A third renal transplantation: is it relevant and is it worth it?

INTRODUCTION: The aim of this retrospective study was to determine the outcome of third cadaveric renal transplantations performed between 1989 and 2004 among a cohort of 35 patients whose immunosuppression included induction therapy and calcineurin inhibitors. Most patients were highly sensitized with 1 (0-4) HLA (classes I + II) incompatibility between donor and recipient. RESULTS: The median follow-up time was 57 months (range, 1-190). Fourteen patients experienced delayed graft function that required posttransplantation hemodialysis. The current patient and graft survival rates were 91.4% and 82.8%, respectively. At last follow-up, 6 grafts had been lost: 1 due to primary nonfunction; 1 due to an urinary leak (day 45); 2 deaths with functioning grafts; and 2 chronic allograft nephropathies (CAN) at 85 and 60 months posttransplantation, respectively. Among the 10 patients who experienced acute rejection episodes, half were steroid-sensitive, whereas the others required OKT3 therapy. Overall, when excluding the 2 patients who presented with early loss of their grafts, 13 of 33 patients (39.4%) developed CAN, which led to the graft loss in only 2 cases. The mean creatinine clearance was 57 +/- 23 mL/min at year 5. Of the 35 recipients, 12 (34.3%) developed graft/perigraft complications, among whom 10 (83.3%) required treatment. The most frequent complication was lymphocele (M = 4; 11.4%) or infections that led to rehospitalization (n = 17). CONCLUSION: Results from third transplantations were encouraging. Thus, despite the organ shortage, a third graft was worth it!     

Minimal access aortic valve replacement: is it worth it?

Controversy surrounds the use of minimal access aortic valve replacement (AVR). This meta-analytical study quantified the effects of minimal access AVR on morbidity and mortality compared with conventional AVR and evaluated study heterogeneity and robustness of the findings using sensitivity analysis. Overall, meta-analysis suggested marginal benefits in perioperative mortality (4,667 patients; odds ratio, 0.72; 95% confidence interval, 0.51-1.00; p = 0.05), intensive care unit stay, total hospital stay, and ventilation time in the minimal access AVR group, although cross-clamp, cardiopulmonary bypass, and total operation times were longer. Study heterogeneity and apparent benefits in perioperative mortality were related to study quality, although results for intensive care unit and hospital stay were maintained according to the sensitivity analysis. This suggests that minimal access AVR can be offered on the basis of patient choice and cosmesis rather than evident clinical benefit.     

Hyperhidrosis: What is it and Why Does it Occur?

Hyperhidrosis is excessive sweating in response to heat or emotional stimuli beyond physiologic need. The ailment is not new and has been described in the literature dating back several centuries. It can be classified as either primary or secondary based on its etiology. Mechanisms that cause excessive sweating can be traced to the sympathetic nervous system, part of the autonomic nervous system. It has been speculated that the primary abnormality is central, and that the hypothalamic sweat center that controls the palms, axillae, and soles is distinct in hyperhidrosis individuals.     

Retroperitoneal approach for aortic surgery: is it worth it?

