New application of the bipolar vapor plasma coagulation system for laparoscopic major liver resections.

BACKGROUND: In recent years, laparascopic techniques have become a more widely used and accepted means for performing various types of liver resections. In this report, the authors describe the use and initial applications of a new approach to laparoscopic liver resection using vapor pulse coagulation. METHODS: Liver resections using vapor plasma coagulation technology were performed for 11 patients at the authors' center. Candidates were initially selected because they had benign disease and lesions amenable to standard resections along anatomic planes. Four resections were performed with a hand-assist technique and seven without it. RESULTS: All the patients faired well. The length of the hospital stay was 3.4 +/- 0.7 days. There were no major surgical complications, bile leaks, or reoperations. None of the patients required blood transfusions. One patient was readmitted for fever and urinary tract infection, and one patient had 1 week of right leg swelling attributable to the use of stirrups. CONCLUSIONS: Vapor plasma coagulation using a laparoscopic approach for hepatic resection is a promising new technology that deserves further exploration.

Hypercoagulability risks among adult living liver donors.

BACKGROUND: Review of the literature is limited with respect to thrombotic risk in the living liver donor. This study examines inherent coagulable changes that occur as a result of the surgery. MATERIALS AND METHODS: At our center, we have performed 353 orthotopic adult liver transplants in the past 4 years. Of these, 20 were adult-adult right lobe living donor transplants. All living donors are alive and doing well. Of these, eight living donors were followed preoperatively and postoperatively monitoring protein C, protein S, antithrombin III, and factor VIII levels. Levels were checked at 48 hours postoperatively, as well as at 2, 4, and 6 weeks. RESULTS: All eight patients had normal levels preoperatively, although significantly low levels were identified postoperatively of these coagulation markers: protein C decreased to as low as 0%, (range 0-29; normal 50-150) within 48 hours postoperatively; protein S decreased to 3% to 40% during the same time frame (normal 50-150), and antithrombin III levels decreased to 47% to 55% (normal range 50-150%). Factor VIII levels significantly increased to >200% (normal 50- 150). All coagulation levels returned to the normal range within 4 to 6 weeks. None of the patients developed a thromboembolic event. CONCLUSIONS: We observed an imbalance of low protein C, S, and antithrombin III and elevated factor VIII levels, which have been documented as thrombotic risks in adults. Our findings suggest that the imbalance in the coagulation profile after surgery may be an independent risk factor for thrombosis beyond the surgical event, a phenomenon that requires further exploration.

Portal Vein Inflow From Enlarged Coronary Vein in Liver Transplantation: Surgical Approach and Technical Tips: A Case Report.

Portal vein thrombosis is common in patients with end-stage liver disease, with an incidence as high as 26% in liver transplant candidates. It is known to be associated with a high risk of morbidity and mortality posttransplantation, and its management can be challenging. The management options range from a simple thrombendvenectomy to multivisceral transplantation in cases with diffuse portomesenteric thrombosis. We report a case of liver transplantation in which we performed a rare reconstruction of the portal vein. Briefly, the patient had diffuse portomesenteric thrombosis, calcified aneurysmosis, and a large collateral coronary vein, to which we directly anastomosed the donor portal vein in an end-to-side fashion. This report describes a unique surgical approach for similar cases of severe portal vein thrombosis in liver transplant candidates.

A national study of burnout among American transplant surgeons.

This study examines burnout in a national sample of transplant surgeons. Data analyses were conducted on a sample of 209 actively practicing transplant surgeons. Measures included the Maslach Burnout Inventory, a demographic survey, and the Surgeon Coping Inventory. Burnout was reflected in 38% of surgeons scoring high on the Emotional Exhaustion dimension, whereas 27% showed high levels of Depersonalization, and 16% had low levels of Personal Accomplishment. Several significant predictors of emotional exhaustion were identified and included questioning one's career choice, giving up activities, and perceiving oneself as having limited control over the delivery of medical services (R2= 0.43). Those who perceived themselves as having a higher ability to control delivery of medical services and who felt more appreciated by patients had lower levels of depersonalization and were less likely to question their career choice (R2= 0.16). Surgeons with high personal accomplishment experienced greater professional growth opportunities, perceived their institution as supportive, felt more appreciated by patients, and were less likely to question their career (R2= 0.24). The prioritization of goals to reflect both professional and personal values accounted for a significant amount of the variance in predicting both emotional exhaustion and personal accomplishment in separate regression equations. Recommendations to decrease burnout would include greater institutional support, increased opportunities for professional growth, and greater surgeon control over important services to facilitate efficient work. Coping strategies to moderate stress and burnout are also beneficial and should include prioritizing goals to reflect both professional and personal values.

Risk factors affecting second renal transplant outcome, with special reference to primary allograft nephrectomy.

