Robotic assisted kidney auto-transplantation as a safe alternative for treatment of nutcracker syndrome and loin pain haematuria syndrome: A case series report.

BACKGROUND: Describe the outcomes and safety of robotic-assisted kidney auto-transplantation (RAKAT) in the treatment of nutcracker syndrome (NCS) and loin pain haematuria syndrome (LPHS). METHODS: This retrospective study included 32 cases of NCS and LPHS seen during December 2016 to June 2021. RESULTS: Three (9%) patients had LPHS and 29 (91%) NCS. All were non-Hispanic whites, and 31 (97%) women. The mean age was 32 years (SD = 10) and the BMI 22.8 (SD = 5). The RAKAT was completed in all patients, 63% had a total improvement of pain. According to the Clavien-Dindo classification, 47% presented with type 1, and 9% with type 3 complications with a mean follow-up of 10.9 months. The incidence of acute kidney injury in post-procedure was 28%. No one required blood transfusions, and there were no deaths during the follow-up. CONCLUSION: RAKAT was a feasible procedure with a similar complication rate to those reported for other surgical techniques.

Acute Pancreatitis Task Force on Quality: Development of Quality Indicators for Acute Pancreatitis Management.

INTRODUCTION: Detailed recommendations and guidelines for acute pancreatitis (AP) management currently exist. However, quality indicators (QIs) are required to measure performance in health care. The goal of the Acute Pancreatitis Task Force on Quality was to formally develop QIs for the management of patients with known or suspected AP using a modified version of the RAND/UCLA Appropriateness Methodology. METHODS: A multidisciplinary expert panel composed of physicians (gastroenterologists, hospitalists, and surgeons) who are acknowledged leaders in their specialties and who represent geographic and practice setting diversity was convened. A literature review was conducted, and a list of proposed QIs was developed. In 3 rounds, panelists reviewed literature, modified QIs, and rated them on the basis of scientific evidence, bias, interpretability, validity, necessity, and proposed performance targets. RESULTS: Supporting literature and a list of 71 proposed QIs across 10 AP domains (Diagnosis, Etiology, Initial Assessment and Risk Stratification, etc.) were sent to the expert panel to review and independently rate in round 1 (95% of panelists participated). Based on a round 2 face-to-face discussion of QIs (75% participation), 41 QIs were classified as valid. During round 3 (90% participation), panelists rated the 41 valid QIs for necessity and proposed performance thresholds. The final classification determined that 40 QIs were both valid and necessary. DISCUSSION: Hospitals and providers managing patients with known or suspected AP should ensure that patients receive high-quality care and desired outcomes according to current evidence-based best practices. This physician-led initiative formally developed 40 QIs and performance threshold targets for AP management. Validated QIs provide a dependable quantitative framework for health systems to monitor the quality of care provided to patients with known or suspected AP.

Incisional Hernia After Peritoneal Dialysis Catheter Placement in a Patient on Sirolimus.

Hernias and peritoneal dialysis (PD) catheter leaks are frequent complications in patients on PD. Transplant recipients have multiple risk factors for delayed wound healing, such as use of corticosteroids and sirolimus, and the presence of uremia and diabetes mellitus. We report a rare occurrence of incisional hernia attributable to internal wound dehiscence after PD catheter placement in a patient on sirolimus.A 34-year-old Latino American man was started on PD training 4 weeks after placement of a PD catheter. Soon after completing training, he developed a large soft bulge close to the PD catheter, with expansile cough impulse suggestive of an incisional hernia filled with peritoneal dialysate. The size of the bulge would decrease after the dialysate was drained. No external leak of dialysate was evident along the exit site.Because of the size of the hernia and the history of it filling soon after dialysis exchange, the feeling was that wound dehiscence had occurred from the peritoneal side, resulting in a large incisional hernia. Because of the large size of the hernia within few weeks of starting PD, sirolimus was suspected to have induced poor wound healing, contributing to formation of the hernia.Sirolimus was stopped, and the patient underwent PD catheter removal and repair of the hernia. A new PD catheter was placed on the opposite side of the abdomen 10 days later. After another 6 weeks, the patient was started on PD. He has been doing well for the 15 months since then, with no recurrence of the hernia. Because he still had residual renal function, he continued to receive low-dose prednisone and mycophenolate sodium. At 10 months after PD start, he stopped the mycophenolate sodium on his own, and we did not resume it. He is still on low-dose prednisone.In end-stage renal disease resulting from failing renal transplantation or from calcineurin inhibitor nephropathy in solid-organ transplantation, sirolimus is a risk factor for wound dehiscence, development of incisional hernia, and peritoneal dialysate leak.Practical tips: Sirolimus should be stopped several days before PD catheter placement. Sirolimus should also be stopped if a PD catheter leak is detected or if incisional hernia develops soon after initiation of PD. Sirolimus should be held till surgical repair of the hernia and removal and replacement of the catheter.

Extended drainage of the pancreatic duct after pancreaticoduodenectomy.