BACKGROUND: Previous reports suggest that earlier hospital discharges and reduced postoperative complications occur when a retroperitoneal approach is used for aortic surgery. Other publications refute this concept. In an effort to determine the most cost efficient method for aortic surgery in our institution, while maintaining high standards of care and outcome, we compared the retroperitoneal approach to the conventional transperitoneal aortic operation. PATIENTS AND METHODS: Between December 1995 and April 1998, 120 patients underwent aortic surgery by either the transperitoneal (n=60) or retroperitoneal approach (n=60). All patients were enrolled prospectively in a vascular registry and retrospectively reviewed. Patients were randomly assigned to one of three vascular surgeons. A clinical pathway for elective aortic surgery was developed and applied to both groups. Patients were evaluated with respect to demographics, comorbidities, preoperative risk stratification, conduct of the operative procedure, length of stay, complications, cost, clinical outcomes and patient satisfaction. The indications for aortic surgery were similar in both groups - 64% for aneurysm disease and 36% for occlusive disease. Both symptomatic and asymptomatic aneurysms were included and size ranged from 4.4 to 14cm. All aortic reconstructions were done in the standard manner using knitted Dacron velour prostheses in either the aortic tube, bi-iliac or bi-femoral configuration. Statistical analysis of means and medians was accomplished using the Wilcoxin Rank-sum test and percentages were compared using Fisher's Exact test. P values less than 0.05 indicate statistical significance. RESULTS: There were no statistically significant differences in patient demographics. The incidence of atherosclerotic coronary artery disease, obstructive pulmonary disease, diabetes, hyperlipidemia, tobacco abuse, distal lower extremity occlusive disease and the results of chemical myocardial stress evaluations were similar in both groups. Comorbidities of pre-existing renal insufficiency/failure and morbid obesity were increased in the retroperitoneal group. Five patients in the retroperitoneal group represented redo aortic surgery and there were no redo procedures in the transperitoneal group. Length of operative procedures and blood replacement requirements for both groups were similar. The transperitoneal group required 2-3l more intraoperative intravenous (IV) crystalloid than the retroperitoneal group (P<0.0001). Statistically significant reductions in ICU days, postoperative ileus and total lengths of stay were observed in the retroperitoneal group (P<0.0001). This resulted in substantial reductions in hospital costs for the retroperitoneal group (P<0.01). Postoperative complications were similar for both groups except for statistically significant increases in pulmonary edema (P<0.01) and pneumonia (P<0.001) in the transperitoneal group. Cardiac arrhythmias, primarily atrial dysrhythmias, were more frequent in the transperitoneal group but this failed to reach statistical significance (P<0.16). Combined thirty day mortality was 0.9%. Time of recovery to full activity and patient satisfaction substantially favored the retroperitoneal group. CONCLUSION: Our clinical pathway and algorithm for aortic surgery was easily followed by those patients in the retroperitoneal approach group and resulted in decreases in ICU time, postoperative ileus, volume of intraoperative crystalloid and total length of stay. The patients in the transperitoneal group often failed to progress appropriately on the pathway. Reduced hospital costs associated with aortic surgery using the retroperitoneal approach has increased the profitability for this surgery in our institution by an average of $4000 per case and has increased the value (quality/cost) of this surgery to our patients and our institution.     

Reaming during anterograde femoral nailing: is it worth it?

A systematic review was performed to assess the relative merits of reamed and unreamed antegrade femoral nailing. To be included, a study had to be prospective, randomised or pseudorandomised, comparing reamed and unreamed antegrade femoral nailing in adults. Where more than one study from the same institution was available, only the study with longest follow-up was included. A literature search found 2044 possible articles. Of these, eight studies compared reamed and unreamed femoral nailing. The methodology of these articles was independently assessed by all the three authors. Five studies met the inclusion criteria. Each outcome measure tested was assessed for heterogeneity. If significant heterogeneity was present, the data were not combined. If there was no significant heterogeneity, a combined odds ratio or weighted mean difference was calculated using a fixed effects model, and a Z-test was performed to test the overall effect. Six hundred and forty-seven femoral fractures (315 reamed; 332 unreamed) were entered into the included studies. Unreamed nailing was quicker and associated with significantly less blood loss (P < 0.00001). Reaming significantly reduced the time to union (P = 0.00001), non-union (P = 0.002), delayed union (P = 0.005), technical problems (P = 0.01) and reoperation rate (P = 0.001). The use of reamed femoral nails gives significant advantages over unreamed femoral nails.     

The electronic environment: How has it,how will it,and how should it affect us?

Nevertheless, the future is bright and offers vastly improved communication, organization, speed of search, and efficiency enabled by the concept of digitized data entry and retrieval. The opportunities are virtually boundless and will change (and may even abolish) the paper world as we now know it. We must be prepared, keep an open mind, and constructively control the electronic environment to meet our needs—the computer should be our slave and not vice versa. As Peter Kilbridge, a pediatrician turned information technology consultant stated, ‘Physician’s main obstacle is time ... for any Internet application to catch on, it has to be easy to use and time efficient.‘³ Not all electronic applications or technologies save time, improve efficiency, or save money. The fact that it can be done electronically does not always mean that it should be done. The challenge will be to control its implementation in a rational, insightful way—for many of us, it will require thinking ‘outside the box.’ Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Ga., May 20–23, 2001.     

Percutaneous endoscopic transforaminal lumbar interbody fusion: is it worth it?

Purpose

Interbody spine fusion with cages was first described by Bagby and has been performed for a long time now in a variety of different conditions. We developed a percutaneous endoscopic lumbar fusion technique based on the principles of Kambin and an original titanium cage.

Materials and methods

From 2004 to 2010, 57 patients were operated on, 17 patients were male with a mean age of 50.29 years (range 34–71 years) and 40 were female with a mean age of 57.42 years (29–90 years). Nineteen patients had a previous operation. Patients were operated on under local anaesthesia in the prone position under image intensifier and a transforaminal percutaneous endoscopic approach.

