Comparison of dural grafts and methods of graft fixation in Chiari malformation type I decompression surgery.

Suboccipital decompression with duraplasty is a widely accepted method for treating patients with Chiari malformation type I. However, important details of the duraplasty technique are still controversial. This retrospective study analyzes clinical and radiological outcomes after surgery depending upon the type of graft and methods of graft fixation. Seventy consecutive decompressions with duraplasty were analyzed. Two types of grafts, nonautologous (Non-AutoG; 60.0%) and autologous (AutoG; 40.0%), and two methods of graft fixation, suturing (S; 67.1%) and gluing (G; 32.9%), were used in four different combinations: (Non-AutoG+S: 31.4%; Non-AutoG+G: 28.6%; AutoG+S: 35.7%; AutoG+G: 4.3%) according to surgeon preference. The mean follow-up was 63.4 months. According to gestalt and Chicago Chiari Outcome Scales, satisfactory results were obtained in 72.9% and 78.6% of cases, respectively, in the long term. The outcomes were not related to the kind of graft (p = 0.44), fixation method (p = 0.89) or duraplasty pattern (p = 0.32). Decreased syringomyelia was observed in 88.9% of cases, and no associations with the kind of graft (p = 0.84), fixation method (p = 1) or duraplasty pattern were found (p = 0.96). Pseudomeningocele occurred 5 times more often in the Non-AutoG group than in the AutoG group (52.4% vs. 10.7%; p < 0.05), whereas their formations were not related to the fixation method (p = 0.34). Three cases (12.0%) required reoperation with reduraplasty. Autologous and nonautologous dural grafts can be sutured or glued with similar clinical results; however, the use of nonautologous grafts is linked with a much higher risk of pseudomeningocele formation.

¿Es el ADN libre circulante (cfDNA) derivado del donante (dd-cfDNA) un nuevo biomarcador para el rechazo de aloinjertos en trasplante? / No disponible

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Anterolateral Ligament Reconstruction Is Associated With Significantly Reduced ACL Graft Rupture Rates at a Minimum Follow-up of 2 Years: A Prospective Comparative Study of 502 Patients From the SANTI Study Group.

BACKGROUND: Graft failure and low rates of return to sport are major concerns after anterior cruciate ligament (ACL) reconstruction, particularly in a population at risk. PURPOSE: To evaluate the association between reconstruction techniques and subsequent graft rupture and return-to-sport rates in patients aged 16 to 30 years participating in pivoting sports. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A prospective study of patients undergoing primary ACL reconstruction with a bone-patellar tendon-bone (B-PT-B) graft, quadrupled hamstring tendon (4HT) graft, or hamstring tendon graft combined with anterolateral ligament reconstruction (HT+ALL) was conducted by the Scientific ACL NeTwork International (SANTI) Study Group. Survivorship data from Kaplan-Meier analysis were analyzed in multivariate Cox regression models to identify the prognosticators of graft ruptures and return to sport. RESULTS: Five hundred two patients (mean age, 22.4 ± 4.0 years) with a mean follow-up of 38.4 ± 8.5 months (range, 24-54 months) were included. There were 105 B-PT-B, 176 4HT, and 221 HT+ALL grafts. The mean postoperative scores at latest follow-up were the following: Lysholm: 92.4 ± 8.6, Tegner: 7.4 ± 2.1, and subjective International Knee Documentation Committee (IKDC): 86.8 ± 10.5 for B-PT-B grafts; Lysholm: 91.3 ± 9.9, Tegner: 6.6 ± 1.8, and subjective IKDC: 85.4 ± 10.4 for 4HT grafts; and Lysholm: 91.9 ± 10.2, Tegner: 7.0 ± 2.0, and subjective IKDC: 81.8 ± 13.1 for HT+ALL grafts. The mean side-to-side laxity was 0.6 ± 0.9 mm for B-PT-B grafts, 0.6 ± 1.0 mm for 4HT grafts, and 0.5 ± 0.8 mm for HT+ALL grafts. At a mean follow-up of 38.4 months, the graft rupture rates were 10.77% (range, 6.60%-17.32%) for 4HT grafts, 16.77% (range, 9.99%-27.40%) for B-PT-B grafts, and 4.13% (range, 2.17%-7.80%) for HT+ALL grafts. The rate of graft failure with HT+ALL grafts was 2.5 times less than with B-PT-B grafts (hazard ratio [HR], 0.393; 95% CI, 0.153-0.953) and 3.1 times less than with 4HT grafts (HR, 0.327; 95% CI, 0.130-0.758). There was no significant difference in the graft failure rate between 4HT and B-PT-B grafts (HR, 1.204; 95% CI, 0.555-2.663). Other prognosticators of graft failure included age ≤25 years ( P = .012) and a preoperative side-to-side laxity >7 mm ( P = .018). The HT+ALL graft was associated with higher odds of returning to preinjury levels of sport than the 4HT graft (odds ratio [OR], 1.938; 95% CI, 1.174-3.224) but not compared with the B-PT-B graft (OR, 1.460; 95% CI, 0.813-2.613). CONCLUSION: In a high-risk population of young patients participating in pivoting sports, the rate of graft failure with HT+ALL grafts was 2.5 times less than with B-PT-B grafts and 3.1 times less than with 4HT grafts. The HT+ALL graft is also associated with greater odds of returning to preinjury levels of sport when compared with the 4HT graft.

