Is completion lymphadenectomy after a positive sentinel lymph node biopsy for cutaneous melanoma always necessary?

HYPOTHESIS: Completion lymph node dissection (CLND) has usually been recommended after metastatic disease is identified in the sentinel lymph node (SLN) biopsy to eradicate further metastases in nonsentinel nodes. We hypothesized that patients with negative lymph nodes included in the initial SLN specimen have low risk of metastases in the residual draining basin and may not require CLND. DESIGN: Chart review. SETTING: University-affiliated tertiary care referral center. PATIENTS: Between January 1, 1997, and May 31, 2003, 506 consecutive patients underwent SLN biopsy for staging of primary cutaneous melanoma. INTERVENTION: The SLN biopsy identified 87 patients (17.2%) with metastatic melanoma, of whom 80 underwent CLND. RESULTS: In 28 patients, all SLNs were found to contain metastatic melanoma. Seven (25%) of these patients had additional metastases identified in the CLND specimen. In 52 patients, 1 or more SLNs did not contain metastatic melanoma. Five (10%) of these patients had additional metastases in the CLND specimen (P =.02). CONCLUSIONS: Although no evidence of metastatic melanoma was found on CLND in most patients in whom negative nodes had been removed with positive SLNs at the initial biopsy, 10% of these patients did have further metastases. This subgroup of patients (positive SLNs and negative nodes in the SLN biopsy specimen) is at significantly lower risk for further metastasis, but CLND cannot be safely omitted even for these patients.     

Semiautomated MIP images created directly on 16-section multidetector CT console for evaluation of living renal donors

Institutional Review Board approval was obtained and informed consent was waived for this HIPAA-compliant study. The aim of this study was to retrospectively compare the accuracy of semiautomated maximum intensity projection (MIP) images created at a 16-section multidetector CT console with three-dimensional (3D)-workstation-generated images for the definition of renal donor anatomy, with intraoperative findings as a reference standard. In examining 40 renal donors (21 men and 19 women; age range, 24-56 years; mean age, 40.4 years), the sensitivity and accuracy for mapping donor anatomy by two readers were greater than 95%, interobserver agreement was excellent (kappa = 0.89-1.00). The 95% confidence interval for sensitivity was also calculated. Simple MIPs compared well with 3D-workstation images. MIPs from a predesigned protocol on the scanner console were generated more quickly than similar images from 3D workstations; postprocessing demands (eg, for renal donors) can be quickly fulfilled at the scanner console itself. The average time to generate simple MIPs at the console was 3.4 minutes (range, 1.7-4.4 minutes), and 22.3 minutes (range, 15-30 minutes) to create images at the 3D workstation.     

Up to 9-day survival and control of thrombocytopenia following alpha1,3-galactosyl transferase knockout swine liver xenotransplantation in baboons

Kim K, Schuetz C, Elias N, Veillette GR, Wamala I, Varma M, Smith RN, Robson SC, Cosimi AB, Sachs DH, Hertl M. Up to 9‐day survival and control of thrombocytopenia following GalT‐KO swine liver xenotransplantation in baboons. Xenotransplantation 2012; 19: 256–264.. © 2012 John Wiley & Sons A/S. Abstract: Background:  With standard miniature swine donors, survivals of only 3 days have been achieved in primate liver‐transplant recipients. The recent production of alpha1,3‐galactosyl transferase knockout (GalT‐KO) miniature swine has made it possible to evaluate xenotransplantation of pig organs in clinically relevant pig‐to‐non‐human primate models in the absence of the effects of natural anti‐Gal antibodies. We are reporting our results using GalT‐KO liver grafts. Methods:  We performed GalT‐KO liver transplants in baboons using an immunosuppressive regimen previously used by our group in xeno heart and kidney transplantation. Post‐operative liver function was assessed by laboratory function tests, coagulation parameters and histology. Results:  In two hepatectomized recipients of GalT‐KO grafts, post‐transplant liver function returned rapidly to normal. Over the first few days, the synthetic products of the donor swine graft appeared to replace those of the baboon. The first recipient survived for 6 days and showed no histopathological evidence of rejection at the time of death from uncontrolled bleeding, probably caused by transfusion‐refractory thrombocytopenia. Amicar treatment of the second and third recipients led to maintenance of platelet counts of over 40 000 per μl throughout their 9‐ and 8‐day survivals, which represents the longest reported survival of pig‐to‐primate liver transplants to date. Both of the last two animals nevertheless succumbed to bleeding and enterococcal infection, without evidence of rejection. Conclusions:  These observations suggest that thrombocytopenia after liver xenotransplantation may be overcome by Amicar therapy. The coagulopathy and sepsis that nevertheless occurred suggest that additional causes of coagulation disturbance must be addressed, along with better prevention of infection, to achieve long‐term survival.     