HYPOTHESIS: Because of better survival following pancreaticoduodenectomy (PD), patients may develop complications due to PD and not due to malignancy per se. Exocrine insufficiency may be related to pancreatic duct obstruction or strictures attributable to duct-to-mucosa anastomosis, as in pancreaticojejunostomy. We propose a technique of managing a post-PD duct obstruction. DESIGN: Retrospective review from September 2005 to August 2008. SETTING: Methodist Dallas Medical Center, Dallas, Texas, a referral, high-volume, nonuniversity tertiary care center. PATIENTS: All patients who underwent surgery for anastomotic pancreaticojejunal stricture. MAIN OUTCOME MEASURES: Perioperative outcomes. RESULTS: All the patients were women and aged 62, 78, and 45 years. Comorbidities were documented in 2 patients. Two patients presented with severe acute abdominal pain and hyperamylasemia while 1 was asymptomatic. Two patients underwent magnetic resonance cholangiopancreatography with secretin stimulation. Endoscopic retrograde cholangiopancreatography was attempted in 1 patient. Operating time was 99 minutes, 158 minutes, and 154 minutes. Estimated blood loss was 250 mL, 400 mL, and 500 mL. A single-layer, side-to-side pancreaticogastrostomy was performed as the drainage procedure in all patients. There was no mortality associated with any of the patients within 30 days. Morbidity was seen only in 1 patient. None of the patients needed a reoperation. The mean length of hospital stay was 9 days. All patients were asymptomatic for pain. CONCLUSION: We propose a durable technique for treating pancreatic ductal strictures post-PD that appears to result in superior postoperative outcome.

CD30, a marker to detect the high-risk kidney transplant recipients.

BACKGROUND: Sensitization of potential renal transplant recipients may impact the selection of donors and the outcome of transplant. Another element of the potential kidney transplant recipient immune system that provides useful information regarding the transplant outcome is the immunologic CD30 molecule. METHODS AND RESULTS: This study shows a significant correlation between the pre-transplant high level of soluble CD30 and increased incidence of post-transplant infection. Only 7/34 (20.6%) of the patients who had a low level of sCD30 (< 90 U/mL) developed infection as compared with the 25/58 (43.1%) of the patients who had a high level (> 90 U/mL) of sCD30 (p < 0.04). Higher level of sCD30 pre-transplant was also correlated with the increased level of serum creatinine (p < 0.05) and pre-transplant malignancy (p < 0.04). A significant higher level of sCD30 was also noted among females (74%), as compared with males (50%) with p < 0.03. In addition, significant effect of 3-6 human leukocyte antigen (HLA) mismatches on rejection was seen. CONCLUSIONS: These results show that higher pre-transplant immunologic reactivity measured by sCD30 level was associated with post-transplant outcome. The high level of sCD30 among females may indicate an active immunologic status, perhaps because of previous pregnancies.

Hepatopancreaticobiliary (HPB) surgery: what is the right fellowship for the right training?

BACKGROUND: Reduced resident work hours over the last several years have led to inadequate exposure to hepatopancreaticobiliary (HPB) and complex upper gastrointestinal (UGI) surgical procedures. Therefore, residents are seeking additional training in this field. The purpose of this study is to determine the role of a new fellowship model in the training of general surgery residents in complex HPB/UGI diseases. METHODS: We propose a surgical training model in benign as well as malignant diseases of the UGI tract. The proposed model would focus on an integrated approach that involves allied specialties such as gastroenterology (GI) and radiology. RESULTS: The fellowship was set as 1-year duration with 1-month rotations on interventional GI and transplantation. The fellow spent the remaining 10 months on a UGI laparoscopic and open surgery service caring for complex benign and malignant disease of the esophagus, stomach, bile duct, pancreas, and liver. Didactic conferences were focused specifically at an organ-based approach to diseases of these organs. During a 12-month fellowship, exposure to complex diseases of the UGI tract was accomplished without negatively impacting the general surgery residency program. CONCLUSION: This new mode of advanced training provides a bridge between surgical oncology and transplantation, and it is an excellent model for postgraduate surgical training in UGI diseases.

Trauma management in the end-stage renal disease patient.

More than 230,000 patients in the United States are being treated for end-stage renal disease (ESRD). This group of patients has not been evaluated for trauma resource use. When these patients are involved in trauma the need for dialysis and awareness of chronic disease processes must be considered in addition to their injuries. There were 4,894 patients admitted to a Level II trauma center over a 4-year period. Fifty-nine of these patients were considered to have ESRD before admission. The charts of these patients were reviewed and compared with those in the general trauma population. The average age of the ESRD patients was 58 years with an average Injury Severity Score of 8 as compared with 31 years of age and Injury Severity Score of 10.9 for the general trauma population. Thirty-four patients required hemodialysis within 48 hours of admission. Ten patients required mechanical ventilation. Eight patients in this study died. The complication and mortality rates among the ESRD patients were 50.8 per cent and 13.5 per cent respectively as compared with 16.3 and 4.7 per cent among the general trauma population. The trauma complication and mortality rates among ESRD patients are approximately three times greater than those in the general trauma population. Because of their coexisting medical problems and the need for dialysis trauma patients with ESRD should be cared for in trauma centers with dialysis capability and access to multidisciplinary services.