Increasing the donor pool using en bloc pediatric kidneys for transplant

OBJECTIVES: En bloc pediatric kidney transplants (EBPKT) are still a subject of controversy. The aim of this study was to determine whether acceptable long-term graft survival and function can be achieved in EBPKT compared with the transplant of single, cadaveric, adult donor kidneys. METHODS: A retrospective review was conducted of 66 recipients of en bloc kidneys from cadaveric pediatric donors and 434 patients who underwent transplantation with a single kidney from an adult donor between January 1990 and May 2002 at the authors' hospital. The recipients were well-matched demographically. Both transplant groups were analyzed for short- and long-term performance in terms of transplant outcome and quality of graft function. RESULTS: Overall death-censored actuarial graft survival rates at 1 and 5 years were 89.2% and 84.6% in the adult kidney transplants (AKT) and 83.3% and 81.1% in EBPKT, respectively (P=0.56). In the EBPKT group, graft function was improved over that observed in AKT. Vascular thrombosis was the most common cause of graft loss in EBPKT. Acute rejection occurred more frequently in AKT and Cox's regression analysis indicated that undergoing an AKT was a predictive factor for acute vascular rejection (adjusted risk ratio, 3.8; 95% confidence interval, 1.4-10.2; P=0.001). CONCLUSIONS: Overall graft survival was similar in both groups, vascular complications were the main cause of graft loss in EBPKT, and the EBPKT showed excellent long-term graft function and a low incidence of acute rejection.     

Combined percutaneous and retrograde approach to staghorn calculi with application of the ureteral access sheath to facilitate percutaneous nephrolithotomy

PURPOSE: We describe our technique and clinical experience with application of the ureteral access sheath for single access ablation of staghorn and partial staghorn calculi. MATERIALS AND METHODS: We retrospectively reviewed our experience with 9 patients who underwent percutaneous nephrolithotomy for staghorn (6) or partial staghorn (3) renal calculi using a combined antegrade and retrograde approach. Patient data, operative parameters, efficacy of stone ablation and convalescence parameters were reviewed. RESULTS: Mean operative time for the primary procedure was 3.1 hours with a mean estimated blood loss of 290 ml. Postoperatively, the mean analgesic requirement was 33.2 mg. MSO(4) equivalents. Hospital stay was 3.2 days. There were no major and 4 minor (44%) complications. No patient required transfusion. Complete stone clearance was achieved in 7 of the 9 cases (78%) using a single percutaneous nephrostomy tract. CONCLUSIONS: Our preliminary clinical experience using the ureteral access sheath during percutaneous nephrolithotomy for simultaneous antegrade and retrograde stone treatment has been favorable. A large renal stone burden can be successfully managed with a single percutaneous access and limited blood loss.     

Stented esophageal transfixion injury

Esophageal perforation is a rare, but life-threatening condition with a mortality rate ranging between 10% and 40%. It can happen at the level of the cervical, intrathoracic, or intra-abdominal segment. It usually occurs as a result of iatrogenic injury after endoscopic procedures or as a spontaneous rupture. It is seen less frequently in trauma after gunshot or stab wounds. Stenting of the esophagus after iatrogenic perforation is well documented in the literature, but yet it is to be published for management of penetrating injury. We report a case of esophageal perforation with a wooden fence post treated successfully with a covered esophageal stent.     

Free DIEP and SIEA breast reconstruction to internal mammary intercostal perforating vessels with arterial microanastomosis using a mechanical coupling device

Autologous breast reconstruction with microsurgical free tissue transfer has become routine, and perforator-based adipocutaneous flaps are recognized as an excellent option for many patients. Current efforts to optimize patient outcomes focus on minimizing operative morbidity both at the donor and recipient sites. The DIEAP flap avoids most of the abdominal wall morbidity associated with the TRAM. At the recipient site, however, partial rib resection, for access to the internal mammary (IM) artery and vein as recipient vessels, has a risk of chest wall pain, deformity, and pneumothorax. Perhaps more importantly, sacrifice of the IM vessels precludes their use for potential future coronary revascularization. To avoid this, the intercostal perforating branches from the internal mammary system may be used as recipient vessels for microanastomosis. This has been well described using suture technique, although the use of a mechanical coupling device for arterial anastomosis to the perforator has not been reported. We report nine cases whereby a mechanical coupling device was used to perform both the arterial and venous anastomoses of DIEAP and SIEA flap pedicles to IM intercostal perforating vessels. Flap ischemia time was shorter in all cases, allowed ease of anastomosis for vessel size mismatch, and is technically easier in deep wounds. This technique is a further refinement to free flap breast reconstruction and is a powerful application of the coupling device.     

Can cost utility evaluations inform decision making about interventions for low back pain?

