Lymphocele Outcomes After Renal Transplantations Performed by an Experienced Surgeon: Is Meticulously Performed Surgery and Experience Adequate to Prevent Lymphocele?

BACKGROUND The purpose of the present study was to analyze the rate of lymphoceles in kidney transplant operations meticulously performed by the same senior surgeon. MATERIAL AND METHODS The present study included 315 patients who were operated on in our organ transplantation center and followed up in the polyclinic after July 2013. The patients were retrospectively divided into 2 groups: patients with and without lymphocele. Symptomatic lymphocele (SL) has been defined as symptomatic fluid collection around the graft that necessitates an intervention for the graft or patient. RESULTS Lymphocele was observed in 82 (26%) patients. An intervention was needed in 16 (5.1%) of these cases. Demographic data such as age and sex of both groups were similar. Lymphocele cases were mostly asymptomatic, with a size <6 cm (75.6%). However, intervention was needed in 16 (75%) of the patients with a size ≥6 cm that were symptomatic. The length of time on dialysis in the pretansplant period was shorter in the group that developed lymphocele, and a lower rate of graft loss was observed in these patients. No statistically significant difference was found between the 2 groups in terms of rejection rates, serum albumin/globulin levels, and development of de novo DSA. CONCLUSIONS The risk factors reported in the literature related with lymphocele formation were not found to be statistically significant in our study. Complications, except lymphocele, were observed less frequently, but lymphocele formation was encountered in our patients despite meticulous surgery.

Management of a Resistant Hypotension Developing After Reperfusion of a Living-Donor Kidney Transplant.

We present a case of hypotension developing after reperfusion of a living-donor kidney transplant and performing a graft nephrectomy and successful retransplant with the same kidney 12 hours later. Preemptive kidney transplant was performed on a 51-year-old woman who had a chronic kidney disease because of hypertension. Her 55-year-old husband was the living kidney donor. The patient was stable before reperfusion. After declamping, pink color of the transplanted kidney, thrill from the renal artery, and urinary output were seen. But shortly after reperfusion, the invasive arterial blood pressure of the patient abruptly decreased from 130/70 mm Hg to 70/40 mm Hg, her pulse was approximately 80 to 110 beats/minute. The thrill disappeared from the renal artery, but blood flow continued. A graft nephrectomy was performed 45 minutes after reperfusion. Invasive arterial blood pressure of the patient was stabilized at approximately 110/70 mm Hg in the intensive care unit, and the patient was retransplanted with the same kidney. The patient was well, with a serum creatinine level of 1.4 mg/dL, 12 months after the operation. Resistant hypotension that occurs after kidney transplant may cause a loss of the graft and the patient. To prevent graft loss, and to stabilize the patient, a graft nephrectomy and retransplant of the graft under suitable circumstances may be considered.

Pulmonary Involvement in Brucellosis, a Rare Complication of Renal Transplant: Case Report and Brief Review.

Brucellosis, a disease endemic in many countries including Turkey, is a systemic infectious disease. Brucellosis is rare in renal transplant recipients. Only 4 cases have been reported in the literature. In this report, we describe the clinical manifestations and laboratory findings of a brucellosis case with pulmonary involvement in a renal transplant recipient. A 20-year-old man who had a living-donor kidney transplant 4 months earlier presented to our transplant clinic with fever, cough, and right flank pain. Clarithromycin and ceftriaxone were started for the diagnosis of pneumonia. However, piperacillin/tazobactam, meropenem plus teicoplanin, and antituberculosis treatment were continued because the patient was unresponsive to the initial therapy. Serum Brucella agglutination titer was found to be 1/320. Treatment was started with a 6-week course of oral doxycycline and rifampin, resulting in cure. Brucellosis and especially its pulmonary involvement are rare after kidney transplant. However, in endemic areas,it should be considered as it mimics several other infectious diseases.

Rupture of a Subcapsular Hematoma After Kidney Transplant: Case Report.

