In vivo study to assess fat embolism resulting from the Reamer-Irrigator-Aspirator 2 system compared to a novel aspirator-based concept for intramedullary bone graft harvesting.

INTRODUCTION: Fat embolism (FE) following intramedullary (IM) reaming can cause severe pulmonary complications and sudden death. Recently, a new harvesting concept was introduced in which a novel aspirator is used first for bone marrow (BM) aspiration and then for subsequent aspiration of morselized endosteal bone during sequential reaming (A + R + A). In contrast to the established Reamer-Irrigator-Aspirator (RIA) 2 system, the new A + R + A concept allows for the evacuation of fatty BM prior to reaming. In this study, we hypothesized that the risk of FE, associated coagulopathic reactions and pulmonary FE would be comparable between the RIA 2 system and the A + R + A concept. MATERIALS AND METHODS: Intramedullary bone graft was harvested from intact femora of 16 Merino sheep (age: 1-2 years) with either the RIA 2 system (n = 8) or the A + R + A concept (n = 8). Fat intravasation was monitored with the Gurd test, coagulopathic response with D-dimer blood level concentration and pulmonary FE with histological evaluation of the lungs. RESULTS: The total number and average size of intravasated fat particles was similar between groups (p = 0.13 and p = 0.98, respectively). D-dimer concentration did not significantly increase within 4 h after completion of surgery (RIA 2: p = 0.82; A + R + A: p = 0.23), with an interaction effect similar between groups (p = 0.65). The average lung area covered with fat globules was similar between groups (p = 0.17). CONCLUSIONS: The use of the RIA 2 system and the novel A + R + A harvesting concept which consists of BM evacuation followed by sequential IM reaming and aspiration of endosteal bone, resulted in only minor fat intravasation, coagulopathic reactions and pulmonary FE, with no significant differences between the groups. Our results, therefore, suggest that both the RIA 2 system and the new A + R + A concept are comparable technologies in terms of FE-related complications.

Lymphedema after saphenous harvesting for coronary artery bypass surgery: case report and literature review.

Different causes have been described for secondary lymphedema as reported in this article. A 75-year-old man was diagnosed with lymphedema about one decade after saphenous harvesting for coronary artery bypass surgery. It took two years for him to find out his diagnosis and receive the proper treatment. After standard complete decongestive therapy, his volume and pain decreased and his quality of life was improved, especially its physical aspect. It is important to recognize the possibility of lymphedema development after saphenous harvesting among patients undergoing coronary artery bypass surgery to prevent significant disturbance of quality of life with timely management.

Laparo-Endoscopic Single-Site Left Donor Nephrectomy In Patients With Uncommon Renal Vascular Anatomy: Does the Technique Make a Difference?

BACKGROUND: To compare donor and recipient outcomes in patients with renal artery and ante-aortic renal vein vs unusual renal vascular anatomy undergoing laparoendoscopic single-site donor nephrectomy (LESSDN). METHODS: A retrospective chart review of the comparative study of donor and recipient outcomes of LESSDN in donors with venous abnormality (n = 28, group A), arterial abnormality (n = 74, group B), and standard donors (n = 248, group C). RESULTS: From September 2016 to August 2022, 350 left LESSDN were performed. The most common anomalies in group A were the retro-aortic and 2 renal veins in 12 patients each. In group B, 72 and 2 patients had 2 and 3 renal arteries, respectively. Operative and warm ischemia times were significantly longer in donors with vascular anomalies. Moreover, patient creatinine on discharge was significantly higher in arterial anomalies; it was 1.61 ± 0.22 compared with 1.26 ± 0.43 and 1.25 ± 0.32 mg/dL for patients with no anomalies and venous anomalies, respectively (P < .001). However, serum creatinine levels recovered after 1 month and were comparable between the study groups. Recipients, operative time, and vascular anastomosis time were significantly longer in recipients with vascular anomaly. Slow graft function was higher in group B (6.9%) than in the other groups. One-year graft survival rates were 96.4%, 94.6%, and 97.1% (P = .496). CONCLUSION: With increased experience, LESSDN in multiple renal arteries and uncommon venous anatomy cases is feasible and safe. Moreover, it does not influence donor or recipient outcomes.

Pure laparoscopic donor hepatectomy: Experience of 556 cases at Seoul National University Hospital.

Pure laparoscopic donor hepatectomy (PLDH) has become a routine procedure at Seoul National University Hospital, and the pure laparoscopic method is now being applied to liver recipients as well. This study aimed to review the procedure and outcomes of PLDH to identify any areas that required improvement. Data from 556 donors who underwent PLDH between November 2015 and December 2021 and their recipients were retrospectively reviewed. Among these, 541 patients underwent pure laparoscopic donor right hepatectomy (PLDRH). The mean hospital stay of the donor was 7.2 days, and the rate of grade I, II, IIIa, and IIIb complications was 2.2%, 2.7%, 1.3%, and 0.9%, respectively, without any irreversible disabilities or mortalities. The most common early and late major complications in the recipient were intraabdominal bleeding (n = 47, 8.5%) and biliary problems (n = 198, 35.6%), respectively. Analysis of the PLDRH procedure showed that operative time, liver removal time, warm ischemic time, Δhemoglobin%, Δtotal bilirubin%, and postoperative hospital stay decreased significantly as the number of cases accumulated. In conclusion, the operative outcomes of PLDRH improved as the number of cases increased. However, continuous caution is needed because major complications still occur in donors and recipients even after hundreds of cases.

