Assessment of the Learning Process After Introducing a New Liver Transplantation Procedure in a Center With Extensive Experience in Kidney Transplantation.

BACKGROUND: Liver transplantation (LTx) is one of the most complex transplant procedures. The aim of the present study was to determine whether the learning process can be observed after the introduction of LTx in a center with extensive previous experience in renal transplantation. METHODS: This retrospective analysis included 264 primary LTx procedures performed with the piggyback technique (2005-2016). The procedures were divided into 4 equal groups. The characteristics of the recipients, data related to the surgery, and the postoperative course and complications were analyzed. RESULTS: We observed a significant reduction in surgical time and in the anhepatic phase duration between Group 1 and the other groups (median surgical time was 455 minutes vs 415 minutes, 410 minutes and 387 minutes, respectively, P < .05; median anhepatic phase duration was 75 min vs 60 min, 62 min, 60 min, respectively, P < .05). There was a decrease in the number of transfused blood units (median in Group 1 of 6 packs vs 3 packs in Group 4, P < .05) and a decrease in blood recovered from the operating field using the Cell Saver system (median in Group 1 of 1570 mL vs 1057 mL, 1123 mL, and 1045 mL, respectively, P < .05). A significant reduction in the number of hemorrhages was found (1.5% in Group 4 vs 13.6%, 10.6%, and 7.6% in the other groups P < .05). The remaining studied parameters were not statistically significant. CONCLUSIONS: Extensive previous transplantation experience affected the lack of typical features of the learning process.

Influence of Experience Acquired by a Liver Transplantation Center on Extension of Donor Acceptance Criteria.

BACKGROUND: Liver transplantation (LTx) is the only effective treatment for end-stage liver failure. Due to the ongoing lack of organs available for transplantation, there is a tendency to extend liver donor selection criteria. The aim of the study was to determine whether extension of donor acceptance criteria with increasing experience in LTx occurred at our transplant center. METHODS: This retrospective analysis included 288 donors harvested between 2005 and 2016. The donors were divided chronologically into 4 equally sized groups. They were assessed in subsequent groups according to sex, age, height, body mass index (BMI), cause of death, amount of days spent in the intensive care unit, number of episodes of cardiac arrest before organ removal, and results of laboratory and virologic tests. RESULTS: A statistically significant increase in the age of accepted donors was observed between group 2 and group 4 (median 40 vs 45 years, P < .05). There was a significant increase in the acceptance of anti-HBc-positive donors (0% in group 1 vs 7% in group 4). The remaining parameters did not show statistically significant differences. CONCLUSION: Experience acquired by our transplant center during the period of analysis did not lead to extension of liver donor acceptance criteria. Statistically significant differences for liver donor age and virologic profile (anti-HBc) between groups were observed; however, overall analysis did not confirm a clear tendency to extend liver donor acceptance criteria at this center.

Analysis of coagulation parameters in the early period after kidney transplantation.

BACKGROUND: Hemorrhagic diatheses observed in patients with chronic renal failure result from platelet defects, vessel wall damage, and deficiency of II, VII, IX, and X clotting factors. In contrast, increased levels of fibrinogen and von Willebrand factor, as well as decreased plasma fibrinolytic activity, may lead to thrombotic complications in nephrotic syndrome. Successful kidney transplantation may reverse these disturbances. The aim of the study was to analyze plasma coagulation parameters in the early postoperative period. MATERIALS AND METHODS: We studied 40 patients who received cadaveric kidney grafts in 2005 and 2006 for activated partial thromboplastin time (APTT), prothrombin time (PT), fibrinogen, and D-dimer concentrations as well as antithrombin III and protein C and S activities. Blood was collected before surgery and on postoperative days 1, 7, and 14. RESULTS: The APTT, PT, and fibrinogen values did not differ before and after transplantation. The activity of antithrombin III pretransplantation was 80.9% +/- 19.3%, increasing to 114.2% +/- 25.5% on postoperative day 14. The activities of protein C and S pretransplantation were 115.1% +/- 32.2% and 120.2% +/- 51.6%, respectively, increasing to 150.2% +/- 56.6% and 139.5% +/- 35.4%, respectively, on postoperative day 14. D-dimer concentrations increased from 252.3 +/- 312.0 ng/mL before transplantation to 951.5 +/- 1170.8 and 739.1 +/- 1049.8 ng/mL on postoperative days 7 and 14, respectively. CONCLUSIONS: Kidney transplantation increased plasma clotting inhibitor activity in the early postoperative period. The high level of D-dimer observed postoperatively suggested increased thrombotic processes in these patients.

