Academic careers and lifestyle characteristics of 171 transplant surgeons in the ASTS.

This manuscript reports the demographics, education and training, professional activities and lifestyle characteristics of 171 members of the American Society of Transplant Surgeons (ASTS). ASTS members were sent a comprehensive survey by electronic mail. There were 171 respondents who were 49 ± 8 years of age and predominantly Caucasian males. Female transplant surgeons comprised 10% of respondents. ASTS respondents underwent 15.6 ± 1.0 years of education and training (including college, medical school, residency and transplantation fellowship) and had practiced for 14.7 ± 9.2 years. Clinical practice included kidney, pancreas and liver organ transplantation, living donor surgery, organ procurement, vascular access procedures and general surgery. Transplant surgeons also devote a significant amount of time to nonsurgical patient care, research, education and administration. Transplant surgeons, both male and female, reported working approximately 70 h/week and a median of 195 operative cases per year. The anticipated retirement age for men was 64.6 ± 8.6 and for women was 62.2 ± 4.2 years. This is the largest study to date assessing professional and lifestyle characteristics of abdominal transplant surgeons.

Morning report: combining education with patient handover.

INTRODUCTION: The advent of resident work hour restrictions has challenged us to train residents within a shorter working week, while ensuring continuity of patient care. We instituted morning report (MR) at the University of Virginia primarily as a means to accomplish these objectives. Serendipitously MR has become an integral educational tool for the surgical residents. The rationale for the format and instructional design are discussed in the context of learning theory. METHODS: The chief residents as primary stakeholders were strongly encouraged to play a leadership role in designing MR. A faculty- led didactic format was rejected because of the importance of focusing on resident team building, and leadership, but poor faculty participation was also an issue. RESULTS: The initial obstacles included timing, and designing the format. CONCLUSIONS: MR is an opportunity for residents to exercise and improve their knowledge, leadership, presentation and problem-solving skills. We would hypothesise that the advantages for teaching are many and include that residents are prepared for actual clinical problems in a supportive environment with opportunities for immediate feedback and assessment. Reports of educational effectiveness of MR are mostly anecdotal and further studies are needed to characterise the types of learning and teaching that occur during MR and to document educational effectiveness.

Survey of the knowledge, perception, and attitude of medical students at the University of Leeds toward organ donation and transplantation.

BACKGROUND: The shortage of organ donors is the key rate-limiting factor for organ transplantation in the United Kingdom. Many strategies have been proposed to increase donation; one strategy aims to improve awareness of organ donation and transplantation (ODT) among medical students. This survey seeks to investigate the knowledge, perceptions, and attitudes of the medical students in the United Kingdom toward ODT and the curriculum content. METHODS: A 32-item online questionnaire was distributed to 957 medical students at the University of Leeds (October to December 2012). RESULTS: There were 216 (22.6%) respondents. Students were aware of kidney, heart, and liver transplantation (91.6%, 88.8%, and 86.5%). Awareness of small intestine (36.7%) and islet of Langerhans (33.0%) transplantation was poor. Students understood the term "brain stem death" (82.3%); however, they lacked understanding of criteria used for brain stem death testing (75.8%). Their perceptions and attitudes were favorable toward ODT; 43.3% of the students were unhappy with their current knowledge, and 87.6% of the students agree that ODT teaching should be included in the curriculum. CONCLUSIONS: Students have a basic understanding of ODT but lack detailed knowledge. They accept its importance and desire further teaching to supplement their current knowledge to be able to understand the issues related to ODT.

Uni- and multi-variate analysis of risk factors for early and late hepatic artery thrombosis after liver transplantation.