Endoscopic Pedicle Saphenous Vein Graft Harvesting.

The excellent long-term patency of no-touch (NT) saphenous vein grafts (SVGs) makes the grafts very attractive for coronary artery bypass grafting; however, NT-SVG harvesting has a greater incidence of wound complications than conventional methods. Since 2009, we have performed endoscopic vein harvesting (EVH) in our department with very few major wound complications. Because NT-SVG harvesting is expected to provide long-term patency, if performed with EVH, the incidence of wound complications will be reduced. Thus, we began performing endoscopic pedicle SVG harvesting (Pedicle-EVH) in March 2019. Herein, we report the early results obtained using our current Pedicle-EVH procedure. No major wound complications were reported, and the early results, including patency, were satisfactory. To harvest the pedicle SVG, however, we used a different method than the NT-SVG procedure, so careful monitoring will be needed to assess long-term outcomes.

Reduction of the scar burden at the donor area of the radial forearm flap with the aid of an endoscopic pedicle preparation.

BACKGROUND: The radial forearm flap is one of the most commonly used flaps of reconstructive microsurgery with its long pedicle and thin structure. The donor site at the forearm is a visible anatomic region that has high mobility and functional importance. In this study, a longitudinal and large scar was avoided on the forearm during pedicle dissection of the conventional radial forearm flap with the utilization of an endoscope. Furthermore, arterial, venous, and nervous injuries were avoided by performing a separate inci-sion of 2-3 cm at the cubital fossa to reduce flap failure and donor site morbidity. METHODS: The patients who underwent pedicle dissection of the radial forearm flap with the aid of an endoscope for head-neck reconstruction between 2014 and 2021 were included in this study. The flap was harvested from the subfascial plane. The cephalic vein was used in all of the patients. When the pedicle dissection reached the antecubital region, an incision of 2-3 cm was performed from the skin. Two vein anastomoses were performed for each patient. RESULTS: This retrospective study consists of 51 patients. While 45 of the patients were the result of head and neck cancer, six of them had a defect caused by trauma. The average area of skin islands was 40.3 cm2, while the full-thickness skin graft size was 24.2 cm2. An average of 2.6 cm of scar tissue was formed at the antecubital region. No venous or arterial compromise was observed in the post-operative period. There was no partial or total flap loss in any patient. Localized numbness persisted in the skin area where the superficial sensory branch of the radial nerve is located in 6 (11.7%) patients. CONCLUSION: With endoscopic radial forearm flap harvesting, the longitudinal incision in the forearm and wound healing prob-lems are avoided. The absence of partial or total flap loss has shown that endoscopic harvesting of the radial forearm flap is a safe and reliable method.

Vein Morphology in Endoscopic Vein Harvesting: 15-Year Outcomes.

OBJECTIVE: Long-term outcomes of vein morphologies in the endoscopic vein harvesting setting are lacking. We analyzed 15-year follow-up for endoscopic versus open vein harvesting and associated vein morphology outcomes in coronary artery bypass grafting at a single center. METHODS: This single-center, prospectively collected, retrospective, observational study evaluated 15-year major adverse cardiovascular events (MACE) of endoscopic versus open vein harvesting and associated vein morphologies. RESULTS: Among 729 patients, no differences were found between endoscopic and open vein harvesting in MACE hazard ratios despite increased risks with native Hawai'ian, Pacific Islander, and Filipino patients. Asian and Filipino patients had more thin-walled veins and Asian and multirace patients had more vasovasoral branches than White patients. Bifid veins were associated with increased risk of cardiac catheterization. Varicose veins were associated with myocardial infarction, congestive heart failure, and death. Thick-walled veins were associated with revascularization and dense adhesions with cardiac catheterization and revascularization. CONCLUSIONS: Fifteen-year adjusted MACE was similar between endoscopic and open vein harvesting in small coronary targets despite increased risks with native Hawai'ian, Pacific Islander, and Filipino patients. Bifid, varicose, thick-walled veins, and dense adhesions had worse MACE.

[First experience of 3D-laparoscopy in donor nephrectomy]. / Nachal'nyi opyt ispol'zovaniya 3D-videosistem pri laparoskopicheskoi donorskoi nefrektomii.