Removal of a failed primary renal allograft was found by some groups to adversely affect the outcome of a second kidney transplant. Recent data does not support this view and fail to show any such effect. Such data, however, are limited by small numbers or univariate analysis. The records of 192 patients receiving a primary and a subsequent kidney transplant between January 1980 and July 1992 were retrospectively reviewed. Immunosuppression initially included azathioprine and prednisone; cyclosporine was introduced in December 1983 with Minnesota antilymphocyte globulin (MALG) added for induction in May 1987. Regraft survival rates were 66% at one year and 60% at two years. Using Kaplan-Meier survival analysis patients having primary transplant nephrectomy had a worse second allograft outcome than patients who kept their failed grafts (P = 0.0003). Multivariate analysis showed a significant relationship between primary allograft survival and retransplant outcome. To eliminate this influence, patients whose first graft failed within six months of transplantation were excluded from the analysis. This resulted in 90 patients whose first graft functioned for more than 6 months. Graft survival was 80% at one year and 73% at 2 years in this select population. Patients with prior transplant nephrectomy still had a worse retransplant outcome than those who kept their failed grafts (P = 0.05). Multivariate analysis identified primary allograft nephrectomy, older donor age, longer interval from nephrectomy to retransplant, and lack of MALG at induction as negative risk factors. In conclusion, primary allograft nephrectomy may have a negative influence on second renal transplant outcome. This result may be improved by reducing donor age and the time interval from nephrectomy to retransplantation, and using MALG at induction.

Quality of life improvements at one, two, and five years after liver transplantation.

We prospectively studied adult liver transplant (OLTX) recipients to evaluate the effect of OLTX on quality of life (QOL). Over an 8-year period, all adult patients undergoing OLTX at our institution were asked to complete a psychological questionnaire that probed broad facets of QOL. Patients seen for their 1, 2, and 5 or more-year post-OLTX visits were also asked to complete the form. Questions were then grouped by categories broadly highlighting self-image (SI), health perception (HP), ability to function (F), and ability to work (W). Questions ranged from demographic and occupational topics to symptom distress/frequency, activities of daily living, and the impact of health on daily life. Numerical scores were assigned to each question, and added to derive scores on SI, HP, and F. Higher scores reflect better QOL. Employment data (W) were also compared, though not amenable to scoring. A total of 573 forms were completed (210 pretransplant, 150 at 1 year, 131 at 2 years, 79 at 5 years). All posttransplant scores were significantly higher than pretransplant ones (P < or = .0001, ANOVA). Scores at posttransplant time points were not significantly different from each other. Subscores of SI and HP revealed less symptom frequency and distress following OLTX (P < or = .0003) continuing to beyond 5 years. Health limitations on activities decreased both at 1 year post-OLTX and again at 2 years (P < or = .0001) and were sustained to beyond 5 years. Fewer people were working for pay at 1 year post-compared with pre-OLTX, but pre-OLTX levels of employment had been regained by the second year, continuing to increase to beyond 5 years. OLTX leads to improved QOL by the end of the first posttransplant year, sustained through the 5th posttransplant year and beyond. Self-image, functioning ability, and perception of health status were significantly improved. Ill health interference in daily life continues to decrease as OLTX becomes more remote. Employment suffers early after OLTX, but recovers by the second post-OLTX year and continues to increase long-term.

A comparison of treatment with transjugular intrahepatic portosystemic shunt or distal splenorenal shunt in the management of variceal bleeding prior to liver transplantation.

Recurrent variceal bleeding in liver transplant candidates with end-stage liver disease can complicate or even prohibit a subsequent transplant procedure (OLT). Endoscopic sclerotherapy and medical therapy are considered as first-line management with surgical shunts reserved for refractory situations. Surgical shunts can be associated with a high mortality in this population and may complicate subsequent OLT. The transjugular intrahepatic portosystemic shunt (TIPS) has been recommended in these patients as a bridge to OLT. This is a new modality that has not been compared with previously established therapies such as the distal splenorenal shunt (DSRS). In this study we report our experience with 35 liver transplant recipients who had a previous TIPS (18 patients) or DSRS (17 patients) for variceal bleeding. The TIPS group had a significantly larger proportion of critically ill and Child-Pugh C patients. Mean operating time was more prolonged in the DSRS group (P = 0.014) but transfusion requirements were similar. Intraoperative portal vein blood flow measurements averaged 2132 +/- 725 ml/min in the TIPS group compared with 1120 +/- 351 ml/min in the DSRS group (P < 0.001). Arterial flows were similar. Mean ICU and hospital stays were similar. There were 3 hospital mortalities in the DSRS group and none in the TIPS group (P = 0.1). We conclude that TIPS is a valuable tool in the management of recurrent variceal bleeding prior to liver transplantation. Intraoperative hemodynamic measurements suggest a theoretical advantage with TIPS. In a group of patients with advanced liver disease we report an outcome that is similar to patients treated with DSRS prior to liver transplantation. The role of TIPS in the treatment of nontransplant candidates remains to be clarified.

