Why we use the donor left kidney in live related transplantation.

UNLABELLED: In addition to the superior graft survival afforded by live related transplantation, this option has assumed an important role in the management of endstage renal failure in centres confronted with a scarcity of cadaveric kidneys. In pursuing this option, it is imperative that the donor has minimal morbidity. An ongoing dilemma is which side the kidney should be harvested from. This study reviews the anatomical basis for selecting the left kidney and the impact on outcome for patient and donor. A database comprising cadaveric and clinical subsets was analysed. The total sample size analysed was 1 244 kidney pairs (305 cadaveric; 939 clinical (61 live related left kidney transplants harvested by the extraperitoneal approach)). RESULTS: Additional renal arteries (ARAs): Right first, second = 18.6%, 4.7%; left first, second = 27.6%, 4.4%. Additional renal veins (ARV): Right first, second = 26%, 3.3%; left first only = 2.6%. Length of renal vein (cm): Right 2.4 +/- 0.7, left 5.9 +/- 1.5. Other venous variations encountered were on the left side only (renal collar 0.3%, retro-aortic vein 0.5%). In the live related transplant series 24.6% ARAs were encountered (first 19.7%, second 4.9%). The postoperative course and outcome of both donor and recipient were not associated with increased morbidity. While greater length of the left renal vein (LRV) afforded easier technical manipulation, it is interesting to note that its length is shorter than that reported in the literature. ARVs are infrequent on the left and when encountered the smaller calibre vessel may be ligated with impunity due to rich intrarenal anastomosis. In selecting the donor kidney the surgeon has to balance the prospect of fewer ARAs on the right against the benefit of a longer LRV. The solution to this dilemma can only arise from a randomised clinical study. In our practice, consistent use of the left kidney has not affected clinical outcome.

Additional renal arteries: incidence and morphometry.

Advances in surgical and uro-radiological techniques dictate a reappraisal and definition of renal arterial variations. This retrospective study aimed at establishing the incidence of additional renal arteries. Two subsets were analysed viz.: a) Clinical series--130 renal angiograms performed on renal transplant donors, 32 cadaver kidneys used in renal transplantation b) Cadaveric series--74 en-bloc morphologically normal kidney pairs. The sex and race distribution was: males 140, females 96; African 84, Indian 91, White 43 and "Coloured" 18, respectively. Incidence of first and second additional arteries were respectively, 23.2% (R: 18.6%; L: 27.6%) and 4.5% (R: 4.7%; L: 4.4%). Additional arteries occurred more frequently on the left (L: 32.0%; R: 23.3%). The incidence bilaterally was 10.2% (first additional arteries, only). The sex and race incidence (first and second additional) was: males, 28.0%, 5.1%; females, 16.4%, 3.8% and African 31.1%, 5.4%; Indian 13.5%, 4.5%; White 30.9%, 4.4% and "Coloured" 18.5%, 0%; respectively. Significant differences in the incidence of first additional arteries were noted between sex and race. The morphometry of additional renal arteries were lengths (cm) of first and second additional renal arteries: 4.5 and 3.8 (right), 4.9 and 3.7 (left); diameters: 0.4 and 0.3 (right), 0.3 and 0.3 (left). Detailed morphometry of sex and race were also recorded. No statistically significant differences were noted. Our results of the incidence of additional renal arteries of 27.7% compared favourably to that reported in the literature (weighted mean 28.1%). The study is unique in recording detailed morphometry of these vessels. Careful techniques in the identification of this anatomical variation is important since it impacts on renal transplantation surgery, vascular operations for renal artery stenosis, reno-vascular hypertension, Takayasu's disease, renal trauma and uro-radiological procedures.

Lithopedion: a case report.

