Renal transplantation in amyloidosis: effects of HLA matching and donor type on recurrence of primary disease

The aim of this study is to evaluate the effect of HLA-matching and donor type on recurrence of amyloidosis after renal transplantation. The study includes 30 patients with systemic amyloidosis who received kidney transplants between 1985 and 2001. Donor source and HLA tissue typing of the donor and recipient were evaluated in each case. Of the 30 patients, 20 developed a recurrence of amyloidosis in their allografts, as confirmed by biopsy. The time from transplantation to diagnosis of amyloidosis in the graft ranged from 18 months to 10 years. Of the 20 patients with recurrence, 18 had received their grafts from living related donors (LRDs), and 2 had received their grafts from cadaveric donors (P<0.01). There was a strong correlation between amyloidosis recurrence and degree of HLA-DR matching (P<0.05). Furthermore, in the recipients of LRD grafts, the risk of amyloidosis recurrence was much higher if the donor-recipient pair were HLA-identical than if they were not perfectly matched (P<0.01). The incidence of amyloidosis recurrence in our patients was significantly higher than the rates reported for other series. Most of the cases in previous reports involved cadaveric grafts. The higher rate of amyloidosis recurrence in our patients may be explained by the high proportion of LRD grafts and by genetic susceptibility.     

Optimal Timing for Surgery After Adriamycin Treatment in Rats

Purpose To determine the optimal timing of surgery after adriamycin treatment, we investigated the time-related effect of adriamycin on wound healing over a long period.Methods We divided 119 female Sprague-Dawley rats into seven treatment groups. Group 1 was subjected to laparatomy only. All the other groups were given 8mg/kg adriamycin intravenously followed by laparotomy on the same day (group 2), 7 days later (group 3), 14 days later (group 4), 21 days later (group 5), 28 days later (group 6), or 35 days later (group 7). On postoperative day 7, the sutures were removed, abdominal bursting pressure was measured, and tissue samples were taken for histopathological evaluation and analysis of hydro-xyproline content.Results Bursting pressures were significantly lower in groups 3, 4, 5, and 6 than in group 1. The hydroxyproline content and histopathological evaluation supported these findings.Conclusions Our results showed that the optimal timing for surgery after adriamycin treatment is before the 7th day or after the 35th day. If surgery is performed between these days, there is a high risk of impaired wound healing.A preliminary study on this subject was accepted as a poster presentation at the Congress of the European Surgical Society of Oncology (ESSO) in 2002     

Modified Limberg Transposition Flap for Sacrococcygeal Pilonidal Sinus

Purpose. To investigate the results of wide rhomboid excision with Limberg transposition flap reconstruction to treat pilonidal sinus.Methods. We analyzed the well-documented records of 238 patients with sacrococcygeal pilonidal sinus who underwent wide excision with a Limberg transposition flap and were followed up for longer than 1 year postoperatively. After the first 40 operations, we modified this flap reconstruction by tailoring the rhomboid excision asymmetrically to place the lower pole of the flap 1–2cm lateral to the midline. Wound infection rates, hospitalization, time required for free mobilization, and recurrence rates were recorded.Results. Postoperative infection developed in two patients (0.8%), which was easily managed by wound care, antibiotics, removal of skin staples, prolonged drainage, or a combination of these treatments. The mean hospitalization was 2.10 ± 0.20 days (range 1–3 days), and the mean time required for recovery and return to daily activities was 8.00 ± 2.50 days (range 4–17 days). There were only three recurrences (1.26%) after a mean follow-up of 29.20 ± 3.10 months (range 12–38 months). Since we started performing our modification of the technique by lateralization of the inferior apex, no further recurrences have been seen. The recurrence rate differed significantly between the classical Limberg flap group and the modified Limberg flap group (P = 0.004)Conclusion. These results provide further evidence that wide excision with a Limberg transposition flap reconstruction is an effective surgical method for primary or recurrent pilonidal sinus, associated with a low complication rate, short hospitalization and disability, and a low recurrence rate. A modification of the technique was devised to further enhance wound healing and reduce the risk of recurrence.     

Unexpected gallbladder cancer during laparoscopic cholecystectomy

Background/Purpose In the present study, we investigated the effectiveness of surgeons in determining incidental gallbladder pathologies at laparoscopic cholecystectomy (LC).Methods This study included 548 patients with gallstones who underwent LC between May 1, 2001 and October 15, 2003. The surgeon made an incision on the gallbladder wall for inspection, and palpated the mucosa after removing the gallbladder from the abdominal cavity to look for unsuspected pathologies. If an abnormal mucosa was observed or palpated, it was marked with a silk suture and then histopathologic examination was performed.Results Fifty of 548 LC specimens were found to be suspi-cious by the surgeon. Histopathological examination of frozen sections revealed incidental pathologies in 15 of these specimens. Strikingly, 5 of these specimens were considered to have gallbladder cancer (GBC). The other incidental pathologies were consistent with adenomyomatosis, xanthogranulomatous cholecystitis, and fibroepithelial and hyperplastic polyps. Four of the other 498 specimens revealed incidental pathologies at definitive histopathological examination, and all of them were consistent with gastric metaplasia. The sensitivity and specificity of the procedure was 78.9% and 93%, respectively.Conclusions A simple prosedure; that is, incision and inspection, and palpation of the gallbladder, seems to be useful for the diagnosis of incidental gallbladder pathologies.     

Plasma D-lactic acid level: a useful marker to distinguish perforated from acute simple appendicitis

Early diagnosis of perforated appendicitis is important for reducing morbidity rates. The aim of this study was to determine the value and utility of plasma D-lactic acid levels in identifying the type of appendicitis. In this clinical study, plasma D-lactic acid levels were assessed in 44 consecutive paediatric patients (23 with acute appendicitis, 21 with perforated appendicitis) before laparotomy. D-lactic acid levels were determined by an enzymatic spectrophotometric technique using a D-lactic acid dehydrogenase kit. Patients with perforated appendicitis had higher D-lactic acid levels (3.970 +/- 0.687 mg/dL) than patients in the control group (0.478 +/- 0.149 mg/dL) and patients with acute appendicitis (1.409 +/- 0.324 mg/dL; p < 0.05). For a plasma D-lactic acid level greater than 2.5 mg/dL, the sensitivity and specificity of the D-lactic acid assay were 96% and 87%, respectively. The positive predictive value was 87%, the negative predictive value was 96%, and the diagnostic value was 91%. These results suggest that the measurement of plasma D-lactic acid levels may be a useful adjunct to clinical and radiological findings in distinguishing perforated from acute non-perforated appendicitis in children.