BACKGROUND: Hepatic artery thrombosis (HAT) is a significant cause of morbidity after liver transplantation. The aims of this study are to identify and compare risk factors that might contribute to HAT. METHODS: A total of 424 liver transplants performed at the University of Virginia were reviewed. HAT was defined as complete disruption of arterial blood flow to the allograft and was identified in 29 cases (6.8%). HAT was classified as early (less than 1 month posttransplant, 9 cases: 2.1%) or late (more than 1 month posttransplant, 20 cases: 5.4%). Possible risk factors for HAT were analyzed using Pearson chi2 test for univariate analysis and logistic regression for multivariate analysis. RESULTS: Multiple transplants, recipient/donor weight ratio >1.25, biopsy-proven rejection within 1 week of transplant, recipient negative cytomegalovirus (CMV) status, arterial anastomosis to an old conduit (defined as a previously constructed aorto-hepatic artery remnant using donor iliac artery), and CMV negative patients receiving allograft from CMV positive donors were found to be significant risk factors for developing early HAT. After logistic regression, factors independently predicting early HAT included arterial anastomosis to an old conduit [odds ratio (OR)=7.33], recipient/donor weight ratio >1.25 (OR=5.65), biopsy-proven rejection within 1 week posttransplant (OR=2.81), and donor positive and recipient negative CMV status (OR=2.66). Female donor, the combination of female donor and male recipient, recipient hepatitis C-related liver disease, donor negative CMV status, and the combination of recipient CMV negative and donor CMV negative were found to be significant risk factors for late HAT. Factors independently predicting late HAT by logistic regression included negative recipient and donor CMV status (OR=2.26) and the combination of a female donor and male recipient (OR=1.97). CONCLUSION: Therefore, in nonemergency situations attention to these factors in donor allocation may minimize the possibility of HAT.

Prospective, randomized trial of nasogastric suction in patients with acute pancreatitis.

The efficacy of nasogastric (NG) suction was evaluated in a prospective, randomized trial in 60 patients with acute pancreatitis of mild to moderate severity. Group I, NG (29 patients) was treated with NG suction, and group II, no NG (31 patients) was treated without NG suction. The presentation, cause of pancreatitis, and clinical parameters at the time of admission of the two groups were similar. The use of NG suction had no discernible benefit during hospitalization. There were no differences in duration of abdominal pain, the interval until bowel sounds returned, the need for narcotic administration, or the length of time intravenous fluid therapy was needed. When compared with group II, no NG, patients in group I, NG tended to resume oral intake later (5.0 +/- 0.3 versus 3.9 +/- 0.5 days) and remain hospitalized longer (13.1 +/- 2.6 versus 10.7 +/- 2.0 days). The incidence of serious complications, such as pancreatic abscess, pseudocyst, biliary obstruction, or pulmonary failure, was no different between the groups. This study demonstrates that the routine use of NG suction in patients with acute pancreatitis of mild to moderate severity is of no benefit in altering the clinical course.

Experimental ischemic pancreatitis: treatment with albumin.

Acute pancreatitis was initiated in the isolated ex vivo, perfused canine pancreas preparation by exposing the gland to a 2 hour period of ischemia before a 4 hour perfusion period. The pancreatitis was manifested by edema formation, weight gain, and hyperamylasemia. When the osmotically active agent albumin was added to the perfusate at the end of the ischemic period, virtually no edema developed, weight gain was minimal, and the amylase level remained within normal limits during the subsequent 4 hour perfusion period. This suggests that a change in capillary permeability may be an early step in the pathogenesis of ischemia-induced pancreatitis in this experimental model.

Crohn's disease of the colon. Is there a role for limited resection?

Forty-one patients underwent resection for Crohn's disease of the large bowel. Twelve patients had a total proctocolectomy for diffuse disease of the colon and rectum, and 29 patients with segmental disease of the large bowel underwent limited resection. Thirteen of the 29 patients had a subtotal colectomy, with 7 patients undergoing immediate ileoproctostomy and 6 having an ileostomy. Further surgery was required in 9 f the 13 patients, and long-term enteric continuity was maintained in only 3 patients. Sixteen patients with more localized Crohn's disease of the colon underwent segmental resection. Seven patients required additional surgery, and enteric continuity was restored in 12 of the 16 patients. There was no mortality among these 29 patients. This study suggests that Crohn's disease of the colon may be successfully treated by limited resection when involvement is segmental. In the patient with more extensive disease of the colon with only rectal sparing, morbidity is high and the probability of maintaining enteric continuity is low. Therefore, in these patients total proctocolectomy should be considered.

Topical antibiotics in the high-risk biliary surgical patient. A prospective, randomized study.

