Posttransplant lymphoproliferative disorder among renal transplant patients in relation to the use of mycophenolate mofetil

BACKGROUND: The introduction of increasingly effective immunosuppressants has raised the question of whether posttransplant lymphoproliferative disorder (PTLD), a complication of immunosuppression, would become more frequent. This study assessed the risk of PTLD in relation to immunosuppression during a period that saw the introduction and eventual market dominance of mycophenolate mofetil (MMF). METHODS: A case-control study was conducted at 23 U.S. transplant centers. All participants received a renal-only transplant on or after July 1, 1995. PTLD cases were reported by centers and confirmed by central review. The United Network for Organ Sharing (UNOS) supplemented case ascertainment and identified controls matched on center, transplant date, and age. Center personnel abstracted risk factor and therapy data for cases and up to four controls per case. Cases and controls were compared, using a matched multivariate analysis, to assess the impact of MMF as one component of triple-therapy adjusted for other drug therapies and known risk factors. RESULTS: Data were collected for 108 PTLD cases and 404 controls. PTLD risk for individuals on triple therapy with MMF was similar to the risk experienced by individuals on triple therapy with no MMF (adjusted odds ratio=1.19; 95% CI 0.55-2.55). There was no dose response relationship between MMF and PTLD risk. CONCLUSIONS: Use of MMF was not associated with an increase in PTLD among patients who received triple immunosuppressive therapy, but an excess in risk as large as 155% or a reduction in risk by as much as 45% cannot be ruled out.     

Benign duodenal strictures: treatment by means of fluoroscopically guided balloon dilation

Fluoroscopically guided balloon (15 or 20 mm in diameter) dilation was performed on eight patients with benign duodenal strictures caused by peptic ulcers (n = 6), Crohn's disease (n = 1), and postoperative adhesion (n = 1). The procedure was technically and clinically successful without complications in seven of the eight patients (88%). Duodenal perforation occurred immediately after 20-mm-diameter balloon dilation in one patient who underwent emergency surgery. During the mean follow-up of 30 months (range, 2-103 months), there was recurrence in two of the seven patients (29%) who then underwent surgery. The other five patients (71%) showed good results with no recurrence.     

Achilles tendon lengthening by triple hemisection in adult

BACKGROUND: The purpose of this study was to investigate the adequate distance between hemisections to prevent complete rupture in a triple hemisection Achilles tendon lengthening. METHODS: Achilles tendon lengthenings by open triple hemisection were done in 18 patients (25 ankles) with spastic paralysis and were followed for more than 1 year. RESULTS: There was a significant correlation between the sum of the gaps (partial thickness defects) after sliding and the amount of corrected angles. When the distal gap was regarded as 1, the ratio of the distal gap to the middle gap to the proximal gap was 1:1.3 (range 0.8 to 3.3):1.6 (range 0.8 to 4.0), and the ratio of the distal connecting portion to the proximal portion was 2.1 (range 0.3 to 8.8):1.9 (range 0 to 8.3). There were marked differences of this ratio in individual cases. There were no complete ruptures. There were two recurrences at the last followup. CONCLUSION: When the angle of correction is more than 30 degrees, there is a risk of complete rupture even though the distance between the hemisections are more than 4 cm.     

Mid-term results of open aortic valvotomy for infants with critical aortic stenosis: seven-year experience including delayed Ross strategy.

OBJECTIVES: The purpose of this study is to provide short- and mid-term results of open aortic valvotomy (OAV) for patients with critical aortic stenosis (AS). METHODS: Between December 1993 and June 1996, 6 patients with critical AS underwent an OAV in our unit. Their ages and body weights at operation ranged from 1 to 65 days (median age, 9 days) and from 2.4 to 5.7 kg (median weight, 3.3 kg), respectively. Peak pressure gradient and diameter of the aortic valve ranged from 25 to 111 mmHg (mean value, 79 mmHg) and from 4.6 to 7.5 mm (mean diameter, 6.1 mm), respectively. OAV comprised the valvular commissurotomy and excision of the myxomatous nodules with cardiopulmonary bypass. RESULTS: No early or late death occurred. Mean peak pressure gradient across the aortic valve was reduced to 33 mmHg (from 15 to 44 mmHg) with no aortic insufficiency in 2 patients and trivial insufficiency in 4. During the follow-up period of 6 to 9 years, 3 out of 6 patients required no reintervention. The other 3 patients required repeated valvotomy for recurrent stenosis within 0.2 to 1.3 years after the operation. Of these, 2 patients required the Ross procedure at 7 years of age or older, and another at 6 years of age awaits the Ross procedure. CONCLUSION: OAV for critical AS was effective without causing mortality or significant aortic insufficiency. Our current strategy comprising the initial OAV and "delayed Ross procedure" for recurrent stenosis with or without insufficiency is a promising therapeutic option for infants with critical AS.     