Use of polypropylene mesh to stabilize the "floating humerus" after total scapulectomy.

Total scapulectomy for malignant disease is a rarely performed procedure that presents a significant challenge for shoulder reconstruction. Failure to stabilize the resulting "floating humerus" may result in significant esthetic and functional problems. Current techniques of reconstruction and stabilization may yield suboptimal results and significant morbidity. We report a case of Ewing's sarcoma of the scapula, which required total scapulectomy. Polypropylene mesh was used in an attempt to prevent migration of the head of the humerus. The result was a stable shoulder with satisfactory motion and no additional morbidity. We believe that polypropylene mesh offers an advantage in shoulder reconstruction after total scapulectomy and should be considered as an option for stabilization of the humerus.

Combination antifungal therapy for invasive aspergillosis infection in liver transplant recipients: report of two patients.

Invasive aspergillosis in solid organ transplant recipients is associated with mortality of approximately 100%. The search for optimal therapy has led clinicians to administer antifungal combinations. Two orthotopic liver transplant recipients developed invasive aspergillosis (pulmonary and perivertebral) after transplantation and were treated with combination antifungal therapy consisting of liposomal amphotericin B and itraconazole. Although both patients were initially stabilized, they died after 94 and 138 days of antifungal therapy, respectively. Presumably, aspergillosis was the principal cause of death. Antifungal serum concentrations and fungicidal titers in both patients indicated that the drugs may have been antagonistic and thus detrimental.

Arterial injuries of the thoracic outlet: a ten-year experience.

Arterial injuries of the thoracic outlet are complex and require a precise plan for adequate management and prompt exposure of injured vessels. Our 10-year experience with 28 such injuries is reviewed. Arteriography was performed whenever possible in stable patients (15) and aided in planning the operative approach. Unstable patients with active bleeding, pulsatile or expanding hematoma, or pulse deficit were taken to the operating room without delay. A thoracic approach was required in 15 patients, and the exposure was extrathoracic in 12 patients. Airway was secured with liberal use of emergency endotracheal intubation (16 patients). Primary repair was possible in 16 patients, with grafting performed in eight and ligation in three. One vertebral artery injury was successfully controlled with embolization. Venous injuries were repaired in six patients and ligation was necessary in eight; there was no significant morbidity. Two patients died in this series from complications of severe hemorrhage. Significant morbidity was encountered from associated neurologic injuries in 15 patients. Stroke was evident in two patients, both of whom were moribund preoperatively. Proximal subclavian artery injuries were particularly more problematic and frequently required an interim anterior thoracotomy for early control of exsanguinating hemorrhage. Our philosophy in the management of these injuries and choices of exposure are discussed in detail.

Cost-utility analysis of living-donor kidney transplantation followed by pancreas transplantation versus simultaneous pancreas-kidney transplantation.

For a type I diabetic with end-stage renal disease, the choice between a kidney-alone transplant from a living-donor (KA-LD) and a simultaneous pancreas kidney (SPK) transplant remains a difficult one. The prevailing practice seems to favor KA-LD over SPK, presumably due to the superior long-term renal graft survival in KA-LD and the elimination of the lengthy waiting time on the cadaver transplant list. In this study, two treatment options, KA-LD followed by pancreas-after-kidney (PAK) and SPK transplant, are compared using a cost-utility decision analysis model. The decision tree consisted of a choice between KA-LD + PAK and SPK. The analysis was based on a 5-yr model and the measures of outcome used in the model were cost, utility and cost-utility. The expected 5-yr cost was $277,638 for KA-LD + PAK and $288,466 for SPK. When adjusted for utilities, KA-LD + PAK at a cost of $153,911 was less cost-effective than SPK at a cost of $110,828 per quality-adjusted year. One-way sensitivity analyses were performed by varying patient and graft survival probabilities, utilities and cost. SPK remained the optimal strategy over KA-LD + PAK across all variations. Two-way sensitivity analysis showed that in order for KA-LD + PAK to be at least as cost-effective as SPK, 5-yr pancreas and patient survival rates following PAK would need to surpass 86 and 80%. In conclusion, according to the 5-yr cost-utility model presented in this study, KA-LD followed by PAK is less cost-effective than SPK as a treatment strategy for a type I diabetic with end-stage renal disease. For patients interested in the benefits of a pancreas transplant, it would be reasonable to offer SPK as the optimal treatment, even if a living kidney donor is available.