 1209 women with stage II breast cancer were enrolled in the study and randomly assigned to one of the two groups. RESULTS: The 10-year cumulative survival rate was 86.6 per cent after level II and 85.7 per cent after level III axillary dissection (hazard ratio (HR) 1.02; P = 0.931, log rank test). The 10-year disease-free survival rate was 73.3 and 77.8 per cent respectively (HR 0.94, P = 0.666). Overall survival and disease-free survival rates in the two groups were similar after both procedures. The duration of surgery was significantly shorter (P < 0.001) and blood loss was significantly less (P = 0.001) after level II dissection. In a survey of patients' symptoms on follow-up, no significant differences were found between the two procedures. CONCLUSION: The addition of pectoralis minor muscle resection and level III axillary lymph node dissection to mastectomy for stage II breast cancer did not improve overall or disease-free survival rates.     

Exit block in pediatric cardiac pacing. Comparison of the suture-type and fishhook epicardial electrodes

Ninety-seven consecutive permanent epicardial pacemaker implantations were performed with either suture-type (group I, n = 52) or fishhook electrodes (group II, n = 45). In addition to epicardial fixation of the electrodes at the collar area, the suture-type was further secured in place by tying the electrode's suture at its exit to another nonabsorbable pledget-supported suture. Acute thresholds and slew rates were not significantly different between the two groups. Although the R wave was lower in group I (8.4 +/- 3.5 mV) than in group II (11.8 +/- 6, p less than 0.01), no sensing problems occurred. The larger surface area of suture-type electrode led to lower resistance in group I (271 +/- 61 omega) compared with group II (356 +/- 72, p less than 0.001); however, the difference in pacemaker generator longevity did not appear significant (group I, n = 12, mean 4.7 +/- 1.6 years; group II, n = 4, mean 5 +/- 0.6 years). The incidence of exit block was significantly higher in group II (40%, 18/45) than in group I (8%, 4/52, p less than 0.01). The length of the stimulation tip and better fixation of the suture-type electrode probably accounted for the observed difference in the incidence of exit block between the two electrodes.     

One-year outcomes in simultaneous kidney-pancreas transplant recipients receiving an alternative dosing regimen of daclizumab

The purpose of this study was to compare the safety and efficacy of two dosing regimen of daclizumab with no-antibody induction in simultaneous kidney-pancreas transplant (SKPT) recipients receiving tacrolimus, mycophenolate mofetil, and steroids. METHODS: A total of 297 SKPT patients were enrolled into this prospective, multicenter, randomized, open-label study. The patients were randomized into three groups: daclizumab 1 mg/kg/dose every 14 days for five doses (group I, n = 107), daclizumab 2 mg/kg/dose every 14 days for two doses (group II, n = 112), and no-antibody induction (group III, n = 78). RESULTS: There were no differences in baseline characteristics among the three groups, except for a higher proportion of African-Americans in group II. The incidence of composite events (acute rejection, graft loss, or death) at 1 year was 36.4%, 32.7%, and 48.7% for groups I, II, and III, respectively (P <.05, group II vs group III). The incidence of acute rejection was highest in group III (34.6%) compared to groups I and II (22.4% and 22.1%, respectively, P <.05). The mean time to acute rejection was delayed in group II (96 days) compared to 23 days in group I and 20 days in group III (P <.05). The adverse-event profiles were comparable among the three groups, except for a higher incidence of infection and readmissions in group III. CONCLUSIONS: Daclizumab was safe and effective in reducing the incidence of acute rejection when compared to no induction. The alternative two-dose regimen of daclizumab was as effective as the conventional five-dose regimen and is logistically more desirable.     

Do the long-term results of carotid surgery influence the status of the contralateral carotid artery?]

