The optimal treatment of lymphoceles following renal transplantation.

Lymphoceles are well-recognized complications following kidney transplantation. The authors describe their experience with the treatment of eight clinically significant lymphoceles (incidence 2.7%). In seven patients percutaneous needle aspiration was attempted, often repeatedly, both for diagnostic and therapeutic purposes. In all of the patients the lymphocele recurred within days and internal marsupialization was therefore performed, in the last two patients utilizing minimal access surgery through laparoscopy. There were no postoperative complications or signs of a recurrence of the lymphocele. Patients following the laparoscopic marsupialization had a much briefer hospital stay and postoperative convalescence. Our results confirm that internal marsupialization is the procedure of choice for most post-transplant lymphoceles. Internal marsupialization through laparoscopy should be used in patients who meet the standard criteria for laparoscopy.

Development of an extracorporeal liver support system: initial results.

A pilot study was undertaken to determine the feasibility of extracorporeal normothermic perfusion of the porcine liver. Seven donor hepatectomies were performed in small 10 kg pigs and the livers were placed in a perfusion cassette of the author's design. Four perfusions were technical failures. Three successful perfusions had several factors in common: hepatic artery inflow roller pump, prompt "pinking up" of the perfused liver, a centrifugal vena cava outflow pump with partial diversion of the outflow into the portal vein with the remaining outflow returned to the anesthetized animal, and production of bile during the perfusion experiment. Successful perfusions lasted 50, 65, and 90 minutes.

Transplantation in the military: state of the art--a progress report from the Army-Navy Transplant Program.

The commitment to clinical transplantation services by the Army and Navy is now in its third decade. Located at the Walter Reed Army Medical Center, the Army-Navy Organ Transplant Service has been staffed and led by some of the most prominent transplant surgeons in America. Military beneficiaries are eligible for evaluation and care regardless of their geographic assignment or residence. Principally a renal transplant clinical service, the Organ Transplant Service also gives support to patients with heart, liver, and pancreas grafts. Organs for transplant are largely (85%) from the civilian sector, although the Department of Defense has officially encouraged organ donation. Research, scientific publication, protocol development, teaching, and interaction with reserve components have been major facets of the Organ Transplant Service. Clinical outcome in renal transplantation at the Army-Navy Unit is comparable to that at the best civilian units: 2-year graft and patient survival 81% and 98%, respectively. These superior clinical results and the major roles that the Army-Navy Transplant Service have played make continued support and expansion of military transplantation compelling.

Successful renal transplantation for Epstein syndrome.

Successful cadaveric renal transplantation was accomplished in a patient with Epstein syndrome, a triad of macrothrombocytopenia, partial high-frequency hearing loss, and nephritis, which often progresses to complete renal failure. The success of the transplant demonstrates that the macrothrombocytopenia which occurs in this syndrome is not a contraindication to aggressive management of end-stage renal disease.

Donor-specific transfusion with diminished sensitization.

Fourteen mixed lymphocyte culture (MLC)-reactive haploidentical recipients have received donor specific transfusions (DSTs) with diminished sensitization to HLA antigens. A single unit of donor blood was obtained in CPD-A anticoagulant, packed, and transfused in three aliquots at 1-week intervals when the blood was 1, 3, and 5 weeks old. Transplantation, performed 22 to 149 days after the last DST, has been successful in all patients for 3 to 26 months except for one experiencing hyperacute rejection despite a negative crossmatch. In vitro studies suggest that blood storage results in the loss of T lymphocytes, which are presumably responsible for the sensitization, and preservation of B cells and monocytes, which remain capable of stimulating a cellular immune response in vitro throughout the 30-day storage period. Apparently this change in the cellular characteristics of blood with storage produces the salutory effects of blood transfusion without the undesirable sensitization to HLA antigens. The mechanisms remain under study.

Cyclosporin A and steroid therapy in sixty-six cadaver kidney recipients.

From nine to 18 months ago, 66 patients were given 67 randomly matched cadaveric kidneys with cyclosporin A and steroid therapy. Nine of the recipients were undergoing retransplantation. The over-all kidney survival rate to date has been 77.6 per cent, and 78.8 per cent of the recipients are dialysis-free. The patient mortality in this learning phase was 13.3 per cent. Nephrotoxicity, hepatotoxicity and other side-effects of cyclosporin A could usually be dealt with by dosage adjustments, making feasible the chronic use of this agent. One B-cell immunoblastic sarcoma was encountered which was monoclonal. It was not responsible for death. Another patient had a perforation of the intestine from a lympho-proliferative reaction in which the B cells were polyclonal. After jejunal resection a year ago, there were no further complications. This lesion was not classified as a lymphoma. Both lympho-proliferative lesions were associated with a rise in antibody to viral capsid antigen of Epstein-Barr virus. Results of this study have verified the effectiveness and relative safety of cyclosporin A with steroids for immunosuppression in human recipients of cadaveric kidneys.

Past and future prospects of orthoptic liver transplantation.

The hopes for liver transplantation have been increased by experience with the new immunosuppressive drug cyclosporin A. Optimal therapy with cyclosporin A has required steroid therapy, but the amounts of prednisone used have been a small fraction of those used in the past.

A durable chronic unit recording device with movable microelectrode.

The design of a durable chronic unit recording device with movable microelectrode suitable for cats and monkeys is presented. Sufficiently rugged to remain on cats for weeks during exploration of a single electrode tract, the device also features: choice of stereotaxic coordinates over a large horizontal area at recording time; good stereotaxic precision; capability to hold a single unit for days; excellent insulation between the recording circuit and the animal; and simplicity of design and materials which allows fabrication of numerous devices in one lab.