Long-term Outcome of a Cuffed Expanded PTFE Graft for Hemodialysis Vascular Access

BACKGROUND: Development of venous outflow stenosis has been a major obstacle in maintaining the patency of dialysis vascular grafts. In the present study, we retrospectively analyzed the long-term results of cuffed expanded polytetrafluoroethylene (ePTFE) and non-cuffed (standard) ePTFE grafts placed for hemodialysis access. MATERIALS AND METHODS: A total of 67 patients who underwent placement of either cuffed (n = 41) or standard (n = 26) ePTFE grafts were retrospectively analyzed. There were no significant differences between the two groups with regard to age, gender, cause of end-stage renal disease, and anatomic placement of the graft. Endpoints consisted of primary (without any intervention) and secondary (with radiological or surgical intervention) graft patency rates at 1-3 years. RESULTS: There was a trend toward better primary graft patency rates in the cuffed versus the standard ePTFE: 37.7% vs. 25.7% at 1 year, 35% vs. 10.3% at 2 years, 28% vs. 5.1% at 3 years, respectively (p = 0.086, Kaplan-Meier). Secondary patency rates in the cuffed group were significantly superior (p = 0.047) to those in the standard group (81.8% vs. 56.1% at 1 year, 61.8% vs. 46.3% at 2 years, 51.5% vs. 33.1% at 3 years, respectively). Thrombosis as a cause of complete graft failure was significantly higher (34%) in the standard group than in the cuffed group (9%) (p = 0.0125). CONCLUSIONS: Compared to the standard ePTFE, the cuffed ePTFE graft provided better long-term outcome, especially in terms of secondary patency rates after radiological intervention.     

Teaching Practices of Thoracic Epidural Anesthesia in the United States: Should Lumbar Epidurals Be Taught Before Thoracic Epidurals?

OBJECTIVE: The purpose of this study was to determine the current teaching practice of thoracic epidural procedures in the United States and to determine the effect of the teaching sequence of thoracic and lumbar epidurals on technical difficulties and complications. DESIGN AND SETTING: The first part was a survey, which was distributed to all American Board of Anesthesiology-accredited programs. The second part was a noninterventional retrospective review of 2,007 epidural procedures in a university teaching program. INTERVENTIONS: The survey questions were designed to determine the number of epidural procedures performed monthly on various services, teaching sequence, insertion technique, indications, and service provider. RESULTS:The survey received 81 responses (60%) from 134 programs; 34% of the programs placed more thoracic than lumbar epidurals, 92% of the programs placed epidurals mainly for postoperative pain control, and 88% of programs mainly teach lumbar before thoracic epidurals, whereas only 10 programs (12%) mainly teach residents thoracic before lumbar epidurals. The authors' residents were divided into 2 groups: group 1 (42 residents, 70%) who learned thoracic before lumbar epidurals and group 2 (18 residents, 30%) who learned lumbar before thoracic epidurals during their earlier obstetric anesthesia training. There were no significant differences between the 2 groups in the degree of technical difficulties or the incidence of procedure-related complications. CONCLUSIONS: Thoracic epidurals are widely taught in the United States. Most programs teach lumbar before thoracic epidurals. Thoracic epidurals are safe to teach without prior experience with lumbar epidurals.