Evolution of trends in the live kidney transplant donor-recipient relationship.

OBJECTIVE: This study examined the changing demographics and age profile between living donors and their recipients. A 46-year review of living donor renal transplants in a single transplant center was performed. PATIENTS: The study included 923 consecutive living donor renal transplants from January 1966 until December 2011. RESULTS: These 923 living donor kidneys transplants represent 41% of all transplants performed during this 46-year review. The majority involved sibling donation (39.5%) followed by parent to child (32.5%). Dividing the 46-year timeframe into quartiles, the mean age of donors has remained stable at 39.3 ± 10.9 years. In contrast, the mean age of recipients has trended upwards, from 28 ± 10.7 years in the first quartile (1966-1978) to 37 ± 17.5 years in the latest quartile (2001-2011). This represents an increase every year of approximately 4 months (P < .001). Over the same period, the difference between a given donor's age and their recipient's has decreased every year by approximately 4 months (P < .001). In a linear regression model of donor-recipient categories and their age difference over time, we found that both the child-to-parent and grandchild-to-grandparent groups had the largest effect on the donor-recipient age difference when compared to the classic parent-to-child relationship. CONCLUSION: This review of center-specific data shows that the difference in the age of the donor to their recipient has been narrowing over time. We have determined that this is primarily due to changes in donor-recipient demographics with an increasing number of younger donors to older recipients. Although the medical risks to donors living with a single kidney have yet to be shown different than that of the general population, the increasing volume of donors who are younger and those with no relation to the recipient should prompt closer follow-up within the transplantation medical community.

Does ultrasonic energy for surgical dissection reduce the incidence of renal transplant lymphocele?

OBJECTIVE: To determine the difference in post-renal transplant lymphocele rate based on the surgical dissection technique for control of lymphatics by examining the historical case group under the direction of a single, university-based surgeon in a retrospective, cohort study. PATIENTS: Five hundred thirty-two consecutive renal transplant patients from January 1994 to December 2009. FINDINGS: Of the 532 cases studied, 259 (48.7%) had suture ligation and 273 (51.3%) employed ultrasonic dissection (UD) for control of lymphatics during renal transplantation. There was no difference found in the rate of lymphocele formation, requiring either percutaneous or surgical drainage, when surgical ties (8.9%) were compared to UD (9.2%; P=.999). Logistic regression analysis showed that the odds ratio for developing a lymphocele was independent of surgical dissection technique. Within the logistic analysis, the prediction for lymphocele was increased 3.29 times for pediatric patients (P=.002) and increased 2.97 times for those who received a living donor graft (P=.001), and there was a trend for those with a history of more than one renal transplant of 2.01 times (P=.079). SUMMARY: Surgical dissection technique was not a factor in the development of post-renal transplant lymphocele. Younger age, living donor transplant, and repeat transplant status were found to be predictive variables for symptomatic lymphoceles requiring drainage, which may be considered when patients present for posttransplant evaluations for laboratory alterations.

Laparoscopic treatment of post renal transplant lymphoceles.

BACKGROUND: Traditionally, a post transplant lymphocele (PTL) is drained by widely opening the wall connecting the lymphocele cavity to the intraperitoneal space via laparotomy. We hypothesize that laparoscopic techniques can be effectively used for the treatment of PTL. METHODS: Patients requiring intervention for PTL between 1993 and 2002 were identified via a retrospective review. Results of drainage via laparotomy and laparoscopy were compared. RESULTS: During the study period 685 renal transplants (391 cadaveric, 294 living) were performed. The incidence of lymphocele was 5% [34/685 (36 cases)]. The indications for surgical drainage were local symptoms (69%), graft dysfunction (14%), or both (17%). The mean time to surgical therapy was 4.9 months. Laparoscopic drainage was performed in 25 patients (74%) and open drainage in 9 patients (26%). Open procedures were performed in cases for: previous abdominal surgery (5), undesirable lymphocele characteristics or location (2), or with concomitant open procedures (3). There were no conversions or operative complications in either group. There was no difference in operative time for the laparoscopic group vs the open group (108 +/- 6 vs 123 +/- 18 min, p = 0.8). Hospital stay was significantly shorter for the laparoscopic group (1.7 +/- 0.8 vs 3.8 +/- 1.0, p = 0.0007), with 88% of laparoscopic patients being either overnight admissions or same day surgery. Two patients (5%) developed symptomatic recurrences requiring reoperation [1 laparoscopic (4%), 1 open (10%)]. CONCLUSIONS: Laparoscopic fenestration of a peritransplant lymphocele is a safe and effective treatment. The large majority of patients treated with laparoscopic fenestration were discharged within one day of surgery. Unless contraindications exist, laparoscopy should be considered first-line therapy for the surgical treatment of posttransplant lymphocele.

Is immediate chest radiograph necessary after central venous catheter placement in a surgical intensive care unit?

BACKGROUND: Current standard of care dictates that central venous catheter (CVC) insertion should be followed by an immediate chest radiograph to confirm appropriate position and rule out complications. We hypothesized that a subset of monitored intensive care unit patients exists that is at low risk for complications and might safely have radiographic evaluation of line placement deferred until the next scheduled radiograph. METHODS: Data regarding patient and procedural characteristics were obtained prospectively for 184 CVC placed between March 1, 1998, and June 30, 1999. Retrospective data regarding complications were obtained by chart review for an additional 174 CVC placed during the study period but for which data sheets were not completed. All procedures were followed by chest radiography. RESULTS: We documented a complication rate of 9% with the vast majority (25 of 31, 81%) of complications consisting of incorrect positioning. The number of needle passes was greater in the group suffering pneumothorax and arterial puncture than the uncomplicated group (5.6 versus 1.9, P = 0.008). "Straightforward" operator gestalt (P = 0.04) and number of needle passes <3 (P = 0.03) were factors correlating with the absence of complications. These factors had negative predictive values of 94% and 96%, respectively. CONCLUSION: Placement of CVC is safe in experienced hands. In monitored intensive care unit patients who undergo a "straightforward" procedure with <3 needle passes, chest radiograph can be safely deferred until the next scheduled examination.