Did volume of lymphocele after kidney transplantation determine the choice of treatment modality?

INTRODUCTION: Lymphocele is a lymph collection that forms after surgery following injury to lymph nodes and vessels. The aim of the study was to perform a retrospective analysis of different treatment modalities of lymphocele in patients after kidney transplantation. MATERIAL AND METHODS: A lymphocele located in renal graft area was observed in 25 of 386 transplanted patients (6.5%). Mean patient age was 45 (95% confidence interval [CI], 40 to 50) years. Mean observation time was 35 (95% CI, 27 to 43) months. RESULTS: Mean time from transplantation to diagnosis of lymphocele was 29 days (range, 4 to 127). In 13 patients (54.2%), the lymphocele was symptomatic, requiring initial treatment by repeated needle aspirations or percutaneous drainage. Among 7 patients with persistence of the lesion treatment by sclerotherapy with doxycycline, povidone-iodine, and/or ethanol was successful in 4 cases who showed maximal lymphocele volume of 500 mL. Three other patients, namely, volumes of 120, 874, and 2298 mL were referred for surgery; in two cases, internal marsupialization was performed and in one case external drainage was necessary due to abscess formation. Mean time from the diagnosis to recovery in patients requiring surgical treatment was 15 (range, 8 to 24) weeks. Eleven patients with asymptomatic lymphoceles (mean volume 45 mL; range, 8 to 140) were monitored to resolution after a mean of 4 (range, 1 to 11) weeks. CONCLUSION: All lymphoceles with the maximal volume exceeding 140 mL were clinically symptomatic. Initial percutaneous drainage with or without sclerotherapy was an effective method of treatment. Punctures, drainage, and sclerotherapy were not effective in patients with lymphoceles (>500 mL).

Simultaneous transabdominal bilateral nephrectomy in potential kidney transplant recipients.

BACKGROUND: Bilateral nephrectomy of potential kidney graft recipients is indicated for patients with recurrent infections in the polycystic kidneys or chronic pyelonephritis resulting from vesicoureteric reflux. The aim of this study was to analyze the frequency of complications after simultaneous bilateral transperitoneal nephrectomy. PATIENTS AND METHODS: Twenty hemodialysis patients (age 28 to 55 years) were referred for simultaneous bilateral nephrectomy between 1996 and 2004. Among the 18 patients with autosomal-dominant polycystic kidney disease, 11 experienced recurrent cysts or urinary tract infections and two, episodes of disabling flank pain. Five patients with extremely enlarged kidneys were asymptomatic. Two patients presented vesicoureteric reflux with chronic pyelonephritis. In all cases the kidneys were removed transperitoneally via a transverse or midline incision. RESULTS: Although no fatal outcome was recorded, three patients required brief hospitalizations in the intensive care unit. The only intraoperative complication was spleen injury in five patients. Surgical postoperative complications developed in nine patients (45%) including: extended drainage and delayed wound healing (n = 4), postoperative hernia (n = 3), prolonged abdominal pain (n = 3), perihepatic hematoma (n = 2), stress duodenal ulceration (n = 1), and subileus (n = 1). Five patients displayed thrombosis of their dialysis access, probably as a consequence of low blood pressure. After surgery 15 patients were placed on the waiting list and 10, successfully transplanted. CONCLUSION: Simultaneous transabdominal bilateral nephrectomy was associated with a high risk of postoperative complications, but may save the suffering associated with a repeated operation in potential kidney graft recipients who have an indication for bilateral nephrectomy.