Subcapsular hematoma after kidney transplant may result in kidney ischemia and graft loss. In this report, we present a patient who had a subcapsular hematoma that had no intraoperative enlargement but ruptured after surgery. A man who had chronic kidney disease secondary to hypertension had a preemptive living-donor kidney transplant from his wife. After declamping, appropriate renal perfusion and urinary output were observed. At perfusion, a subcapsular hematoma (diameter, 3 cm) was observed at the upper pole of the kidney. The hematoma did not enlarge during the surgery. Capsulotomy was not performed due to possible risks, and transplant surgery was completed with the plan for close postoperative ultrasonography and hemodynamic follow-up. Decreased urinary output was observed early after surgery. Renal Doppler ultrasonography showed decreased diastolic flow and a hematoma (width, 9 mm) that completely surrounded the transplanted kidney. The patient had emergency reoperation due to active hemorrhage from his surgical drain at 40 hours after surgery. Rupture of the capsule and hemorrhage from the surface of the kidney were observed. Extended capsulotomy and hemostasis of the kidney were performed. After surgery, urinary flow increased and renal Doppler ultrasonography findings improved. In summary, intervention for a subcapsular hematoma after kidney transplant is controversial. Capsulotomy should be considered for treatment of increased pressure to the graft, risk of permanent damage, and risk of graft loss.

The effects of hyperoxaemia on tissue oxygenation in patients with a nadir haematocrit lower than 20% during cardiopulmonary bypass.

UNLABELLED: Excessive haemodilution and the resulting anaemia during CPB is accompanied by a decrease in the total arterial oxygen content, which may impair tissue oxygen delivery. Hyperoxic ventilation has been proven to improve tissue oxygenation in different pathophysiological states of anaemic tissue hypoxia. The aim of this study was to examine the influence of arterial hyperoxaemia on tissue oxygenation during CPB. Records of patients undergoing isolated CABG with CPB were retrospectively reviewed. Patients with nadir haematocrit levels below 20% during CPB were included in the study. Tissue hypoxia was defined as hyperlactataemia (lactate >2.2 mmol/L) coupled with low ScVO2 (ScVO2 <70%) during CPB. One hundred patients with normoxaemia and 100 patients with hyperoxaemia were included in the study. Patients with hyperoxaemia had lower tissue hypoxia incidence than patients with normoxaemia (p<0.001). Compared with patients without tissue hypoxia, patients with tissue hypoxia had significantly lower PaO2 values (p<0.001) and nadir haematocrit levels (p<0.001). Nadir haematocrit levels <18% (OR: 5.3; 95% CI: 2.67-10.6; p<0.001) and hyperoxaemia (OR: 0.28; 95% CI: 0.14-0.56; p<0.001) were independently associated with tissue hypoxia. CONCLUSIONS: Hyperoxaemia during CPB may be protective against tissue hypoxia in patients with nadir haematocrit levels <20%.

Comparison of anti-reflux mechanism between Double-J-Stent and standart Double-J-Stent use for risk of BK nephropathy and urinary tract Infection in kidney transplantation.

OBJECTIVES: There are studies that show that double J stenting (DJS) increase BK nephropathy (BKN) 4 fold. DJS may cause vesicoureteral reflux (VUR) with normal bladder contraction. The aim of this study is to comparison risk of BKN, urinary tract infections (UTI) and postoperative urologic complications with the use DJS with anti-reflux device (ARD-DJS) and standart double J stent (St-DJS). Matherial and methods: Ninety patients (male/female: 50/40) that had undergone kidney transplantations in Diyarbakir Training and Research Hospital and Dicle University, Faculty of Medicine Hospital between January 2012 and April 2015 were enrolled in the study. Demographic data, immunosuppression protocols, presence of rejection, graft loss, postoperative urologic complications, UTI, plasma BK levels of the patients were evaluated retrospectively. RESULTS: Median and IQR follow up time for ARD-DJS and St-DJS patients were 14 (12-18) months and 25 (16-30) months respectively. Five cases (5.5%) had BK viremia (P=0.025). All 5 cases with BK viremia were St-DJS users. CONCLUSION: As a result for postoperative UTI and postoperative urinary complication risk there were no statistically significant difference between ARD-DJS use and St-DJS use during ureteral anastomosis. BKN univariate analysis were significantly less than those st-DJS used. Risc factors were evaluated. But results were not statistically significant in the logistic regression analysis. We think that to demonstrate this benefit, we need randomized controlled studies with more patients and longer follow up.