Splenectomy in high-risk patients with splenomegaly.

BACKGROUND: Splenectomy in patients with massive splenomegaly and hematologic malignancy results in higher morbidity and mortality with primarily palliative benefit. METHODS: From a 14-year experience with 172 splenectomies, the perioperative course of 39 high-risk patients with splenomegaly was reviewed for comorbidities, indications, complications, and mortality. RESULTS: Twenty-three males and 16 females with a mean age of 54.2 years and a mean 12.8-day postoperative length of stay were reviewed. Sixteen patients (41%) had 23 major complications related to age (P = 0.047) and operative time (P = 0.01). Intraoperative transfusion was related to splenic size (P = 0.04), and estimated blood loss (P = 0.02) was inversely related to use of splenic artery preligation. Three perioperative deaths were secondary to sepsis and multi-organ system failure. CONCLUSION: Splenomegaly and comorbidities of the primary disease result in higher morbidity and mortality. Splenic artery preligation is valuable to limit intraoperative blood loss and facilitate splenectomy.

Decreased mortality from necrotizing pancreatitis.

BACKGROUND: Necrotizing pancreatitis has been associated with mortality rates of 25% to 80%. We reviewed our experience to determine whether aggressive debridement and comprehensive critical care improves survival. METHODS: The records of 989 patients with the diagnosis of pancreatitis admitted between January 1990 and September 1997 were retrospectively reviewed. Twenty-six patients required surgery for necrotizing pancreatitis and are the subjects of this review. RESULTS: Five of twenty-six patients (19%) died. For all patients, mean Ranson's score was 4.3 of 11, mean admission APACHE II score was 17.2, and mean Multiple Organ Dysfunction (MOD) score was 9.1. Poor outcome was associated with infected pancreatic necrosis (P = 0.03), elevated APACHE II score on admission (P = 0.04), and progression of MOD during the week after admission (P = 0.02). CONCLUSIONS: This review demonstrates improved survival in seriously ill patients with necrotizing pancreatitis as a result of comprehensive surgical and critical care.

Chemical paralysis reduces energy expenditure in patients with burns and severe respiratory failure treated with mechanical ventilation.

Predictive formulas often overestimate energy requirements, particularly in patients being treated with mechanical ventilation, resulting in significant overfeeding. The purpose of this study was to quantify the effect of chemical paralysis on energy expenditure in patients with burn injuries receiving ventilation treatment, and compare measured energy expenditure with estimates of energy expenditure based on predictive formulas. The study was a retrospective review of 14 patients with burn injuries treated with mechanical ventilation that required chemical paralysis to reduce inspiratory pressures or improve oxygenation. Indirect calorimetry was performed before, during, and after paralysis. Measured energy expenditure (MEE) was compared with the energy predictions of the Harris-Benedict (HBEE) and Curreri (CEE) estimates. During paralysis, mean MEE was significantly lower than pre- or postparalysis (19.65 +/- 1.65 versus 26.00 +/- 2.42 and 29.49 +/- 2.83 kcal/kg/24 hr, respectively). Mean HBEE (2031 +/- 145 kcal/24 hr) approximated MEE pre-(1989 +/- 350 kcal/24 hr) and postparalysis (2237 +/- 269 kcal/24 hr), but overestimated MEE during paralysis (1532 +/- 208 kcal/24 hr; p < 0.05). Mean CEE (2957 +/- 229 kcal/ 24 hr) estimates significantly overestimated MEE before, during, and after paralysis (1989 +/- 350, 1532 +/- 208, and 2237 +/- 269, respectively p < 0.05). Predictive formulas significantly overestimate measured energy requirements in these patients. Indirect calorimetry should guide nutrition support in patients requiring prolonged mechanical ventilation.

Predictors of mortality in pulmonary contusion.

BACKGROUND: Associated injuries and central nervous system (CNS) trauma are historically associated with poor outcome in patients with pulmonary contusions, but the value of specific factors reflecting shock, fluid resuscitation requirement and pulmonary parenchymal injury in predicting mortality in this population is not well established. METHODS: The medical records of 100 consecutive patients with pulmonary contusion, admitted over a 5-year period, were retrospectively reviewed. Survivors and nonsurvivors were compared in terms of age, Injury Severity Score (ISS), Glasgow Coma Score (GCS), PaO2/FiO2 (oxygenation ratio), the severity and adequacy of shock resuscitation reflected in plasma lactate, resuscitation volume and transfusion requirements, using one-way ANOVA. To determine the contribution of individual, interdependent variables to mortality, the data were then analyzed using multivariable analysis. RESULTS: ISS and transfusion requirement were significantly higher, and GCS and PaO2/FiO2 at 24 and 48 hours after admission were significantly lower in nonsurvivors than in survivors. After multiple regression analysis, the factors most strongly associated with mortality included patient age, oxygenation ratio at 24 hours after admission, and resuscitation volume. CONCLUSIONS: Outcome in patients with pulmonary contusion is dependent upon a number of variables including the severity of pulmonary parenchymal injury as reflected in PaO2/FiO2 ratio.