Surgical treatment of urological complications after kidney transplantation.

Urological complications after kidney transplantation develop in 2.5% to 14.1% of recipients. The aim of the study was to analyze postoperative urological complications that required surgical treatment. Thirty-three urological complications developed in 30 among 321 patients (9.3%). Complications were divided into two groups: I, related to urine retention (60.6%); and II, related to urine leakage (39.4%). For 70% of group I, in patients a double pigtail ureteral stent was inserted; for 53.8% of group II, a vesicoureteric reanastomosis was performed. Good urine outflow was achieved in 90.0% of patients. Total early graft loss was 20% of patients. Urological complications related to stenosis or leakage can be treated with ureteral stent insertion or vesicoureteral reanastomosis. Hemorrhage or infection coexisting with a urological complication increased the risk of early graft loss. Long-term graft survival among patients after successful treatment of urological complications was similar to that of patients without them.

Surgically treated early complications after kidney transplantation.

Early surgical complications after kidney transplantation (KTx) remain important clinical problems. The 35 patients in whom forty-six complications appeared within 1 month required surgical treatment. The causes were divided into four groups: bleeding and/or hematoma of the perigraft region (n = 22); urological complications (n = 9); simultaneous bleeding and/or hematoma and urological complications (n = 6); and others (n = 9). Among the 28 cases of hemorrhagic complication, the source of bleeding was not localized during the reoperation in 53.7% cases. Vascular anastomotic leakage was confirmed only in 7.1% of patients. The most common urological complications were stricture of (46.7% cases) and leakage at (26.7%) the vesicoureteral anastomosis. Within 3 months after KTx nephrectomy was performed in 27.5% of patients who had been previously operated for surgical complications compared to 4.6% patients without interventions. Among patients with a single reoperation the graft had to be removed in 20.0% compared with 44.4% for those with multiple reoperations. Localization of the bleeding source causing an early perigraft hematoma is not always possible. The most common early urological complication is a vesicoureteral stricture caused by edema. Surgical complications that appear within 1 month after KTx increase the risk of early graft loss.

[Male sterility caused by a lack of the acrosome in spermatozoa with a round shaped head]. / Nieplodnosc meska wywolana brakiem akrosomu w plemnikach z okragla glówka.

Only properly structured spermatozoa are able for transportation and penetrating the permeable membrane of oocyte. The key role in the process of fertilization belongs to the anterior part of acrosome, i.e., the spermatozoon's head. A case of a married couple, with diagnosed 8-year-long infertility, has been presented. A spermocytogram, run in the man, revealed all spermatozoa to be with rounded heads, i.e., without acrosome. That pathology was confirmed in electron microscopy. The significance of correct examination--spermocytogram--has been stressed in the diagnostic of male infertility.

[The effects of micro-laparoscopic ovarian electrocautery as a method of polycystic ovary syndrome treatment]. / Mikrolaparoskopia operacyjna--elektrokauteryzacja jajników w nieplodnosci wywolanej zespolem PCO.

The paper concerns the treatment results of 113 women with PCO-S by laparoscopic (102) and microlaparoscopic (11) ovarian electrocautery. All of them were qualified for operation on the basis of the following criteria: menstrual cycle disturbances (oligo-/amenorrhoea), anovulation, hirsutism, obesity, LH/FSH ratio > 2 and when more than 10 follicles of < 8 mm diameter are seen in the ovary under theca albuginea in USG examination. During the one year after operation these women were observed. In the first group (patients after laparoscopy) ovulation occurred in 86 (84%) and pregnancy in 54 (53%); accordingly in the second group (women after microlaparoscopy) ovulation occurred in 9 (83%) and pregnancy in 4 (45%). The treatment results by microlaparoscopic and laparoscopic ovarian electrocautery are similar, but the method by microlaparoscopy is easier to carry out in selected cases.