AIM: The main cause of long-term death and disability of patients undergoing carotid artery surgery is coronary artery disease. To identify the prognostic value of the status of the contralateral artery, we studied the course of 224 patients operated consecutively on one or both carotid arteries in the same institution between 1985 and 1995. PATIENTS AND METHODS: The 224 patients were divided into three groups: group I (n = 56) having an occluded contralateral carotid artery; group II (n = 56) in which both carotids were operated on; and, group III (n = 112) having a normal contralateral carotid artery. The clinical status of all patients was ascertained by one of us for all patients except one. This study concerned also the course of 40 patients (group R) belonging to the three groups, who had during the follow-up period a coronary and/or a peripheral vascular intervention with a preoperative coronarography. RESULTS: The median follow-up was 62.8, 78 and 65 months for groups I, II and III, respectively. Actuarial survival rates were 67%, 73%, 72.5% at 5 years, and 39%, 51.5% and 42% at 10 years, for group I, II and III respectively. Actuarial stroke-free rates were 96%, 100%, 91% at 5 years, and 96%, 100% and 78.5% at 10 years for group I, II and III respectively. Actuarial cardiac death rates were 26%, 23%, 19% at 5 years, and 49%, 42% and 37% at 10 years for group I, II and III, respectively. None of the differences between the three groups regarding these three different end-points was significant. The group R fatal or non-fatal cardiac event-free rates at 5 and 10 years were 88% and 53% respectively. When compared with the rates of other patients (without revascularization): 68% and 25.5% at 5 and 10 years, the results were almost significant (P = 0.07). Average age for group R patients was significantly lower (65 vs. 69 years, P < 0.05). Using Cox's model, age alone emerged as a factor influencing survival (P = 0.07) but not revascularization (P = 0.13). CONCLUSION: The status of the contralateral artery does not influence the long-term prognosis of patients undergoing carotid artery surgery. A periodic cardiological and vascular follow-up of these patients tends to improve their survival.     

The effects of tramadol and fentanyl on gastrointestinal motility in septic rats

In this study, we investigated the effects of tramadol and fentanyl on gastrointestinal transit (GIT) during acute systemic inflammation in an experimental model of cecal ligation and perforation (CLP). One-hundred-twenty male Swiss-Albino rats were divided randomly into 6 groups: Group I = sham-operated + saline; Group II = sham-operated + fentanyl; Group III = sham-operated + tramadol; Group IV = CLP + saline; Group V = CLP + fentanyl; Group VI = CLP + tramadol. Suspension of charcoal was administered as an intragastric meal to measure the GIT. GIT% (mean +/- sd) were 46.1% +/- 9.8%, 43.2% +/- 9.8%, 45.9% +/- 10.2%, 33.2% +/- 9.2%, 24.9% +/- 4.1%, and 31.8% +/- 8.4% in Groups I, II, III, IV, V, and VI, respectively. GIT% was significantly less in Group V than in Groups I, II, III, and IV (P < 0.05). The Group VI mean value was significantly lower than those of Groups I, II, and III (P < 0.05) but not different from those of Groups IV and V (P > 0.05). The antitransit effect of fentanyl was shown to have increased in the experimental sepsis model, but no decrease in GIT was obtained with tramadol. This was thought to be the result of an associated endogenic opioid system activation and receptor upregulation in sepsis.     

Hepato-venous reconstruction in orthotopic liver transplantation with preservation of the recipients' inferior vena cava and veno-venous bypass