This randomized, prospective study has evaluated the efficacy of topical antibiotics in preventing infective complications in patients undergoing high-risk biliary surgery. Sixty-nine patients who underwent bile duct exploration, choledochoenteric anastomosis, or cholecystectomy, either for acute cholecystitis or because they were older than 65 years of age, were randomized to the following three groups: Group I, topical antibiotics alone (22 patients); Group II, cefoxitin and topical antibiotics (24 patients); and Group III, penicillin, tobramycin, clindamycin, and topical antibiotics (23 patients). The incidence of infective complications was no different among the groups. There was one wound infection in each group, one episode of bacteremia in Group II, and no intraabdominal abscesses. This study has demonstrated that parenteral antibiotics administered prophylactically in the perioperative period offer no additional benefit over the use of effective topical antibiotics used intraoperatively in patients undergoing high-risk biliary surgery.

Transjugular intrahepatic portosystemic stent-shunt (TIPSS) insertion as a prelude to orthotopic liver transplantation in patients with severe portal hypertension.

OBJECTIVE: To investigate the impact of preoperative transjugular intrahepatic portosystemic stent-shunt (TIPSS) on patients undergoing liver transplantation. DESIGN: A retrospective non-randomized comparative clinical study. SETTING: Tertiary referral institution. PATIENTS, PARTICIPANTS: Twenty-four patients with liver cirrhosis, portal hypertension and gastro-oesophageal varices who underwent liver transplantation. INTERVENTIONS: TIPSS insertion had been performed preoperatively in 12 patients. MAIN OUTCOME MEASURES: Operative dissection times and blood transfusion requirements during liver transplantation. Postoperative complication rate. Cumulative patient and graft survival. RESULTS: There were no significant differences in outcome measures between patients with and without previous TIPSS insertion with respect to recipient hepatectomy times (mean 192 min (126-280) versus 196 min (145-254)), total operating time (mean 484 min (330-690) versus 486 min (370-580)), intraoperative blood transfusion (mean 11 units (2-29) versus 12 units (2-30)), intraoperative fresh frozen plasma transfusion (mean 9 units (1-16) versus 11 (2-23) units), patient survival (83% versus 92% cumulative 1-year survival), graft survival (80% versus 83% cumulative 1-year survival), or postoperative complication rates. CONCLUSION: TIPSS insertion is feasible and relatively safe as a 'bridge to transplantation' in patients who have had a variceal haemorrhage. There is little evidence that preoperative TIPSS insertion directly affects the performance of liver transplantation as TIPSS neither, hinders nor facilitates surgery or post operative survival. Although it is important that the potential hazards of TIPSS extension into the inferior vena cava or superior mesenteric vein be recognized, liver transplant surgeons need not be unduly concerned about the overall impact of TIPSS as it becomes more universally available in the management of variceal haemorrhage.

Pseudocysts of the pancreas, a review of 97 cases.

Pseudocysts represent a relatively common problem in the management of patients with pancreatic disease. In evaluating the outcome of treatment, many authors have failed to differentiate between those pseudocysts that follow an attack of acute pancreatitis and those that occur with established chronic disease. We retrospectively reviewed the outcome of treatment in 97 patients admitted to the University of Virginia Hospital in Charlottesville over a 6-year period with a diagnosis of pancreatitis pseudocyst. In 50 of the 97 patients (52%), the pancreatic pseudocyst followed an attack of acute pancreatitis, and 47 (48%) patients had chronic disease. The mean age at presentation was 48.6 +/- 16.4 years for the entire group. Twenty-four patients (25%) were black, and 73 (75%) were white. Sixty-four patients were male (66%), and 33 were female (34%). Alcohol was the important etiological agent in 30 of the 47 patients with chronic pancreatitis (64%), but only 13 of the 50 patients (26%) with acute pancreatitis. By comparison, gallstones were the precipitating cause in 13 of the 50 patients with acute pancreatitis (26%), but only 5 of the 47 patients (11%) with chronic pancreatitis. Thirty-one patients (32%) were treated by observation, 37 patients (36%) by percutaneous aspiration or drainage, and 46 patients (47%) by surgical drainage or resection. Some patients fell into more than one category. Our findings suggested that many patients with small cysts (less than 6 cm) can be managed by a period of observation.(ABSTRACT TRUNCATED AT 250 WORDS)

The pathogenesis of acute pancreatitis. The source and role of oxygen-derived free radicals in three different experimental models.