An 80-year-old Black, South African woman presented in the outpatient department with severe abdominal pain. Ultrasound examination revealed a large echogenic mass (20 x 20 cm) in the right upper quadrant. An abdominal x-ray demonstrated the skeleton of a fully developed extrauterine fetus. It is presumed from the patient's history that this fetus was present for at least 40 years. Radiography revealed a fetus shrouded in a mantle of calcification. The fetus was hyper-flexed with other signs of "intrauterine" death. Fetal dentition charts dated the fetus at 34 weeks, the epiphyses being obscured by extensive calcification. In addition to subcutaneous calcification there was extensive visceral and intracranial calcification.

Bilateral styloid chain ossification: case report.

The styloid chain is defined as the styloid process of the temporal bone, the stylohyoid ligament and the lesser cornua of the hyoid bone. Unusually long, incidental bilateral styloid chain ossification is described. This paper is presented for its unusual incidence, unusual length, the presence of ossification rather than calcification and its embryological correlation. Brief mention is made on the embryology and clinical significance of this condition.

Left renal vein variations.

The highly complex embryological development of the left renal vein compared to its right counterpart results in greater variations which are clinically significant. The study aimed to identify these variations and to document its incidence. Cadaveric study: 153 kidney pairs were harvested en bloc, dissected, 100 resin casts prepared and 53 plastinated; renal venography performed on further 58 adults and 20 foetal cadavers. Clinical study: (retrospective analysis): a) radiological study, 104 renal venograms; b) live related renal transplantation, 148 donor left kidneys; c) abdominal aortic aneurysm surgery, 525 patients. Total sample size: 1008. Renal collars observed in 0.3%; retro-aortic vein 0.5%; additional veins 0.4%; posterior primary tributary 23.2%, (16.7% Type IB; 6.5% Type IIB, cadaveric series, only). Our results differ significantly in incidence to that reported in the literature: renal collar 0.2-30%; retro-aortic vein 0.8-7.1%; additional renal vein 0.8-6%. Variations are clinically silent and remain unnoticed until discovered during venography, operation or autopsy. To a transplant surgeon, morphology acquires special significance, since variations influence technical feasibility of operation. Prior knowledge of circum-aortic vein is important when blood samples from suprarenal or renal veins are collected. Collar may provide developed collateral pathway immediately after surgery if renal interruption planned without awareness of its presence. Variations restrict availability of vein for mobilisation procedures. In aortic aneurysm repair, retro-aortic vein is important. During retroperitoneal surgery, the surgeon may visualise a pre-aortic vein but be unaware of an additional retroaortic component or a posterior primary tributary, and may avulse it while mobilising the kidney or clamping the aorta.

Absence of renal vein valves in humans and baboons.

There is disagreement on the presence of renal vein valves. Cadaveric anatomical and radiological studies were undertaken on renal veins to determine their presence. No valves were demonstrated in the samples studied (56 adult human, 11 fetal and 11 Chacma baboon kidney pairs). The significance and reasons for this disagreement are discussed.

The renal veins in the human cadaveric fetus: their importance as contributors to collateral flow.

The venous collateral flow emanating from and around the renal veins was investigated in the human cadaveric fetus. Experimental venous occlusion was performed along several venous pathways under the sphere of influence of the renal veins in 11 fetuses. Radiological techniques were used to investigate renal venous collateral flow. Extensive venous collaterals centered on the left renal vein were observed. It is concluded that the left renal vein is a major venous collateral pathway in the fetus whereas the right renal vein contributes little. This potential for collateralisation may be operative in the adult and may play a dominant role in disease states.

Case report: pedicular cleft associated with bilateral pars interarticularis defects and transverse process hypoplasia of a fifth lumbar vertebra.

The rare anomaly of cleft pedicle co-existing with bilateral pars interarticularis defects and ipsilateral transverse process hypoplasia of a lumbar vertebra is described in a 39-year-old male presenting with chronic low backache. The importance of recognizing pedicular clefts as congenital anomalies and distinguishing them from fractures or destructive processes is emphasized, and the relationship of pedicular clefts to hypoplastic or absent pedicles is discussed.

Fractures of the acromion in tetanus neonatorum [corrected].

