Management of major postsurgical gastroesophageal intrathoracic leaks with an endoscopic vacuum-assisted closure system.

BACKGROUND: Endoscopic treatment options for postsurgical intrathoracic leaks include injection of fibrin glue, clip application, and stent placement. Endoscopic vacuum-assisted closure (E-VAC) may be an effective treatment option. OBJECTIVE: To demonstrate that E-VAC is an effective endoscopic treatment option for closure of major intrathoracic postsurgical leaks. DESIGN AND SETTING: A prospective, single-center study at an academic medical center. PATIENTS: Eight consecutive patients with major intrathoracic postsurgical leaks. INTERVENTIONS: Endoscopic placement of transnasal draining tubes, armed with a size-adjusted sponge at their distal end, in the necrotic anastomotic cavities, followed by continuous suction. Sponge and drainage were changed twice weekly. Patients were followed-up for 193 +/- 137 days. MAIN OUTCOME MEASUREMENT: Successful leak closure. RESULTS: Successful closure of leaks was achieved in 7 of 8 patients (88%) after a mean of 23 +/- 8 days. A median of 7 endoscopic interventions was necessary. No major treatment-associated short-term or long-term (follow-up, 193 +/- 137 days) complications were noted. LIMITATIONS: Small sample size, single-center study, and lack of randomization. CONCLUSION: E-VAC is an effective endoscopic treatment modality for major postsurgical intrathoracic leaks. (This study is registered at Clinicaltrials.gov, identifier NCT00876551.).

Renal transplantation today.

BACKGROUND: The first successful renal transplant was carried out more than five decades ago between identical twins. At these early days, acute rejection was the limiting factor. DISCUSSION: Due to tremendous progress in immunosuppressive therapy and surgical technique, today, renal transplantation is the gold standard therapy for patients with end-stage renal disease. In fact, in comparison with chronic hemodialysis, renal transplantation offers an increase in quality of life while reducing comorbidities associated with dialysis treatment. RESULTS: Despite numerous beneficial achievements, no further improvement regarding patient outcome can be observed over the last two decades. Graft survival rates remain unchanged. The leading causes for graft loss are chronic allograft nephropathy and death with functioning graft. This might be related to a constant increase of the proportion of donors presenting extended donor criteria as well as a more liberal acceptance of candidates for a renal transplant. CONCLUSION: In the near future, one has to focus more closely on the posttransplant patient care to minimize factors associated with chronic allograft damage. These include post-transplant diabetes, hyperlipidemia, high blood pressure, cytomegalovirus infection, etc.

Quality of life in adult transplant recipients more than 15 years after kidney transplantation.

BACKGROUND: With continuously rising survival rates following renal transplantation, health-related quality of life (HQOL) of long-term transplant survivors becomes increasingly important. METHODS: Recipients more than 15 years after successful renal transplantation were studied retrospectively. HQOL in 139 long-term transplant recipients was assessed using the SF-36 and the disease-specific kidney transplant questionnaire (KTQ-25). RESULTS: Long-term transplant recipients revealed satisfactory HQOL that was comparable to the healthy population in four of eight SF-36 categories (role physical, social functioning, role emotional and mental health). Other SF-36 categories such as physical functioning, physical pain, general health, and vitality were reduced. Among the study population, disease-specific HQOL was comparable or even improved to that of patients awaiting transplantation. In contrast to retired or unemployed patients, employed recipients revealed a highly significant improved HQOL in numerous SF-36 categories such as physical functioning (P<0.001), physical pain (P<0.001), general health (P<0.001), vitality (P<0.001), social functioning (P<0.005), and mental health (P<0.001), as well as for the KTQ-dimensions physical symptoms (P<0.001), fatigue (P>0.001), uncertainty/fear (P<0.01), and emotions (P<0.05). Other factors positively correlating with improved HQOL in certain dimensions were living situation, systolic blood pressure, and recipient age. CONCLUSIONS: More than 15 years after renal transplantation, recipients present satisfactory HQOL comparable to the general healthy population or at least to pretransplant patients. Vocational rehabilitation following renal transplantation is of highest importance among long-term survivors and is associated with improved HQOL.

Living donor nephrectomy: flank incision versus anterior vertical mini-incision.

BACKGROUND: Currently, many centers perform laparoscopic donor nephrectomy (DN). We studied the outcome of donors and recipients following open DN using either flank incision (ODN) or mini-incision (MIDN). METHODS: Data of 196 living kidney donors were recorded prospectively. In 127 cases ODN and 69 cases MIDN were performed. RESULTS: Demographic details of donors were comparable for both groups. The left kidney was procured in 58% for ODN and in 64% for MIDN. Multiple arteries were more frequently present when MIDN (11% vs. 28%) was performed. The mean operating time was 129 min for ODN and 133 min for MIDN. Early complications occurred in 7% following ODN and in 4% following MIDN. Late complications were observed in 21% after ODN and 1% after MIDN. The mean hospital stay was significantly longer following ODN compared with MIDN (7.5 vs. 6.4 days). The primary graft function rate was 97% in both groups. One-year graft survival was 97% after ODN and 100% after MIDN. CONCLUSIONS: Results following MIDN are superior to those following ODN. Even in case of multiple renal vessels MIDN can be safely applied. In comparison with laparoscopic DN advantages of MIDN may be reduced costs, shorter operating time, and comparable cosmetic results.

Presence of small parathyroid glands in renal transplant patients supports less-than-total parathyroidectomy to treat hypercalcemic hyperparathyroidism.