Recent experimental work has suggested that oxygen-derived free radicals may play an important role in initiating the early capillary injury in acute pancreatitis. Data from models of ischemic injury in other organs have suggested the enzyme xanthine oxidase is important in generating oxygen-derived free radicals. The present study was performed to determine whether xanthine oxidase is the source of free radical production in experimental pancreatitis. Utilizing the isolated, perfused, ex vivo canine pancreas preparation, three models of pancreatitis were initiated with (1) free fatty acid infusion (FFA), (2) partial duct obstruction and secretin stimulation (POSS), and (3) ischemia (ISCH). In each model, during a 4-hour perfusion, edema developed, weight gain occurred (FFA 120.6 +/- 21.1 gm; POSS 44.5 +/- 6.9 gm; ISCH 63.3 +/- 14.0 gm), and the serum amylase became elevated (FFA 1827 +/- 397 u/dl; POSS 10,171 +/- 1487 u/dl; ISCH 1860 +/- 365 u/dl). When the xanthine oxidase enzyme inhibitor allopurinol was added to the perfusate prior to the 4-hour perfusion, edema formation was absent or minimal, weight gain was significantly less (FFA 15.2 +/- 2.5 gm p less than 0.05; POSS 8.8 +/- 2.7 gm p less than 0.001; ISCH 12.3 +/- 2.8 gm p less than 0.01), and the amylase remained normal or the elevation was significantly decreased (FFA 996 +/- 189 u/dl p less than 0.05; POSS 3021 +/- 1074 u/dl p less than 0.001; ISCH 993 +/- 214 u/dl p less than 0.002). These data confirm that oxygen-derived free radicals play an important role in the pathogenesis of experimental acute pancreatitis, and suggest that the enzyme xanthine oxidase may well be the source of their production.

The role of oxygen-derived free radicals in the pathogenesis of acute pancreatitis.

Acute pancreatitis may be initiated in the ex vivo, perfused canine pancreas preparation by a variety of stimuli. These include oleic acid infusion (FFA), partial duct obstruction with secretin stimulation (POSS), and a 2-hour period of ischemia (ISCH). In each model, pancreatitis is characterized by weight gain, edema, and hyperamylasemia. Oxygen-derived free radicals such as superoxide, hydrogen peroxide, and the hydroxyl radical are highly reactive toxic substances that are normally produced in small amounts during oxidative metabolism. Ordinarily, these substances are detoxified by endogenous intracellular enzymes called free radical scavengers (FRS), such as superoxide dismutase (SOD) and catalase (CAT). These studies were undertaken to evaluate the possible role of oxygen-derived free radicals in the initiation of acute pancreatitis in the isolated canine model. All preparations were perfused for 4 hours with autologous blood. Controls (N = 6): these glands remained normal in appearance, gained minimal weight (6 +/- 1 g), and serum amylase remained normal (less than 1000 u/dl). FFA pancreatitis, FFA alone (N = 6): these glands became edematous, gained weight (113.5 +/- 27.0 g), and developed hyperamylasemia (2087 +/- 387 u/dl). FFA + FRS (N = 6), SOD (50 mg) and CAT (50 mg) were added to the perfusate at time zero: these glands became only minimally edematous, gained less weight (31.8 +/- 10.1 g, p less than 0.05), and amylase remained normal (p less than 0.05). POSS pancreatitis, POSS alone (N = 8): these glands became edematous, gained weight (38.6 +/- 4.6 g), and developed marked hyperamylasemia (9522 +/- 3226 u/dl). POSS + FRS (N = 6): these glands did not develop edema, gained less weight (15.1 +/- 2.6 g, p less than 0.05), and serum amylase only increased to 1815 +/- 343 u/dl, (p less than 0.05). ISCH pancreatitis, ISCH alone (N = 6): these glands became edematous, gained weight (75.8 +/- 25 g), and developed hyperamylasemia (1679 +/- 439 u/dl). ISCH + FRS (N = 6): these glands did not develop edema, gained only 18.3 +/- 9.0 g (p less than 0.005), and serum amylase remained normal (p less than 0.05). These studies demonstrate that, in this canine preparation, acute pancreatitis is significantly ameliorated by oxygen-free radical scavengers. Since this was true whether the pancreatitis was produced by FFA infusion, POSS, or ischemia, it suggests that oxygen-derived free radicals may mediate a common essential step in the pathogenesis of all forms of pancreatitis.