BACKGROUND AND AIMS: The potential advantages of vena cava-preserving recipient hepatectomy in orthotopic liver transplantation are reduced hemorrhage, improved cardiovascular stability and preserved renal perfusion without the requirement of veno-venous bypass as compared with recipient hepatectomy including the vena cava. No detailed information is available on the use of veno-venous bypass during complicated vena cava preserving recipient hepatectomy and liver transplantation. In the present study, the peri- and postoperative courses of adult liver transplant recipients in whom the hepatovenous reconstruction was performed according to three different techniques with and without the use of veno-venous bypass were investigated. PATIENTS/METHODS: During primary orthotopic liver transplantation, an end-to-end (ETE) cavo-caval interposition of the donor vena cava to the recipient's vena cava was performed in 75 patients (group I). In 15 patients, a termino-terminal piggyback (PB) anastomosis was constructed to the remnant of the recipient's hepatic vein (group II), and in 72 transplantations a latero-lateral cavo-cavostomy (LLC) of donor-to-recipient's vena cava (group III) was performed. The use of bypass, operative time and cold ischemia time, perioperative blood product requirements, incidence of relaparotomy, the evolution of postoperative renal function, technical complications and the survival were analyzed and compared using multivariate statistics and actuarial techniques for statistical evaluation. RESULTS: No differences could be found in preoperative patient conditions, donor conditions, operating time, anastomosing time or cold ischemia time. In groups I-III, the veno-venous bypass was used in 50 (67%), 8 (53%) and 6 (8%) cases respectively (P=0.02 for group III). The mean preoperative packed cells requirements were 20.4 vs 29.6 vs 10.8 units (P=0.01 for group III), while postoperative blood product requirements (first 24 h) were 2.6 vs 5.0 vs 0.20 units of packed cells (P=0.02 for group III). Relaparotomy for diffuse retroperitoneal hemorrhage was performed 14 times (19%) in group I, 3 times (20%) in group II and 7 times (8.3%) in group III (P=0.002). The incidence of posteropative early renal dysfunction (increase of > or =1.3 mg% serum creatinine) in group I vs group II vs group III was 24% vs 60% vs 16.7% (P=0.001 for group II) for patients without the use of veno-venous bypass. No significant difference was observed concerning early renal dysfunction in patients where a veno-venous bypass was used. The survival at 12 months was 81% for group I, 86% for group II and 93.0% for group III. In group III there were four complications (P=0.03) at the hepatovenous anastomosis of which two were eventually fatal. CONCLUSION: Preservation of the recipient's vena cava and LLC can reduce, but not avoid, the requirement for veno-venous bypass. In orthotopic liver transplantation, postoperative hemorrhage, as measured by surgical revisions and requirement for blood products, is significantly reduced with LLC with and without bypass. Early renal dysfunction also occurs in the group of LLC as compared with the termino-terminal cavostomy independent of the bypass. A technical failure resulting in patient death can be associated with LLC.     

Intravenous magnesium sulphate decreases postoperative tramadol requirement after radical prostatectomy

BACKGROUND: The purpose of this study was to assess whether the addition of intravenous magnesium sulphate (Mg) at the induction of anaesthesia to a balanced anaesthetic protocol including wound infiltration, paracetamol and tramadol resulted in improved analgesic efficiency after radical prostatectomy. METHODS: We conducted a randomized, double-blind, controlled study. Thirty ASA I or II males scheduled to undergo radical retropubic prostatectomy with general anaesthesia were prospectively assigned to one of the two groups (n = 15 each). The Mg group (Gr Mg) received 50 mg kg-1 of MgSO4 in 100 mL of isotonic saline over 20 min immediately after induction of anaesthesia and before skin incision. The patients in the control group (Gr C) received the same volume of saline over the same period. At the time of abdominal closure, wound infiltration with 190 mg (40 mL) of ropivacaine was performed in both groups. Pain was assessed by a 10-point visual analogue scale in the recovery room starting from the time of tracheal extubation. Standardized postoperative analgesia included paracetamol and tramadol administered via a patient-controlled analgesia device. RESULTS: In the postoperative period, both groups experienced an identical pain course evolution. Cumulative mean tramadol dose after 24 h was 226 mg in the magnesium group and 446 mg in the control group (P < 0.001). Postoperative nausea occurred in two patients in each group. Two vs. eight patients required analgesic rescue in magnesium and control groups, respectively (P = 0.053). CONCLUSIONS: This study shows that intravenous magnesium sulphate reduces tramadol consumption when used as a postoperative analgesic protocol in radical prostatectomy.     