Intolerancia a tornillo interferencial tibial. Una rara complicación en la Cirugía de reconstrucción del ligamento cruzado anterior / Intolerance to tibial fixation devices for ACL repair. A rare complication

Introducción: Se presenta una serie de casos de pacientes que han desarrollado bultoma, secreción y dolor pretibial tras la reconstrucción del LCA fijado con tornillos reabsorbibles (HA-PLLA [Hidroxiapatita- ácido L-poliláctico]). Método: Se revisan de manera retrospectiva todas las reconstrucciones de LCA realizadas entre 2008 y 2014 para identificar las complicaciones relacionadas con el sistema de fijación bioabsorbible. Durante ese periodo de 6 años se realizaron 620 reconstrucciones de LCA usando el tornillo bioabsorbible (HA-PLLA) para la fijación tibial del injerto tetrafascicular de isquiotibiales. Resultados: Nueve pacientes (1,45%) con un rango de edad de 29,8 (19-44 años), presentaron el periodo postoperatorio dolor, tumoración y secreción pretibial en la zona de inserción del tornillo. Todos presentaron marcadores inflamatorios normales. Todos los pacientes requirieron desbridamiento quirúrgico, y retirada de los restos del tornillo y de los tejidos reactivos. Se evidenció infección en 4 cultivos intraoperatorios. La anatomía patológica reveló restos detríticos birrefringentes en el citoplasma de los macrófagos. La retirada de los restos del tornillo y el desbridamiento y curetaje del túnel, supuso la recuperación completa de todos los pacientes de nuestra serie. Conclusiones: La tumoración pre-tibial como respuesta biológica adversa, debe considerarse como una posible complicación en la reconstrucción del LCA. Se aprecia una incidencia de 1,45% de reacción pretibial tras el uso de tornillos reabsorbibles (HA-PLLA) en tibia proximal en la reconstrucción de LCA

Background: We report a series of cases that presented as pre-tibial cyst, swelling and pain following anterior cruciate ligament (ACL) reconstruction using bioabsorble fixation devices (HA-PLLA). Methods: All ACL reconstructions were done between 2008 and 2014 reviewed retrospectively to identify complications related to bioabsorbable fixation devices. During this period of 6 years, 620 ACL reconstructions were performed using the bioabsorbable screw (HA-PLLA) for tibial fixation of the quadrupled hamstring autograft. Results: Nine patients (1,45%) with mean age of 29,8 (19-44) years, presented in the post-operative period, pre-tibial pain, cyst and swelling in tibial screw site. All of them had normal inflammatory markers. All of these patients underwent surgical debridement, which revealed remnants of screw and reactive material. There was evidence of infection in 4 intra-operative specimen cultures. Histopathology revealed detritic birefringent remains in macrophages cytoplasm. Removal of screw debris and curettage of the tunnel resulted in complete recovery of all patients in our series. Conclusions: Pre-tibial cyst as an adverse biological response should be considered as a possible complication in ACL reconstruction. We report a 1,45% of pre-tibial reaction in patients undergoing ACL reconstruction with bio-absorbable (HAPLLA) interference screw fixation for the proximal tibia

Estrategias de optimización del donante multiorgánico / No disponible

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Low volume is associated with worse patient outcomes for pediatric liver transplant centers.