Solid and papillary neoplasm of the pancreas. A potentially curable surgical lesion.

Two patients with a recently recognized pancreatic neoplasm are reported. In both cases the tumors occurred in young women (21 and 24 years) who presented with an abdominal mass. Both tumors were large (approximately 12 x 12 cm), one requiring a distal 85% pancreatectomy and the other a total pancreatectomy. Gross pathologic examination revealed apparent encapsulation, cystic degeneration, and hemorrhagic necrosis. Microscopically, the tumors were characterized by distinctive solid and papillary patterns. Such lesions have been reported recently in the pathology literature as "solid and papillary" or "papillary-cystic" neoplasms of the pancreas. Approximately 60 such cases have been reported to date. The histogenesis of these lesions is debatable. They may be diagnosed incorrectly as adenocarcinomas, islet cell tumors, cystadenomas, or cystadenocarcinomas. Assessing the degree of malignancy can be difficult since this tumor is capable of local invasion but usually does not metastasize. There is only one report of a patient dying from distant metastases. Both patients presented here are alive and well seven and 24 months post-surgery. It would appear that despite their large size these pancreatic tumors are potentially curable by surgical resection.

Steroid withdrawal in kidney transplant recipients: is it a safe option?

The long-term side effects of lifelong steroid immunosuppression are well documented, therefore, steroid withdrawal (SW) if safe would clearly be of benefit. From 1987-1996, 470 kidney transplants were performed at our institution. During this time period, steroid withdrawal was offered to a select group of patients (n = 43) who were at least 1 year post transplant (27.6 +/- 12.0 months, 15-64 months), had stable graft function and had experienced only mild episodes of rejection in the postoperative period. Informed consent was obtained from all participants. Twenty-five patients were male and 18 were female. The mean age at time of transplantation was 42.4 +/- 14.1 years (17-65 years). There were 28 cadaveric renal transplants (CRT), 10 living related kidney transplants (LRT) and 5 simultaneous kidney-pancreas transplants (SPK). Maintenance immunosuppression in all patients consisted of CSA 3-5 mg/kg, and AZA 1-2 mg/kg. Twenty-nine patients (67%) have remained off steroids with good renal function for 13-59 months (38.3 +/- 11.0). Steroids were restarted in 14/43 (32%) patients 1-36 months post SW (13.3 +/- 11.0 months). Eight of these 14 patients had a rise in creatinine and biopsy proven rejection, 5 of whom responded to reinstitution of steroid immunosuppression, and have stable renal function (CR = 2.0 +/- 0.4) 41-53 months (45 +/- 4.0 months) post SW. Three (7%) patients lost their allograft. One was a SPK recipient who retained good pancreatic function and subsequently received a successful 2nd kidney transplant. The other 2 patients died awaiting retransplantation. Steroids were recommenced in 6/14 patients who did not develop rejection for inability to tolerate CSA/AZA (2), anxiety (2) or recurrent disease (2). In the majority of our patients, (93%) SW did not result in immunologic graft loss. A graft loss of 7% (3) is not significantly different from the expected graft loss in a kidney transplant recipient population over a time period of 9 years. Therefore, we feel that with careful monitoring steroid withdrawal can be safely accomplished in select patients.

Carcinoma arising in Barrett's esophagus.

Between 1951 and 1983, 32 patients who had adenocarcinoma develop in Barrett's esophagus were identified at our institution. Twenty-nine patients were male (91 per cent) and 29 were white. Amongst the 23 patients in whom the relevant data were available, 78 per cent admitted to regular alcohol intake and 78 per cent smoked. Only one of these patients did not smoke or drink alcohol. Surprisingly, only 61 per cent of the patients had symptoms suggestive of gastroesophageal reflux and reflux was demonstrated roentgenographically in only 41 per cent. Twenty-one of the patients underwent esophagogastrectomy. Life table analysis revealed a survival rate of 34 per cent at two years and 14.8 per cent at five years.