Aprotinin and recombinant human erythropoietin reduce the need for homologous blood transfusion in cardiac surgery

The effects of low dose aprotinin (Trasylol) and preoperative administration of recombinant human erythropoietin (EPO) were evaluated in 144 patients undergoing cardiopulmonary bypass divided into four groups. Group I (n=43) received a subcutaneous administration of EPO (18,000 U) one week before operation and intraoperative administration of low-dose aprotinin (mean; 1.38 ± 0.26 × 10⁶ kallikrein inactivator units; KIU) from extracorporeal circulation, group II (n=39) received only preoperative administration of EPO, group III (n=28) received only intraoperative administration of low-dose aprotinin (mean; 1.46 ± 0.25 X 10⁶ KIU), and group IV (n=34) were not administered either drug. Compared with group IV, the intraoperative blood loss was significantly lower in group I (p<0.01), and in group II or III (p<0.05). The postoperative drainage in 24 hours was significantly lower in groups I and III receiving aprotinin than in the other groups. The mean volume of total homologous blood transfusion and the percentage of cases not requiring a homologous blood transfusion in each group was, respectively, 74 ± 235 ml and 88.4% in group I, 282 ± 1289 ml and 87.2% in group II, 414 ± 584 ml and 60.7% in group III, and 976 ± 1931 ml and 44.1% in group IV. Significant differences were recognized between group I and group IV (p<0.05). These findings indicate that when used in combination, both drugs reduce blood loss and the need for a homologous blood transfusion more effectively than either drug alone.     

Hospital volume: operative morbidity, mortality and survival in thoracotomy for lung cancer. A Spanish multicenter study of 2994 cases.

INTRODUCTION: It has been hypothesized that medical procedures performed in high-volume units carry less risk and achieve a better outcome. OBJECTIVE: To determine the relationship between the number of interventions and the operative morbidity, mortality and long-term survival in the surgery of bronchogenic carcinoma (BC). PATIENTS AND METHOD: Prospective, multicenter Spanish study was conducted in 19 departments of thoracic surgery on 2994 patients operated on consecutively with the aim of curing BC. The thoracic surgery departments have been classified into three groups, according to the number of interventions performed per year: I (1-43 cases/year; centers=7; n=565; 18.9%), II (44-54 cases/year; centers=6; n=1044; 34.9%) and III (55 or more cases/year; centers=6; n=1385; 46.3%). RESULTS: When the three groups were compared, the frequency of complete surgery was found to be 84% for group I, 76% for group II and 83% for group III (p=0.001, for comparisons between groups I/II and II/III). The pathological stages were identical in the three groups. The overall morbidity and the mortality in all patients or above the age of 75 or in pneumonectomies were not different among the groups. When considering all the patients with prognostic information (n=2758), no differences were found regarding the 5-year survival among the groups. When only patients in postoperative stage I-II and complete resection were evaluated, excluding operative mortality (n=1128), 5-year survival was 0.58 for group I, 0.57 for group II and 0.50 for group III (p=0.06 between groups II and III; p=0.08 between groups I and III). CONCLUSIONS: No significant differences that do not favor the hypothesis that there is increased surgical risk and worse survival in centers having a lower volume were found in this Spanish multicenter study.     

Influence of pancreas and kidney transplant function on recipient survival

The aim of this study was to evaluate long-term survival after simultaneous pancreas and kidney (SPK) transplantation in relation to function of both grafts. Among 67 recipients who received SPK transplants between 1988 and 2004, 35 had follow-up longer than 18 months, and were divided into: group I (n = 20), recipients with good function of both grafts; group II (n = 7), patients who had lost transplanted pancreas but had still good kidney graft function; group III (n = 8), patients who had lost both grafts. Comparison of survival rates and analysis of the reason of mortality among groups was performed. The cumulative survival rate was significantly higher in group I than in group III (after 3, 5, 10 years: 100%, 100%, 80% vs 75%, 50%, 37%, respectively). Cumulative survival rate for group II after 3, 5, 10 years was 100%, 100%, 33%, respectively. There were no significant differences in survival rates between groups I and II and between groups II and III. In group I deaths for cardiovascular event and for leukemia were noted. In group II deaths due to cardiovascular event and sepsis were observed. In group III all patients died due to cardiovascular events and the mean time from loss of pancreas and kidney graft function to death was: 75 +/- 51 months (range from 19 to 142), and 49 +/- 26 months (range 19 to 99), respectively. Good pancreas and kidney graft functions prevent death due to cardiovascular event.