Evaluation of Quality of Life Early and Late After Kidney Transplantation.

BACKGROUND The most important purpose of transplantation is to improve quality of life (QOL) together with increasing life expectancy. The aim of this study was to compare the QOL of both donors and kidney transplant recipients and a control group at the 3rd and 9th postoperative months by using the SF36 health survey, to investigate the changes in this 6-month period and to evaluate descriptive data and satisfaction of patients and donors. MATERIAL AND METHODS Forty-seven donors and 47 kidney transplant recipients who were operated on in Diyarbakir Gazi Yasargil Training and Research Hospital between August 2012 and March 2015 and had been followed up for at least 9 months and 47 healthy controls were enrolled in the study. RESULTS Physical functioning (PF) was higher at the 9th postoperative month compared to the 3rd month in the recipient group (p=0.028). Donors had higher PF (p=0.007) and functioning physical role (PR; p=0.01) compared to recipients. Recipients had lower PF (p=0.016), PR (p=0.004), and functional-emotional role (ER; p=0.03) at the 3rd month and had lower PR (p=0.002) at the 9th month postoperatively comparing to the control group. Donors had lower PF (p=0.007) and PR (p=0.01) at the 3rd month and had lower PR (p=0.035) at the 9th month postoperatively comparing to the control group. Donors and recipients had similar QOL at the 9th month. CONCLUSIONS During follow-up, we observed an increase in QOL (in some subgroups) at 9 months postoperatively. Donors and recipients had similar QOL (except for PR) with the control group at the 9th month. QOL was better in younger and male patients and educated persons. Donors did not show any regret regarding their donation.

Relationship between cobalamin deficiency and delirium in elderly patients undergoing cardiac surgery.

BACKGROUND: Delirium is common after cardiac surgery and is independently associated with increased morbidity, mortality, prolonged hospital stays, and higher costs. Cobalamin (vitamin B12) deficiency is a common cause of neuropsychiatric symptoms and affects up to 40% of elderly people. The relationship between cobalamin deficiency and the occurrence of delirium after cardiac surgery has not been examined in previous studies. We examined the relationship between cobalamin deficiency and delirium in elderly patients undergoing coronary artery bypass grafting (CABG) surgery. MATERIAL AND METHODS: A total of 100 patients with cobalamin deficiency undergoing CABG were enrolled in this retrospective study. Control group comprised 100 patients without cobalamin deficiency undergoing CABG. Patients aged 65 years or over were included. Diagnosis of delirium was made using Intensive Care Delirium Screening Checklist. Delirium severity was measured using the Delirium Rating Scale-revised-98. RESULTS: Patients with cobalamin deficiency had a significantly higher incidence of delirium (42% vs 26%; P=0.017) and higher delirium severity scores (16.5±2.9 vs 15.03±2.48; P=0.034) than patients without cobalamin deficiency. Cobalamin levels were significantly lower in patients with delirium than patients without delirium (P=0.004). Delirium severity score showed a moderate correlation with cobalamin levels (ρ=-0.27; P=0.024). Logistic regression analysis demonstrated that cobalamin deficiency was independently associated with postoperative delirium (OR 1.93, 95% CI 1.03-3.6, P=0.038). CONCLUSION: The results of our study suggest that cobalamin deficiency may be associated with increased risk of delirium in patients undergoing CABG. In addition, we found that preoperative cobalamin levels were associated with the severity of delirium. This report highlights the importance of investigation for cobalamin deficiency in patients undergoing cardiac surgery, especially in the elderly.

Comparison of outcomes of laparoscopic intracorporeal knotting technique in patients with complicated and noncomplicated acute appendicitis.