BACKGROUND: An inverse association between hospital procedure volume and postoperative mortality has been demonstrated for a variety of pediatric surgical procedures. The objective of our study was to determine whether such an association exists for pediatric liver transplantation. METHODS: We performed a retrospective analysis of pediatric liver transplant procedures included in the Scientific Registry of Transplant Recipients over a 7.5-year time period from July 1, 2000, through December 31, 2007. Pediatric liver transplant centers were divided into three volume categories (high, middle, low) based on absolute annual volume. Mean 1-year patient survival rates and aggregate 1-year observed-to-expected (O:E) patient death ratios were calculated for each hospital volume category and then compared using ordered logistic regression and chi square analyses. RESULTS: High-volume pediatric liver transplant centers achieved significantly lower aggregate 1-year O:E patient death ratios than low-volume centers. When freestanding children's hospitals (FCH), children's hospitals within adult hospitals (CAH), and other centers (OC) were considered separately, we found that a significant volume-outcomes association existed among OC centers but not among FCH or CAH centers. Low-volume OC centers, which represent 41.6% of all pediatric liver transplant centers and perform 10% of all pediatric liver transplantation, had the least favorable aggregate 1-year O:E patient death ratio of all groups. CONCLUSIONS: We demonstrate that a significant center volume-outcomes relationship exists among OC pediatric liver transplant centers but not among FCH or CAH centers. These findings support the possible institution of minimum annual procedure volume requirements for OC pediatric liver transplant centers.

The 'current state of play' in transplantation and restoration research of the CNS.

At the Network of European CNS Transplantation and Restoration 2005 meeting, a number of revealing studies were reported that could be divided into two broad, overlapping groups; methods to maximize the efficacy of cell transplants in vitro and their use in vivo. A variety of different forms of stem cells ranging from embryonic stem cells to cells expressing specific genes following lentiviral vector transduction were investigated. Methods to improve the efficacy of transplants included the cotransplantation of other cell lines, exposure of the recipient to an enriched environment and methods to promote differentiation. The majority of the studies, if disease-specific, related to Parkinson's disease, but additional reports on Huntington's disease, Alzheimer's disease and spinal cord injury were also present. A few studies related to different animal models of disease. Overall the future for transplantation and restoration of functional activity in diseased states is very promising.

Organ donation in the United States: 1988-2001.

Based upon information reported to the United Network for Organ Sharing (UNOS) as of December 12, 2002: 1. There were 6,082 cadaveric and 6,535 living donors recovered in 2001, a 49% and 258% increase over those recovered in 1988. 2. The number of cadaveric donors aged 50 or older increased from 12% of all donors in 1988 to 31% of all donors in 2001. 3. The typical cadaveric donor in 2001 was a white male with ABO blood type O between the ages of 35-49. In 2001, a typical living donor was a white female with ABO blood type O between the ages of 35-49. 4. Between 1988-2001, the percentage of minority donors increased for cadaveric donors (from 17% to 27%), and for living donors (from 24% to 30%). 5. The percentage of living donors who were either spouses or unrelated to the recipient increased from 5% in 1988 to 27% in 2001. 6. In 2001, California (10.2%) was most often listed as the state of residence for cadaveric donors, followed by Texas (7.9%) and Florida (7.2%). 7. In 2001, cadaveric donors were recovered most often on Tuesdays (15.1%), followed by Sundays (14.7%) and Mondays (14.6%). 8. In 2001, living donors were recovered most often on Wednesdays (28.7%), followed by Tuesdays (25.9%) and Thursdays (19.5%). 9. In 2001, cadaveric donors were recovered most often in October (9.2%), followed by May (9.0%), and August (8.8%). 10. In 2001, living donors were recovered most often in August (9.4%), followed by July (9.4%) and October (9.1%).