[Modern methods of early diagnosis and treatment of ectopic-oviduct pregnancy]. / Wspólczesne metody wczesnego rozpoznawania i leczenia ciazy ektopowej--jajowodowej.

Medical documentation of 80 women operated on because of ectopic pregnancy between the years 1991-1992 was analyzed. Methods of early diagnosis and ways of surgical approaches were discussed. Authors of this article give priority to controlling beta sub-unit HCG acc. to Romero, to ultrasonographic vaginal probe examination and to diagnostic laparoscopy. Early surgical intervention increases the chances to maintain woman's fertility. All procedures on women with ectopic--oviduct pregnancy should be sparing, depending on the ward equipment and personnel training and should be performed by the means of operative laparoscopy method.

[Postcoital test evaluated in peritoneal fluid]. / Test po stosunku oceniany w plynie otrzewnowym.

The role of the peritoneal fluid in the physiology of reproduction, as well as in the transportation and survival of gametes, is little recognized. Taking this into consideration, the authors have examined the occurrence of spermatozoa in the peritoneal fluid, collected from patients during diagnostic laparoscopies, following intrauterine insemination with husband's sperm, in, so-called, Templeton's Test. In the group of patients with cervical factor six (6) mobile spermatozoa (85%) were observed, in the group with male factor -- three (3) (42%) and in the group with idiopathic infertility -- 1 (25%). A high utility of this test has been indicated, especially in infertility caused by the male factor and in endometriosis.

[A test for sperm cell survival in peritoneal fluid]. / Test przezycia plemników w plynie otrzewnowym (Test P.P.O).

The role of the peritoneal fluid in the physiology of reproduction, as well as in the transportation and survival of gametes, is little known. The authors have examined interactions between spermatozoa and the peritoneal fluid, collected during laparoscopy in the, so-called, survival test, from 42 infertile couples. The studied survival of spermatozoa in the peritoneal fluid was relatively high--19% after 48 hours--longer than in Menezo B2 fluid. Values of the test have been indicated, especially in cases of endometriosis-caused and idiopathic infertility.

[Treatment of infertility in marriage using a method of transcervical gamete introduction into the fallopian tube under control of USG]. / Leczenie nieplodnosci malzenskiej metoda przezszyjkowego gamet do jajowodu pod kontrola USG.

GIFT under USG control (USGIFT) was performed in 18 females between may and december of 1992. The ovulation was stimulated by gonadotropin and Clomid. In result we obtained four pregnancies--three normal uterine pregnancies and one ectopic pregnancy. One of these pregnant women gave birth to a child in February 1993.

[Laparoscopic or laparotomic surgery in the treatment of ovarian benign teratomas?]. / Chirurgia laparoskopowa czy tradycyjna w leczeniu potworniaków dojrzalych jajników?

The operation treatment of ovarian dermoid cysts by laparoscopy (examined group) and by laparotomy (control group) was compared. The mean size of teratomas measured by USG was similar: in the examined group 59 +/- 20 mm, in the control group 62 +/- 27 mm. There was no significant difference in the operation time: laparoscopy 65 +/- 27 min. (range 35-105 min.) and laparotomy 66 +/- 27 min. (range 40-120 min.). The antibiotic therapy both intra-operation and after operation was applied twice more frequent for laparotomy operated patients. The number of patients with post-operative fever was much higher in the control group (laparotomy: 7 patients--26.9%) than in examined group (laparoscopy: only 1 patient--3.9%). The hospitalization after operation was longer in the control group (mean: 6.8 +/- 3.7 days) than in examined group (mean: 3.1 +/- 2.8 days). Laparoscopic surgery is valuable operating method for selected teratomas in comparison with classical surgery.

Risk factors for early hemorrhagic and thrombotic complications after kidney transplantation.