Background contextLow back pain (LBP) is associated with high health-care utilization and lost productivity. Numerous interventions are routinely used, although few are supported by strong evidence. Cost utility analyses (CUAs) may be helpful to inform decision makers.PurposeTo conduct a systematic review of CUAs of interventions for LBP.Study designSystematic review.MethodsA search strategy combining medical subject headings and free text related to LBP and health economic evaluations was executed in MEDLINE. Cost utility analyses combined with randomized controlled trials for LBP were included. Studies that were published before 1998, non-English, decision analyses, and duplicate reports were excluded. Search results were evaluated by two reviewers, who extracted data independently related to clinical study design, economic study design, direct cost components, utility results, cost results, and CUA results.ResultsThe search produced 319 citations, and of these 15 met eligibility criteria. Most were from the United Kingdom (n=8), published in the past 3 years (n=12), studied chronic LBP or radiculopathy (n=13), and had a follow-up >12 months (n=13). Combined, there were 33 study groups who received a mean 2.1 interventions, most commonly education (n=17), exercise therapy (n=13), spinal manipulation therapy (n=7), surgery (n=7), and usual care from a general practitioner (n=7). Mean baseline utility was 0.57, improving to 0.67 at follow-up; the mean difference in utility improvement between study groups was 0.04. Based on available data and converted to US dollars, the cost per quality-adjusted life year ranged from $304 to $579,527, with a median of $13,015.ConclusionsFew CUAs were identified for LBP, and there was heterogeneity in the interventions compared, direct cost components measured, indirect costs, other methods, and results. Reporting quality was mixed. Currently published CUAs do not provide sufficient information to assist decision makers. Future CUAs should attempt to measure all known direct cost components relevant to LBP, estimate indirect costs such as lost productivity, have a follow-up period sufficient to capture meaningful changes, and clearly report methods and results to facilitate interpretation and comparison.     

Goal-Directed Fluid Therapy on Laparoscopic Sleeve Gastrectomy in Morbidly Obese Patients

Background

In bariatric surgery, there are no guidelines available for intraoperative fluid administration. Goal-directed fluid therapy (GDFT) is a new concept of perioperative fluid management that has been shown to improve the prognosis of patients undergoing abdominal surgery. The aim of our study is to assess the impact of the implementation of a GDFT protocol in morbidly obese patients who underwent laparoscopic sleeve gastrectomy (LSG).

Methods

A before-after intervention study, in morbidly obese patients who underwent LSG, was conducted at the Obesity Unit of the General University Hospital Elche. Data from the GDFT implementation group (January 2014 to December 2015) were prospectively collected and compared with a preimplementation group (January 2012 to December 2013).

Results

Baseline demographic and comorbidity data between the two groups of patients were similar. The length of stay in the hospital was significantly shortened in GDFT group from 4.5 to 3.44 days (p?<?0.001). Intraoperative fluid administration was significantly lower in the GDFT group (1002.4 vs 1687.2 ml in preimplementation group, p?<?0.001). In the postoperative period, there was a statistically significant reduction in postoperative nausea and vomiting (PONV) after GDFT implementation (48 to 14.3 %, p?<?0.001).

Conclusions

Implementation of GDFT protocols can prevent intraoperative fluid overload in patients undergoing bariatric surgery. It could improve outcomes, for example decreasing PONV or even hospital stay.

     

Effect of preoperative keratometric power on intraoperative complications in LASIK in 34,099 eyes

PURPOSE: To evaluate the effect of preoperative keratometric power on the intraoperative complications in LASIK for myopia, hyperopia, and astigmatism. METHODS: In this retrospective study, the records of 34,099 eyes of 17,388 patients who underwent LASIK for myopia, hyperopia, and astigmatism using the Moria LSK One manual microkeratome and the Bausch & Lomb Technolas 217 Z excimer laser were reviewed. RESULTS: One thousand three hundred thirty-eight (3.92%) intraoperative microkeratome complications were identified in the total number of eyes: 571 (1.67%) free caps, 320 (0.93%) epithelial abrasions, 282 (0.82%) thin/irregular flaps, 126 (0.36%) incomplete flaps, and 39 (0.11%) flap buttonholes. When eyes were stratified according to preoperative keratometric power, eyes with flatter corneas usually had more free caps and incomplete flaps than eyes with steeper corneas (P < .05), whereas eyes with steeper corneas usually had more epithelial abrasions and thin/irregular flaps than eyes with flatter corneas (P < .05). The risk of free caps, incomplete flaps, and epithelial abrasions was greater when bigger keratome rings (H) were used than when smaller rings (-1) were used (P < .05). The incidence of buttonholes was independent of the preoperative keratometric power, keratome plate (100 or 130 microm), and keratome ring (-1, -2, or H). CONCLUSIONS: No statistically significant relationship was found between preoperative keratometric power and incidence of flap buttonholes in this series. Eyes with flatter corneas tended to have more free caps and incomplete flaps, whereas eyes with steeper corneas tended to have more epithelial abrasions and thin/irregular flaps.