[Requirements for a surgical documentation system and its realization]. / Anforderungen an ein Operationsdokumentationssystem und deren Realisation.

Adequate documentation of all surgical procedures is now essential. High demands in terms of quality and quantity mean that computerized databases and evaluation procedures are required. In the Department of Abdominal and Transplantation Surgery within Hanover Medical School a standardized but individually adaptable documentation system has been greated using standard hardware and software. A hierarchical code system has been established for surgical procedures, and this also offers the options of automatic online coding and translation into the coding used in the International Classification of Procedures in Medicine. The advantages and limitations of this system are discussed.

Symposium Trasplante de órganos en México: Trasplante de hígado: estado actual y experiencia en el Instituto Nacional de la Nutrición "Dr. Salvador Zubirán" / Liver transplantation

Objetivo. Revisar y actualizar algunos aspectos del trasplante de hígado e informar la experiencia con el mismo en el Instituto Nacional de la Nutrición "Dr. Salvador Zubirán" (INNSZ). Sede. Departamento de Trasplantes del INNSZ (México, D.F.) Diseño. Estudio retrospectivo, observacional y longitudinal. Revisión de la literatura. Antecedentes. Existen tres tipos de trasplante: A) heterotópico o auxiliar, B) ortotópico y C) trasplante de hepatocitos. Las indicaciones más frecuentes para trasplante en el adulto son: hepatitis crónica autoinmune, enfermedad hepática colestásica y cirrosis postnacrótica y por alcohol. En niños: atresia de vías biliares y los errores congénitos del metabolismo. La evaluación pre-operatoria del receptor incluye: estudios generales, hematológicos, hepáticos, renales, gastrointestinales, cardiovasculares, pulmonares, nutricionales e inmunológicos. Actualmente se obtiene una preservación adecuada del injerto hepático "ex vivo" hasta por 24 hs empleando la solución denominada Universidad de Wisconsin. Como terapia inmunosupresora puede utilizarse: ciclosporina, prednisona, azathioprina, suero antilinnfocitos y FK506. Las complicaciones post-operatorias incluyen: falla primaria del injerto, problemas técnicos, rechazo, complicaciones renales, respiratorias e infecciones. Resultados. En el INNSZ hemos operado 10 pacientes, 4 varones y 6 mujeres, con edades de 15 a 56 años (promedio de 35.5); en 8 de ellos la idicación fue cirrosis hepática (post-necrótica en 4, post alcohólica en 2 y biliar primaria en otros 2), en uno hepatitis crónica autoinmune y en otro hipercolesterolemia familiar tipo II. El tiempo de espera del receptor varió entre 3 y 16 meses (promedio 8.9), en 8 empleamos la solución tipo Universidad de Wisconsin y en dos la Euro-Collins. En los 10 sujetos el trasplate fue de tipo ortotópico, con tiempo de isquemia de injerto de 4 a 18 hr (promedio de 12.5 hr) y un tiempo operatorio de 7 a 15 hr (promedio de 11.2 hr). Todas las reconstrucciones venosas fueron porta y cava término-terminal; las arteriales, arteria hepática término terminal en 9 y biliares, todas colédoco-colédoco término-terminal. El fenómeno de rechazo agudo se presentó entre 8 días y 3 años en 7 pacientes y en todos se resolvió adecuadamente. Actualmente tres pacientes tienen sobrevivencia de 22 a 60 meses. Los fallecidos tuveron sobrevivencia de 1 día a 12 meses.