Avulsion fractures of the acromion [corrected] are described in 10 patients with severe tetanus neonatorum. Typically bilateral and invariably contemporaneous, they result from isometric contraction. Forced abduction of the arm against adductor resistance leads to avulsion of that segment of the acromium where the multipenate fibres of the deltoid muscle originate. To our knowledge this unique and ominous orthopaedic complication of severe neonatal tetanus has not been documented previously.

Carcinoma of the prostate with multiple osteolytic metastases simulating multiple myeloma. A case report.

A patient with multiple osteolytic metastases--ribs, pelvis, spine, skull and mandible--from carcinoma of the prostate is described.

Bronchobiliary fistula after chronic pancreatitis. A case report.

A case of cholangitis secondary to chronic pancreatitis is reported. A liver abscess ruptured into the chest and the patient presented coughing bile. Symptoms were cured by a choledochojejunostomy, providing drainage for the obstructed common bile duct. To our knowledge this is the first reported case of a bronchobiliary fistula developing as a result of chronic pancreatitis. The principles of treatment are discussed.

A retrospective study of children after pneumonia.

Sixteen Black children were examined 5 years after hospitalization for pneumonia. Sixty-three per cent had had recurrent symptoms since that time. Of this group 60% had physical signs present although they were reportedly symptom-free at the time of examination. A family history of asthma was common in the symptom-free group and in the group with intermittent symptoms, but in only 1 child could a minor degree of exercise-induced bronchospasm be produced. Airway obstruction was detected in 19% of the children using peak expiratory flow rate measurements. Only 1 child had a completely normal chest radiograph at the follow-up examination. In this retrospective study long-term sequelae of pneumonia in early childhood were common and should be considered in the assessment of children with recurrent symptoms and signs and/or persistent radiographic changes.

Control of major haemorrhage associated with pancreatic pseudocysts by transcatheter arterial embolization.

Massive haemorrhage from a pancreatic pseudocyst is an uncommon cause of upper gastrointestinal bleeding. The condition carries a high mortality and presents a major clinical problem both in terms of timely diagnosis and appropriate surgical therapy. Four patients are presented with pseudocyst-related bleeding arising from the gastroduodenal artery. In all instances the bleeding was successfully controlled by transcatheter embolization with gelfoam. No untoward sequelae were noted and the occlusion remained effective as shown by follow-up angiography 2 months later. The importance of early diagnostic angiography is stressed and it is concluded that interventional angiography may obviate the need for high risk emergency surgery.

Segmental artery occlusion for sequential renal injuries. A case report.

We report on a patient who experienced life-threatening haemorrhages in 1974 and 1980 after receiving stab wounds to the same kidney. Treatment by means of segmental artery occlusion was successful. Nephrectomy would have been necessary to control exsanguinating bleeding in both instances. Successful evasion of nephrectomy on two occasions for trauma to the same kidney has not been reported previously.

Transcatheter embolization of the internal thoracic artery for post-traumatic haemorrhage. A case report.

In certain cases transcatheter embolization is an accepted technique for the control of arterial bleeding. A case is described in which post-traumatic haemorrhage from the internal thoracic artery was successfully controlled by embolization, thereby avoiding thoracotomy.

A clinical re-evaluation of intravenous aortography for aortic aneurysms.

The value of intravenous aortography in the preoperative assessment of patients with abdominal aortic aneurysms is discussed. Fifteen patients with abdominal aortic aneurysms were investigated by ultrasonography followed by intravenous aortography, and the diagnostic accuracy of pre-operative clinical assessment was compared with these investigations. Particular attention was paid to the relationship of the renal arteries to the level of origin of the aneurysm, as this determines the operative approach. In 6 patients the operative approach was altered when intravenous aortography indicated erroneous clinical or ultrasonic diagnoses. We have found this a safe and useful part of the routine pre-operative investigation of patients with aortic aneurysms.

Popliteal false aneurysm complicating osteochondroma. A case report.

A false aneurysm of the popliteal artery, caused by an exostosis in a patient with multiple exostoses, is described.