BACKGROUND: Parathyroid glands (PG) are rarely analyzed in renal transplant (RTX) patients. This study analyzes comparatively PG of RTX and end-stage renal disease (ESRD) patients. The clinical part of the study evaluates if total parathyroidectomy with autotransplantation (TPT+AT) treats appropriately hypercalcemic hyperparathyroidism in RTX patients. METHODS: TPT+AT was performed in 15 of 23 RTX and 21 of 27 ESRD patients. Remaining patients underwent less-than-total PT. Volume and stage of hyperplasia were determined from 86 PG of RTX and 109 PG of ESRD patients. Patients were categorized according to the presence of small PG (volume < 100 mm(3)). Calcium homeostasis and hyperparathyroidism were evaluated 2 years after PT in RTX patients. RESULTS: PG of RTX patients were significantly smaller, but similar hyperplastic in comparison to PG of ESRD patients. Small PG were more frequent in RTX than in ESRD patients (19% vs 6%) and mainly graded normal or diffuse hyperplastic (94%). Forty-seven percent of RTX, but only 14% of ESRD, patients receiving a total PT possessed ≥1 small PG (P < .05). Overall, PT treated successfully hypercalcemic hyperparathyroidism. However, TPT+AT caused permanent hypocalcemia in 50% of RTX patients without small PG and even in 83% of RTX patients with small PG. All RTX patients receiving less-than-total PT were normocalcemic at 2-year follow-up. Logistic regression revealed a 10.7 times greater risk of permanent hypocalcemia in RTX patients with small PG receiving TPT+AT compared with RTX patients without small PG receiving TPT+AT or RTX patients undergoing less-than-total PT. CONCLUSION: Surgeons performing PT should be aware of the high frequency of small and less diseased PG in RTX patients. In this context, TPT+AT might overtreat hypercalcemic hyperparathyroidism in RTX patients, especially when small PG are present.

Endoscopic vacuum-assisted closure of upper intestinal anastomotic leaks.

BACKGROUND: Management of intrathoracic anastomotic leaks remains an interdisciplinary challenge. Established treatment options include percutaneous drainage, endoscopic closure, or even surgical revision. All these procedures are associated with high morbidity and mortality rates. OBJECTIVE: We report a new, effective endoscopic treatment option for intrathoracic esophageal anastomotic leaks by using an endoscopic vacuum-assisted closure system. PATIENTS: Two patients with intrathoracic anastomotic leaks after esophagectomy and gastrectomy were included. METHODS: Surgical reinterventions failed to seal the leaks in 1 patient, whereas in the other patient the anastomotic leakage persisted after endoscopic placement of 2 covered self-expanding metal stents. We endoscopically placed transnasal draining tubes that were armed with a size-adjusted sponge at their distal tip in the necrotic anastomotic cavities. Continuous suction was applied. Sponge and drain were changed twice a week. RESULTS: No complications were noted during the course of treatment. After a median of 15 days, closure of the wound cavities was achieved in all cases. A median of 5 endoscopic interventions was necessary. Both patients returned gradually to a solid diet without recurrence of the leaks. CONCLUSION: Endoscopic vacuum-assisted closure might be an effective alternative in the treatment of upper intestinal anastomotic leaks.

Health-related quality of life in adult transplant recipients more than 15 years after orthotopic liver transplantation.

With continuously rising survival rates following orthotopic liver transplantation (OLT), health-related quality of life (HRQOL) of transplant recipients becomes increasingly important. Recipients more than 15 years after OLT were studied retrospectively. HRQOL in 104 adult liver transplant recipients surviving more than 15 years after OLT was assessed using the German Version of the 36-Item Health Survey (SF-36). Liver transplant recipients surviving more than 15 years after OLT scored lower in all categories of SF-36 revealing a poor HRQOL in comparison to the German reference population. A statistical significance was reached in almost all SF-36 categories with the exceptions of mental health and bodily pain, where our study population scored similarly to the reference population. Job rehabilitation after OLT had a positive effect on HRQOL. Patients who returned to their job during the first year after OLT scored significantly higher in the SF-36 categories of physical functioning and role physical. Marital status and the immunosuppression used didn't affect HRQOL as there was no statistical significance reached in any of the comparisons performed. More than 15 years after OLT, long-term survivors present a poor HRQOL comparable to the reference population. Occupational rehabilitation was the only factor shown to positively influence long-term HRQOL.

Living kidney donors >60 years of age: is it acceptable for the donor and the recipient?

Donors >60 years are now frequently accepted for living kidney transplantation (LKT). We asked whether a donor age >60 years may result in a higher risk for donor and recipient. All adult LKT from May 1996 to June 2005 were included. Long-term outcome was analysed, and results were compared for donors >60 and 60 (group A) and 158 from donors 60 years, we suggest that age should no longer be considered as a contra-indication for living donation.

Quality of life following living donor nephrectomy comparing classical flank incision and anterior vertical mini-incision.

In this study we focused on the quality of life and satisfaction of living kidney donors comparing traditional lumbar (LDN) and mini-incision donor nephrectomy (MIDN). From May 1996 to December 2002, 174 donor nephrectomies including 127 cases of LDN and 47 cases of MIDN were performed. Donors were evaluated using the SF-36 quality-of-life survey as well as a questionnaire dealing with donors' attitude towards kidney donation, financial burdens, pain, cosmetic satisfaction and duration of sick leave. Our donors achieved comparable or even higher scores in all the SF-36 categories in comparison to the general US population. Following MIDN, quality of life tended to be superior compared to that of LDN donors; however, statistical significance was reached only in one of the eight categories. Duration of sick leave following surgery was in favor of MIDN compared to LDN donors. Statistically significant differences favoring MIDN were observed regarding postoperative hospital stay and cosmetic satisfaction. The procedure would be again undergone by 94 of LDN and 97% of MIDN donors. Open-donor nephrectomy is a safe and cost-effective procedure. Introduction of the here-described MIDN has led to comparable or even improved results compared to LDN.