Trends in US Kidney Transplantation During the COVID-19 Pandemic.

Solid organ transplants have been impacted significantly during the COVID-19 pandemic in the United States. Limited data exist regarding changes in living donor kidney transplants. The aim of this study was to describe national trends in kidney transplantation during COVID-19. This descriptive cross-sectional study used publicly available data from the United Network for Organ Sharing (UNOS) and the National Kidney Registry (NKR). Plots of national waitlist inactivations, waitlist additions, deceased donor transplants and living donor transplants were created. An Auto Regressive Integrated Moving Average (ARIMA) model with interrupted time series analysis adjusting for first-order autocorrelation was used to evaluate for significant changes in outcome trends every four-week period during the COVID-19 era between March 15 and August 1, 2020. A statistical significance of 0.05 (𝛼) was established for analysis. Changes in kidney transplant volumes during the COVID-19 outbreak were registered. Density mapping and linear regression with interrupted time series analysis were used to characterize changes over time nationwide. Kidney transplants were affected significantly in recent months due to COVID-19. Deceased donor and living donor kidney transplant trends are described in this paper in addition to operative recommendations.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy combined with two-stage hepatectomy for multiple and bilobar desmoplastic small round cell tumor liver metastases.

Desmoplastic small round cell tumor (DSRCT) is a rare mesenchymal tumor usually affecting young patients. Local dissemination is common, and liver is the most common site for extraperitoneal metastases. Multimodal management has been shown to be the most effective treatment. Some authors consider liver metastases especially bi-lobar disease as a contraindication for surgical resection. We present a case of a DSRCT with bi-lobar metastases in an adult patient who underwent multi-modal management along with hepatectomy. A 51-year-old man was found to have a large intraperitoneal mass with bi-lobar liver metastases during work up for new onset reflux and abdominal pain. Biopsy confirmed it as DSRCT. The patient was treated with multi-modal therapy including cytoreductive surgery (CRS), hyperthermic intraperitoneal chemotherapy (HIPEC), two-stage hepatectomy (TSHP) combined with (90Y) Yittrium-90 radioembolization of the right hepatic lobe and systemic chemotherapy. The patient had a right-sided pleural empyema one month after the surgery for which he required right-sided video-assisted thoracoscopy and decortication. He remains disease free at 2 years follow-up. DSRCT with bi-lobar liver metastases are best managed with multimodal therapy. TSHP seems to be a feasible and safe option in selected cases, with a potentially good outcome.

Outcomes of Reimplantation of the Artificial Bowel Sphincter.

BACKGROUND: Outcomes of artificial bowel sphincter reimplantation for severe fecal incontinence remain unknown. OBJECTIVE: The purpose of this study was to evaluate the feasibility and outcomes of artificial bowel sphincter reimplantation versus implantation. DESIGN: This was a retrospective review study. SETTINGS: The study was conducted at a single institution. PATIENTS: Patients with severe incontinence who underwent de novo implantation and re-implantation between January 1998 and December 2012 were included. MAIN OUTCOME MEASURES: Complications, length of functional device time, success rates (functioning device at follow-up), patient demographics, comorbidities, etiology of incontinence, operative data, postoperative complications, and outcomes of initial implantation versus reimplantation were analyzed. RESULTS: A total of 57 patients (mean age, 49.3 ± 13.5 years; 44 women) underwent implantation. Sixteen (28%) succeeded and 41 (72%) failed, requiring explantation; 17 of 41 patients underwent reimplantation; 5 had 2 reimplantations. There were 79 implantations and 50 explantations (63.3%) in total. Implantation and reimplantation procedures had similar lengths of operation, hospital stay, postoperative complications, and explantation rate. Most common reasons for device explantation were infection/erosion (27/50 (54%)) and malfunction (19/50 (38%)). Reasons for reimplantation included device malfunction/migration (17/22 (77.3%)) and/or infection/erosion (5/22 (22.7%)). Seven (41.2%) of 17 patients for whom reimplantation was attributed to noninfectious reasons had a functioning device, whereas only 1 (20.0%) of 5 who had reimplantation because of infection/erosion had a working device. At a median follow-up of 29.5 months (range, 1.0-215.0 months), 24 patients (42%) retained a functioning device (implantation = 16; reimplantation = 8). Success rates were not significantly different between initial implantation and reimplantation procedures (p = 0.755). There were no differences in the length of functional device time between implanted and reimplanted devices (p = 0.439). LIMITATIONS: The study was limited by its retrospective nature and small sample size. CONCLUSIONS: Artificial bowel sphincter implantation has a high failure rate, requiring explantation in 72% of patients in this study. Reimplantation was often possible, with a success rate of 47%. Selected reimplantation for noninfectious complications had better outcomes than did reimplantation for septic causes. Short- and long-term outcomes are comparable to initial implantation.

Outcomes of Sacral Neurostimulation Lead Reimplantation for Fecal Incontinence: A Cohort Study.

BACKGROUND: Adverse events and complications have been reported after sacral neurostimulation for fecal incontinence, which may result in surgical revision and device explantation. Lead reimplantation may be feasible; however, available data regarding outcomes are less robust. OBJECTIVE: The aim of this study was to determine the outcomes of sacral neurostimulation lead reimplantation for fecal incontinence. DESIGN: This was a retrospective review of prospectively collected data. SETTINGS: The study was conducted at 2 clinical sites from a single institution. PATIENTS: Patients with fecal incontinence who underwent sacral neurostimulation implantation or reimplantation between 2011 and 2014 were included in the study. INTERVENTIONS: Sacral neurostimulation reimplantation was the included intervention. MAIN OUTCOME MEASURES: Change in the Cleveland Clinic Florida Fecal Incontinence Score (0 best; 20 worst) in reimplantation as compared with index implantation controls was the main measure. Secondary outcomes included the frequency and type of adverse events and complications. RESULTS: A total of 112 patients underwent either sacral neurostimulation implantation or reimplantation between 2011 and 2014. Ninety-seven patients underwent an index percutaneous nerve stimulation trial, 93 of whom also underwent a stimulator implantation. Fifteen patients underwent lead reimplantation, with 5 performed before stimulator implantation and 10 after stimulator implantation. The index implanted and reimplanted groups had similar demographics, comorbidities, and complication profiles including explantation rates. The most common reason for reimplantation was lead related (6/15), including 4 lead migrations, 1 lead fracture, and 1 lead erosion. Significant decreases in the incontinence score were achieved in each group (index implantation: p < 0.001; reimplantation: p = 0.006). When comparing the efficacy of sacral neurostimulation therapy in decreasing the fecal incontinence score from baseline in each group, patients with an index implantation were found to have a more significant improvement in their incontinence score as compared with the reimplantation group (p = 0.047). LIMITATIONS: This was a retrospective study. A large number of patients with incomplete functional assessment data were excluded from analysis. CONCLUSIONS: The improvements in fecal incontinence are significantly better after index implantation than after reimplantation.