Symposium Trasplante de órganos en México: Trasplante de corazón, experiencia en México / Cardiac transplantation. Experience in Mexico

En el presente artículo se hace una revisión histórica del trasplante cardiaco desde 1907, año en que Alexis Carrel inició los trabajos experimentales en este campo, hasta su culminación en 1967, cuando Christian Barnard, en Sud-Africa, realiza el primer trasplante clínico en un ser humano. En México se han realizado hasta junio de 1994 un total de 27 trasplantes de corazón, por 4 grupos quirúrgicos, en un lapso de 5 años, tiempo en que en el resto del mundo se han efectuado más de 20,000. De esos 27 pacientes sobreviven un total de 10 enfermos. En nuestro país, por diversas causas, que son analizadas en este trabajo, el trasplante de corazón aún no se realiza con la frecuencia y en la cantidad suficiente para satisfacer su demanda

Symposium Trasplante de órganos en México: Trasplante pulmonar, el segundo respiro / Lung transplantation: the second breath

El trasplante pulmonar ha sido el último de los trasplantes de órganos en llegar al escenario clínico. Sin embargo, tiene antecedentes con los trabajos experimentales de Alexis Carrel a principios de siglo. No es sino hata 1963 en que se incia la fase clínica con los primeros trasplantes en la Universidad de Mississippi y la Universidad de Pittsburgh. Problemas de rechazo y de cicatrización adecuada a nivel de la anastomosis bronquial impidieron que se desarrollará esta área y no fue sino hasta que en la Universidad de Toronto se efectuó el primer trasplante exitosos en 1993. Existen actualmente más de 1500 trasplantes de pulmón efectuados a nivel internacional. El tipo de trasplante puede ser unilateral (derecho o izquierdo), o bien bilateral secuencial. La indicación es la enfermedad terminal con insuficiencia respiratoria. La patología puede ser obstructiva (enfisema), restrictiva (fibrosis), infecciosa (fibrosis quística), o vascular pulmonar (hipertensión pulmonar). La sobrevida actuarial calculada a dos años es del 60 por ciento. En México, la experiencia es anecdótica y se reduce a un caso vivo con sobrevida de 4 años. Existe una reconocida falta de donadores cadavéricos y problemas organizacionales que han impedido el desarrollo adecuado de esta modalidad terapéutica en nuestro país

Procuración de organos para transplantes / Organ for transplantation

Muerte cerebral. Mantenimiento del donante. Ablación multiorgánica. Soluciones de Preservación. Etica y transplantes. Ley 24.193 Transplante de Organos y Materiales Anátomicos

Procuración de organos para transplantes / Organ for transplantation

Muerte cerebral. Mantenimiento del donante. Ablación multiorgánica. Soluciones de Preservación. Etica y transplantes. Ley 24.193 Transplante de Organos y Materiales Anátomicos

Trasplante del polo anterior del Ojo

1.Por cirugia experimental en animales se ha comprobado que no existe reyección del trasplante en todos nuestros casos, 2.Los ojos operados en perros no tuvieron complicaciones necrosis ni infección, 3.En los primeros trasplantes se opacifico la córnea ello secundario a defectos de oposición entre donante-recptor Mejorando la sutura entre córnea y esclera los resultados en cuanto a transparencia fueron más funcionales, 4.En el hombre la cirugia es más facil porque existe menor vascularización ademas debemos tener en cuenta que nuestros pacientes guardarón el reposo necesario, 5.Nuestro primer trasplante en el hombrecumple un año de evolución dentro de un mes la córnea continua transparente el globo presenta una ligera coloración rosa especialmente en conjuntivo bulbar a traves de la córnea se puede ver fondo de ojo, 6.El aspecto estético es satisfactorio, 7. En el segundo paciente cuyo injerto no fue reyectado la cornea perdio su transparencia todavia estamos en la duda de que si realmente la causa del transtorno funcional fue el contacto del iris con el entelio corneal o si fue el traumatismo el que acasino la pacificación corneal, 8.Es una cirugia que no requiere de material adicional y por tanto esté al alcance de cualquier centro oftalmologico, 9.Se requiere un mayor número de casos a através de los cuales se puede elaborar una casuistica infelizmente en nuestro medio sobre todo por su pequeñez no contamos con el flujo de pacientes que no permita aumentar la estadistica