Results

Fifty cases had a bilateral cage through a bilateral endoscopic approach, and seven cases had a unilateral endoscopic approach only; of those, three cases had only one cage. Eleven patients had a contemporary posterior plate fixation at the same time of the endoscopic cage fusion. Eight patients had a postoperative radicular pain with paresthesias. Asymptomatic migration of the cages occurred in two cases and symptomatic migration requiring a conventional secondary reoperation in 13 cases after a mean delay of eight months (range three to 36 months). The mean ODI after two years or more was 34.3 % (initial ODI 69.4 %).

Conclusions

The technique was introduced in our practice to take care of difficult or grave co-morbidity patients, and some patients had excellent lasting results following a very short procedure and hospital stay. However, given the 36 % complication rate in this series, we do not recommend it unless decisive technical improvements are made.     

Some people move it,move it… for pressure injury prevention

Objective: To describe differences in in-seat behavior observed between individuals with a spinal cord injury (SCI) with and without a history of recurrent pressure injuries.

Design: Cross-sectional cohort study.

Setting: General community.

Participants: Twenty-nine adults more than 2 years post SCI, who used a wheelchair as their primary mobility device and had the ability to independently perform weight shift maneuvers. Participants were grouped according to whether or not they had a history of recurrent pressure injuries (PrIs), with 12 subjects having had two or more pressure injuries in the pelvic area (PrI Group).

Interventions: Not applicable.

Main Outcome Measures: Daily time in wheelchair, number of transfers, and frequency of pressure reliefs (full unloading), weight shifts (30% load reduction), and in-seat movements (transient center of pressure movements or unloading).

Results: The median participant spent 10.3 hours in his wheelchair and performed 16 transfers to or from the wheelchair daily. Pressure reliefs were performed less than once every 3 hours in both groups. Weight shifts were performed significantly more often by the No PrI Group (median (interquartile range) 2.5 (1.0–3.6) per hour) than the PrI Group (1.0 (0.4–1.9), with P?=?0.037 and effect size r?=?0.39). In-seat movements were performed 46.5 (28.7–76.7) times per hour by the No PrI group and 39.6 (24.3–49.7) times per hour for the PrI group (P?=?0.352, effect size r?=?0.17).

Conclusion: Weight shifts that can be produced by functional activities and that partially unload the buttocks should be considered as an important addition to individuals’ PrI prevention regimen.     

Hemivertebrae resection for unbalanced multiple hemivertebrae: is it worth it?

Purpose

To assess the correction effect of hemivertebra resection for unbalanced multiple hemivertebrae by measuring corresponding parameters in both coronal and sagittal planes on series posteroanterior and lateral radiographs and report the related complications.

Methods

Twelve children with unbalanced multiple hemivertebrae were operated on by hemivertebra resection through a combined anterior and posterior approach or a posterior-only procedure. Mean age at time of surgery was 9.8 years (range 2–14 years). They were retrospectively studied with a mean follow-up of 48.7 months (range 30–60 months).

Results

The mean Cobb angle of the main curve was 65.3° (range 45°–92°) before surgery and 13.8° (range 4°–30°) at the last follow-up. The correction rate was 80.0 % (range 65.5–92.4 %). The compensatory cranial curve was corrected from 25.8° (range 5°–53°) to 11.7° (range 0°–34°) with a correction rate of 65.9 % (range 33.3–100 %), and the compensatory caudal curve was corrected from 32.4° (range 17°–57°) to 7.1° (range 0°–20°) with a correction rate of 81.4 % (range 53.1–100 %). The angle of segmental kyphosis was 41.3° (range 12°–76°) before surgery and 17.0° (range ?12° to 45°) at the final follow-up. The coronal imbalance was ?1.0 cm (range ?3.5 to 3 cm) before surgery and 0.0 cm (range ?1.0 to 1.5 cm) at the most recent follow-up. The sagittal imbalance was 0.9 cm (range ?3.2 to 3 cm) before surgery and 0.6 cm (range ?3.0 to 3.5 cm) at the most recent follow-up. Complications including pedicle fractures, and pseudarthrosis were found in two patients (20 %).

Conclusions

In the patients with unbalanced multiple hemivertebrae, hemivertebra resection allows for excellent correction in both the coronal and sagittal planes, and great care should be taken to reduce the rate of complications.