BACKGROUND AND AIM: In our study we aimed to compare laparoscopic intracorporeal knotting technique (base of the appendix was ligated with 20 cm of 2.0 silk) in patients with complicated acute appendicitis (CAA) and noncomplicated acute appendicitis. PATIENTS AND METHODS: Ninety patients (female/male: 40/50, age ranging from 16 to 60 years, median age and interquartile range [IQR]: 25 [20; 32] years) who underwent laparoscopic appendectomy were included in the study. The patients were evaluated for the type of acute appendicitis, duration of operation, duration of hospital stay, and postoperative complications. RESULTS: The number of cases diagnosed as CAA was 28 (31.1%), and the number of noncomplicated cases was 62 (68.9%). We found that there was no significant difference in postoperative complication rates between complicated and noncomplicated appendicitis cases. Incision site infection was seen in seven cases (7.8%) and ileus was seen in two cases (2.2%). Bleeding, intra-abdominal abscess, and appendix stump leakage were not observed in any of the cases. Median and IQR duration of operation were 42 (35; 52) minutes and median and IQR duration of hospital stay were detected as 2 (1; 2) (range 1-10) days. CONCLUSION: Laparoscopic intracorporeal knotting technique may be a safe, effective, and reliable technique as the materials needed for closing the appendix stumps are easily available for both CAA cases and noncomplicated cases.

Role of diclofenac in the prevention of postpericardiotomy syndrome after cardiac surgery.

OBJECTIVE: Postpericardiotomy syndrome (PPS), which is thought to be related to autoimmune phenomena, represents a common postoperative complication in cardiac surgery. Late pericardial effusions after cardiac surgery are usually related to PPS and can progress to cardiac tamponade. Preventive measures can reduce postoperative morbidity and mortality related to PPS. In a previous study, diclofenac was suggested to ameliorate autoimmune diseases. The aim of this study was to determine whether postoperative use of diclofenac is effective in preventing early PPS after cardiac surgery. METHODS: A total of 100 patients who were administered oral diclofenac for postoperative analgesia after cardiac surgery and until hospital discharge were included in this retrospective study. As well, 100 patients undergoing cardiac surgery who were not administered nonsteroidal anti-inflammatory drugs were included as the control group. The existence and severity of pericardial effusion were determined by echocardiography. The existence and severity of pleural effusion were determined by chest X-ray. RESULTS: PPS incidence was significantly lower in patients who received diclofenac (20% vs. 43%) (P<0.001). Patients given diclofenac had a significantly lower incidence of pericardial effusion (15% vs. 30%) (P=0.01). Although not statistically significant, pericardial and pleural effusion was more severe in the control group than in the diclofenac group. The mean duration of diclofenac treatment was 5.11±0.47 days in patients with PPS and 5.27±0.61 days in patients who did not have PPS (P=0.07). Logistic regression analysis demonstrated that diclofenac administration (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.18-0.65, P=0.001) was independently associated with PPS occurrence. CONCLUSION: Postoperative administration of diclofenac may have a protective role against the development of PPS after cardiac surgery.

Factors affecting morbidity and mortality in traumatic colorectal injuries and reliability and validity of trauma scoring systems.

BACKGROUND AND AIM: This study aims to determine the factors that affect morbidity and mortality in colon and rectum injuries related with trauma, the use of trauma scoring systems in predicting mortality and morbidity. PATIENTS AND METHODS: Besides patient demographic characteristics, the mechanism of injury, the time between injury and surgery, accompanying body injuries, admittance Glasgow coma scale (GCS), findings at surgery and treatment methods were also recorded. With the obtained data, the abbreviated injury scale (AIS), injury severity score (ISS), revised trauma score (RTS) and trauma-ISS (TRISS) scores of each patient were calculated by using the 2008 revised AIS. RESULTS: Of the patients, 172 (88.7 %) were male, 22 (11.3 %) were female and the mean age was 29.15 ± 12.392 (15-89) years. The morbidity of our patients were 32 % and mortality were 12.4 %. ISS (p < 0.001), RTS (p < 0.001), and the TRISS (p < 0.001) on mortality were found to be significant. TRISS (p = 0.008), the ISS (p < 0.001), the RTS (p = 0.03), the trauma surgery interval (TSI, p < 0.001) were observed to have significant effects on morbidity. Regression analysis showed that the ISS (OR 1.1; CI 95 % 1.01-1.2; p = 0.02), the RTS (OR 0.37; CI 95 % 0.21-0.67; p = 0.001) had significant effects on mortality. While the effects of TSI (OR 5.3; CI 95 % 1.5-18.8; p = 0.01) on morbidity were found to be significant. CONCLUSION: Predicting mortality by using scoring systems and close postoperative follow up of patients in the risk group may ensure decreases in the rates of morbidity and mortality.