A survey: the prevalence of laparoscopic donor nephrectomy at large U.S. transplant centers.

BACKGROUND: There is controversy whether laparoscopic donor nephrectomy (LDN) is the procedure of choice for live kidney donors. The purpose of this survey therefore was to determine the current practices, attitudes, and plans regarding LDN in high-volume renal transplant centers. METHODS: Medical directors of the 31 highest volume kidney transplant centers were surveyed via telephone. Kidney transplant data for 1998 and 1999 were collected. RESULTS: The surveyed centers performed 5213 transplantations in 1998, representing 43% of all kidney transplantations done nationally. Twelve (39%) of the 31 centers performed LDN in 1998, increasing to 20 (65%) of 31 in 1999. Of 1174 live donor operations performed by the 20 centers in 1999, 365 (31%) were LDNs. Among the surveyed centers, four had no plans to begin an LDN program. The most commonly cited incentive for LDN was "shorter recovery time," whereas the most common disincentive was "concern about graft quality." A combination of observation and animate laboratory was the most commonly reported method of learning the LDN procedure. Six-month follow-up interviews found that 26 (84%) of 31 centers had performed LDN; only 1 of the 31 centers had no plans to perform LDNs. CONCLUSIONS: LDN may be the de facto procedure of choice for live donors within the next year. Efforts should now focus on improving techniques for performing and teaching this procedure.

Esophageal rupture complicated by a gastrocardiac fistula: review of the literature and report of a successfully treated case.

A 62-year-old man developed a fistula between the right ventricle and the stomach after Thal fundic patching of an emetogenic rupture of the esophagus. He underwent emergency surgical correction of the fistula and survived.

A case control study for major trauma in geriatric patients.

This study analyzed age as a univariate factor in survival in a national group of 46,613 major trauma patients and compared 180 elderly major trauma patients (greater than or equal to 65 years) to a similarly injured group of 3,918 younger patients (less than 65 years). In the national group, mortality rose sharply between age 45 (10%) and 55 (15%) and doubled at age 75 years (20%). This age-dependent survival decrement occurred at all Injury Severity Score values, for all mechanisms of injury, and for all body regions. In the comparison study, mortality in the elderly group was nearly double that of mortality in the younger group (27% vs. 14%). The older patients had a markedly higher complication death rate, especially for pulmonary (14/100 vs. 6.1/1100) and infectious complications (4.6/100 vs. 0.7/100). The median length of stay was twice as long for the older patients (14 days vs. 7 days). Cost data showed that the DRG prospective payment system grossly underestimated the cost of care for these patients (mean loss of $2,177.14 per patient). To minimize mortality and morbidity, triaging elderly trauma victims to trauma centers at a much lower threshold than similarly injured younger patients is recommended. The current DRG system should be altered to account for age-dependent morbidity. Further study is needed to determine whether more rigorous infection prophylaxis, immunomodulation, and pulmonary therapy will augment survival in elderly patients.