Early postoperative evaluation of groins after laparoscopic total extraperitoneal repair of inguinal hernias.

BACKGROUND: Minimally invasive laparoscopic total extraperitoneal (LTEP) repair of bilateral and/or recurrent groin hernias has been popularized as one of the procedures of choice in the past decade. The early postoperative course is uneventful in most cases. A few patients, however, will develop temporary postoperative groin swelling. The aim of our study was to evaluate clinical and sonographic findings in the groin during the early postoperative period following LTEP. METHOD: One hundred and five consecutive patients with primary bilateral (n = 90), recurrent unilateral (n = 12), and primary unilateral (n =3) groin hernias operated on during an 18-month period underwent clinical and sonographic examination two to three weeks after LTEP. RESULTS: On clinical examination, a localized groin swelling was found in 21 patients (20%). The most frequent sonographic findings were localized groin collections compatible with seroma or hematoma, found in 35 patients (33%). Hypoechoic diffuse tissue swelling around the mesh, lipomas, and residual hernias was found in four patients each (4%). None of the patients with hypoecoic mass had any clinical manifestations postoperatively. Extraperitoneal close suction drains were left for 8-12 hours in 46 patients. The average volume of fluid drained was 62 mL (range, 30-200 mL). There was no correlation between the use of suction drains and the frequency of fluid collections detected on sonography. Cord lipoma was detected postoperatively in four patients and was excised in one using an open anterior approach. Residual or recurrent hernia was detected postoperatively on sonography in four patients, but only one developed a symptomatic and clinically detectable hernia during eight months of follow-up. Overall, postoperative ultrasonographic findings following LTEP repair were found in 37% of patients. CONCLUSION: Clinical and sonographic findings such as localized fluid collections compatible with seroma or hematoma are common following LTEP. Postoperative suction drains did not reduce the frequency of sonographically detected collections. The clinical relevance of suspected postoperative hernia detected on sonography without clinical manifestations remains uncertain, and has to be determined on long-term follow-up.

Social and utilitarian considerations for allocating organs within a national organ sharing system: a computerized simulation model for policy decision-making.

BACKGROUND: An organ-sharing system should achieve fairness and optimal graft longevity. Balancing between social and utilitarian considerations is a sensitive ethical, public and medical issue that requires a means to examine the consequences of any allocation policy or planned changes thereof. OBJECTIVE: To evaluate the performance and applicability of a computerized simulation model by examining the impact of two opposing organ allocation policies (social or utilitarian) on predicted organ distribution regarding age, waiting time, recipient sensitization measured by panel reactive antibody level, and overall donor-recipient tissue matching (measured by the number of HLA antigen mismatches). METHODS: Using a computerized simulation model, virtual donors and recipients were emulated and organs were allocated according to either social algorithms or utilitarian policies. The resulting number of HLA mismatches, PRA, age, and waiting time distributions were compared between allocation strategies. RESULTS: Simulating allocation of 7,000 organs to 17,000 candidate recipients and implementing social policies yielded donor-recipient compatibility comparable to utilitarian policies (0-1 mm: 19.4% vs. 28%) while allocating 66.7% of organs to long waiters (>48 months). CONCLUSION: This computerized simulation model is a valuable tool for decision-makers establishing or modifying organ allocation policies.

Detrimental effects of cyclosporin A on long-term graft survival in familial Mediterranean fever renal allograft recipients: experience of two transplantation centers.

BACKGROUND: Cyclosporin A has been associated with severe toxic side effects in patients with familial Mediterranean fever who underwent renal transplantation. Nevertheless, the impact on graft function and survival is not well documented. OBJECTIVE: To compare long-term graft function and survival, between CsA-based vs. CsA free immunosuppressive protocols in FMF recipients of renal allograft. METHODS: Data of FMF recipients were analyzed retrospectively. Graft survival and function and the incidence of acute rejection were correlated to graft source (living donor vs. cadaveric donor), colchicine dose, presence of proteinuria, and immunosuppression protocol (CsA-based triple drug therapy vs. azathioprine-prednisone alone). RESULTS: There were 35 FMF patients with primary renal grafts (13 from living donors and 22 from cadaveric donors). Mean follow-up was 10.6 +/- 6.05 years. Sixteen patients were on CsA-based triple drug therapy and 19 patients on AZA-Pred alone. Mean overall graft survival was 11.2 +/- 0.6 years and 9.4 +/- 1.36 vs. 11.6 +/- 0.4 years for CsA-treated and AZA-Pred groups respectively (P = 0.05). One-year survival was 94% and 96.6% for CsA-treated vs. non-CsA patients (not significant), but 5 and 10 years survival were 76% and 46%, compared to 94.5% and 86% respectively (P = 0.05 at 5 years and 0.001 at 10 years). Mean serum creatinine at time of data collection was 2.3 +/- 1.5 mg/dl in the CsA group vs. 1.6 +/- 0.7 mg/dl in the AZA-Pred group (P = 0.02). There were 14 and 13 reversible rejection episodes in the AZA-Pred and CsA groups respectively (not significant). CONCLUSION: It is suggested that CsA exerts detrimental effects on long-term renal graft function and survival in FMF patients.