INTRODUCTION: Clotting disturbances resulting from chronic renal failure do not remit immediately after successful kidney transplantation (KTx). Hemorrhagic and thrombotic complications after KTx increase the risk of transplanted kidney loss. The aim of the study was to analyze the influence of clotting system disturbances and applied antithrombotic prophylaxis on the development of hemorrhagic and thrombotic complications among KTx patients in the early postoperative period. MATERIALS AND METHODS: Sixty seven KTx patients underwent measurement of plasma activated partial thromboplastin time (APTT); international normalized ratio; fibrinogen and D-dimer concentration; activity of antitrombin III; protein C and S, VIII, IX; and von Willebrand factors, as well as platelet counts. RESULTS: A perigraft hematoma developed in 25.4% patients, of whom 4.5% required reoperation. Lower antithrombin III activity (96.2±27.6 vs 112.3±17.4, P=.02) on postoperative day (POD) 7 and higher fibrinogen concentration (4.41±2.03 vs 3.35±0.87, P=.01) and platelet count (269.8±117.5 vs 215.8±64.8, P=.03) on POD 14 were noted in recipients with a hematoma compared to those free of this complication. A perigraft hematoma developed in 57.9% patients undergoing antithrombotic prophylaxis and in 12.5% without this treatment (P=.0002). Among patients receiving unfractionated heparin, we observed extension of APTT on POD 1 (45.9±53.2 vs 30.9±7.5 seconds, P=.04), higher von Willebrand factor activity on POD 7 (348.8±122.2 vs 218.5±125.5, P=.02), and higher D-dimer concentrations POD 7 and 14 (1662±894 vs 757±708, P=.002 and 1614±1372 vs 672±532, P=.003, respectively). No significant differences were observed as regards to analyzed parameters between patients receiving low-molecular-weight heparin versus those not receiving antithrombotic prophylaxis. CONCLUSIONS: Disturbances in analyzed parameters of hemostasis did not increase the risk of hemorrhagic and thrombotic complications in the early period after KTx. Antithrombotic prophylaxis increases the risk of hemorrhagic complications and should be introduced only for selected renal transplant recipients.

Intraoperative resistance index measured with transsonic flowmeter on kidney graft artery can predict early and long-term graft function.

INTRODUCTION: Resistive index (RI) measured by Doppler sonography in the early period after kidney transplantation is a well-known predictor of kidney transplant outcome. The purpose of this study was to analyze the impact of RI values calculated intraoperatively in renal allograft artery using transit time flowmetry (TTF) on both early and long-term kidney graft function. MATERIAL AND METHODS: TTF was performed on 72 patients who received kidney grafts fed by a single artery. TTF was performed before wound closure. We excluded patients with an early acute rejection (n=8), an early graft loss (n=2), or primary graft nonfunction (n=1). Recipients were divided into RI tertile groups. The initial kidney graft function was defined as immediate (IGF), slow or delayed. Kidney graft estimated glomerular filtration rate (eGFR) was analyzed upon long-term follow-up. RESULTS: Patients with a low RI (<0.57) showed the highest incidence of immediate graft function (65% versus 5.3%), whereas the high RI group (>0.70). Show the most frequent rate of delayed graft function (52.6% versus 15%). Recipients with low RI values displayed significantly better eGFR (by at least 12 mL/min/1.73 m2) than those with medium or high RI values at all analyzed times; subjects with medium or high RI showed similar eGFR at 48-months. CONCLUSION: An high RI value measured intraoperatively was a valuable predictor of inferior early and long-term kidney graft function.

Biliary complications after orthotopic liver transplantation: a 5-year experience.