Management of Infected Grafts and Aneurysms of the Aorta

Seventeen patients treated for infected grafts (11/17) or aneurysms (6/17) of the aorta between 1998 and 2003 were reviewed to evaluate our experience with aortic infection. The causative organisms were identified in 12 patients (71%), with 5 (29%) having methicillin-resistant Staphylococcus aureus. A periaortic abscess occurred in eight patients, and all of them were associated with infected grafts. Surgical treatment included cryopreserved allograft replacement in eight patients, prosthetic graft replacement in four patients, and drainage with or without omental wrapping in five patients. One patient was still hospitalized at the end of the study period. Five patients with infected grafts died after the operation during the initial hospitalization. No early mortality occurred in the aneurysm group. The early mortality rate was 31% for all patients, 50% for the graft group, and 63% for patients with a periaortie abscess. Another patient with an infected aneurysm died of arrhythmia after discharge from the initial hospitalization, Ten patients are still alive without evidence of reinfection. The early mortality rate for patients with infected aortic grafts is higher than that for those with infected aneurysms, especially when a periaortic abscess accompanies them. However, the late outcome is favorable, with no reinfection or late treatment-related deaths.     

The actual incidence of bladder perforation following transurethral bladder surgery

PURPOSE: In this prospective study we evaluated the incidence of bladder perforation after transurethral bladder tumor resection. MATERIALS AND METHODS: A total of 36 patients (33 male, 3 female, mean age +/- SD 65.6 +/- 11.43 [range 26 to 81]) with a solid mass in the bladder (mean 20.3 +/- 8.7 mm, range 5 to 40) were included in the study. Transurethral resections were performed with a 24Fr resectoscope. After the procedure an 18Fr Foley catheter was inserted into the bladder and 400 ml of 1/4 saline diluted contrast solution was instilled under gravity from 60 cm above the bladder. Complete filling and post-drainage radiographs were taken and examined for any evidence of extravasation. Regular evaluations with cystoscopy and ultrasound/computerized tomography were done to detect possible tumor recurrence and perivesical seeding. RESULTS: Histopathological examination of the tumors showed transitional cell carcinoma in 35 patients and chronic eosinophilic cystitis in 1. Review of the cystograms revealed various degrees of extraperitoneal contrast extravasation around the resected area in 21 patients (58.3%). The only statistically significant difference between patients with and without extravasation was in tumor size (logistic stepwise regression p = 0.030,) among factors tested including patient age and localization, number of foci, tumor grade and stage. No apparent clinical problems requiring medical or surgical intervention other than urethral catheterization developed and no evidence of extravesical tumor seeding as per ultrasound and/or computerized tomography was seen during a mean followup of 21.9 months (range 7 to 40). CONCLUSIONS: The extravasation of urine (asymptomatic perforation) after transurethral bladder tumor resection may occur much more frequently than believed or reported. It seems that this extravasation does not impose a significant risk of extravesical tumor seeding.     

Use of a refined operative strategy in combination with the multidisciplinary approach to manage blunt juxtahepatic venous injuries

BACKGROUND: Despite continuous advances in traumatology, juxtahepatic venous injuries are still the most difficult and deadly form of liver trauma. Most deaths result from exsanguination, and reported mortality ranges from 50% to 80%. This is an evaluation on our experience with the management of this high mortality injury following a refined operative strategy. METHODS: This is a retrospective study of consecutive patients sustaining blunt juxtahepatic venous injuries. The management for these patients was mainly a refined operative strategy combined with a multidisciplinary approach. Preoperative conditions and the patient demographics were gathered. In addition, the number and type of interventional procedures, overall complications, and operative procedures were collected and analyzed. RESULTS: From January, 1996 to March, 2004, 19 patients (M:F = 13:6) with juxtahepatic venous injuries were included and all were managed operatively. The operative procedures included hepatectomy by finger fracture technique for direct repair (8), perihepatic packing (1), packing and hepatic artery embolization (1), packing and hepatic artery ligation (1), hepatorrhaphy and packing (5), packing followed by hepatectomy (2) and atriocaval shunt for direct repair (1). The survival rate for the packing group was higher than that of the direct repair group (75% versus 45%), but was not statistically significant (p = 0.352). Injury to the retrohepatic vena cava influenced the patient's survival significantly (p = 0.041). The overall survival was 58% (11/19). CONCLUSION: A well-defined operative strategy helps surgeons deal with the problem of blunt juxtahepatic venous injury, and its combination with multidisciplinary management will improve patient outcomes.