INTRODUCTION: Biliary complications, particularly bile duct stenosis or leak, remain the "Achilles' heel" of orthotopic liver transplantation (OLT), significantly increasing the risk of graft loss and recipient death. The aim of the study was to retrospectively analyze biliary complications over a 5-year experience seeking to identify risk factors for these complications. MATERIAL AND METHODS: Eighty-seven OLT performed in 84 recipients were included in the analysis. In all cases but one, we performed an end-to-end hepatic duct anastomosis with a 7-0 running suture under 2.5× magnification. RESULTS: Biliary complications developed after 17.2% OLT: anastomosis site stenosis (10.3%), multiple stenoses (5.7%), or bile duct necrosis (1.1%). A bile leak was not observed. Two recipients died from biliary sepsis. Among the patients with biliary complications, there was an higher rate of hepatic artery problems (33.3% vs 2.7%; P<.01), and a longer anhepatic phase (85 vs 72 minutes; P<.01). We performed endoscopic treatment in 73% and percutaneous drainage in 6.6% of recipients. Good treatment results were achieved in 36.4% of cases with biliary complications whereas they were satisfactory in 27.3%. Five patients with biliary complications required re-transplantation. CONCLUSIONS: A bile duct anastomosis performed end-to-end with a running suture under magnification decreased the risk of bile leakage after OLT. A prolonged anhepatic phase or an hepatic artery thrombosis or stenosis increased the risk of biliary complications after OLT.

Donor-dependent risk factors for early surgical complications after simultaneous pancreas-kidney transplantation.

INTRODUCTION: The success of simultaneous pancreas-kidney transplantation (SPK) depends in a large degree on avoidance of surgical complications in the early postoperative period. The aim of the study was to analyze the Pre-procurement Pancreas Allocation Suitability Score (P-PASS) and the deceased donor parameters included within it as risk factors for early surgical complications after SPK. MATERIAL AND METHODS: Forty-six consecutive donors whose kidney and pancreas were simultaneously transplanted were included in the study. RESULTS: Donor age was older among recipients who lost their pancreatic grafts: 30.4±6.9 versus 24.1±6.9 years. Donor age was also older among recipients who lost their pancreatic grafts or died compared with those discharged with a functioning graft: 29.3±5.7 versus 24.0±6.9 years. Donor body mass index (BMI) was higher among patients who died compared with those who were discharged: 25.3±1.1 versus 23.2±2.5 kg/m2. P-PASS was higher in patients who lost their pancreatic grafts (17.6±2.1 vs 15.2±1.8) or died (15.3±1.9 vs 17.2±1.9), or lost pancreatic graft or died (15.2±1.8 vs 17.0±2.2) or with intra-abdominal infections (IAI; 17.1±1.7 vs 15.0±1.8). The incidence of donors≥30 years old was higher among recipients with IAI (45.4% vs 14.3%; P=.04). An higher rate of donors with P-PASS>16 was revealed among patients who lost their pancreatic grafts (26.7% vs 3.2%), died (26.7% vs 3.2%), lost the pancreatic graft or died (33.3% vs 6.4%), or experienced IAI (46.7% vs 9.7%). Multivariate logistic regression analysis revealed P-PASS (odds ratio 2.57; P=.014) and serum sodium (odds ration, 0.91; P=.048) to be important predictors of IAI development. CONCLUSION: Older age and higher BMI among deceased donors increased the risk of IAI, pancreatic graft loss, or recipient death after SPK. Transplantation of a pancreas from a donor with a low P-PASS score was associated with a lower risk of surgical complications after SPK.

The effect of molluscan glue proteins on gel mechanics.

Several molluscs have been shown to alternate between a non-adhesive trail mucus and a similar gel that forms a strong glue. The major structural difference between the two secretions is the presence of specific proteins in the adhesive mucus. The present study identifies similar proteins from the glue of the slug Arion subfuscus and the land snail Helix aspersa. To investigate the role played by these proteins in adhesion, the proteins were isolated from the adhesive mucus of different molluscs and added to commercial polymer solutions. The effect was observed qualitatively, and quantified using a dynamic rheometer. The isolated proteins triggered gelling or visible stiffening of agar, pectin and polygalacturonic acid. The effect was stronger on more negatively charged polymers. The effect of the proteins was concentration dependent with an optimal concentration of 1-1.5 mg ml(-1), and was weakened when their structure changed. Other proteins and carbohydrates found in the adhesive mucus had no clear mechanical effect on gels. These findings show that the addition of these proteins to large, anionic polymers plays a central role in the formation of a glue from a mucus-like secretion. Such a mechanism may be common among invertebrates, and it may guide biomimetic approaches in the development of glues and gels.