OBJECTIVE: To assess the first experience of 3D imaging for laparoscopic donor nephrectomy. MATERIAL AND METHODS: The study included 28 laparoscopic donor nephrectomies and 28 subsequent transplantations to related recipients. Of these, 14 laparoscopic donor nephrectomies were performed using 3D camera. The main intraoperative parameters and information about postoperative period in donors and recipients were compared with similar data on previous laparoscopic donor nephrectomies and kidney transplantations with traditional 2D imaging. There were 15 left-sided and 13 right-sided nephrectomies. Twenty and eight laparoscopic nephrectomies were performed via retroperitoneal and transperitoneal access, respectively. There were no significant between-group differences in age, sex ratio, BMI, side of surgery and number of renal arteries. RESULTS: Surgery time (119.28±9.18 and 124.85±7.49 min, respectively) and blood loss (106.78±16.12 and 119.28±19.79 ml, respectively) were similar. Laparoscopic nephrectomy with 3D imaging was followed by significantly shorter primary warm ischemia (2.41±0.79 and 3.23±0.57 min, respectively, p=0.004) and time of extracorporeal preparation of the transplant (back table) under cold preservation (27.21±5.42 and 32.36±5.33 min, respectively, p=0.02). CONCLUSION: Initial experience of video systems with 3D imaging in laparoscopic donor nephrectomy has not yet led to significant reduction of surgery time and improvement of transplant function compared to traditional 2D imaging. At the same time, there was a shorter period of primary warm ischemia and back table time. Further analysis is needed to assess possible benefits of 3D imaging in laparoscopic donor nephrectomy.

Donor Safety and Risk Factors of Pure Laparoscopic Living Donor Right Hepatectomy: A Korean Multicenter Study.

OBJECTIVE: The aim of this study was to identify safety and risk factors of living donor after pure laparoscopic donor right hepatectomy in a Korean multicenter cohort study. BACKGROUND: Pure laparoscopic donor right hepatectomy is not yet a standardized surgical procedure due to lack of data. METHODS: This retrospective study included 543 patients undergoing PLRDH between 2010 and 2018 in 5 Korean transplantation centers. Complication rates were assessed and multivariate logistic regression analyses were performed to identify risk factors of open conversion, overall complications, major complications, and biliary complications. RESULTS: Regarding open conversion, the incidence was 1.7% and the risk factor was body mass index >30 kg/m 2 [ P =0.001, odds ratio (OR)=22.72, 95% CI=3.56-146.39]. Rates of overall, major (Clavien-Dindo classification III-IV), and biliary complications were 9.2%, 4.4%, and 3.5%, respectively. For overall complications, risk factors were graft weight >700 g ( P =0.007, OR=2.66, 95% CI=1.31-5.41), estimated blood loss ( P <0.001, OR=4.84, 95% CI=2.50-9.38), and operation time >400 minutes ( P =0.01, OR=2.46, 95% CI=1.25-4.88). For major complications, risk factors were graft weight >700 g ( P =0.002, OR=4.01, 95% CI=1.67-9.62) and operation time >400 minutes ( P =0.003, OR=3.84, 95% CI=1.60-9.21). For biliary complications, risk factors were graft weight >700 g ( P =0.01, OR=4.34, 95% CI=1.40-13.45) and operation time >400 minutes ( P =0.01, OR=4.16, 95% CI=1.34-12.88). CONCLUSION: Careful donor selection for PLRDH considering body mass index, graft weight, estimated blood loss, and operation time combined with skilled procedure can improve donor safety.

How the websites of high-volume US centers address the risks of living kidney donation.

BACKGROUND: The websites of US transplant centers may be a source of information about the renal risks of potential living kidney donors. METHODS: To include only likely best practices, we surveyed websites of centers that performed at least 50 living donor kidney transplants per year. We tabulated how risks were conveyed regarding loss of eGFR at donation, the adequacy of long-term ESRD risk data, long-term donor mortality, minority donor ESRD risk, concerns about hyperfiltration injury versus the risk of end-stage kidney diseases, comparisons of ESRD risks in donors to population risks, the increased risks of younger donors, an effect of the donation itself to increase risk, quantifying risks over specific intervals, and a lengthening list of small post-donation medical risks and metabolic changes of uncertain significance. RESULTS: While websites had no formal obligation to address donor risks, many offered abundant information. Some conveyed OPTN-mandated requirements for counseling individual donor candidates. While actual wording often varied, there was general agreement on many issues. We occasionally noted clear-cut differences among websites in risk characterization and other outliers. CONCLUSIONS: The websites of the most active US centers offer insights into how transplant professionals view living kidney donor risk. Website content may merit further study.

An unusual case of huge fibrotic sac of hematoma at saphenous vein harvest site for coronary artery bypass grafting: a case report.

Great saphenous vein is a conduit commonly used for coronary artery bypass grafting. However, several complications could occur at leg wound site for vein harvesting. Here, we describe a huge sac of hematoma as an uncommon complication of saphenous vein harvest for coronary artery bypass grafting.A 62-year-old gentleman was readmitted with swelling at left thigh 30 days after coronary artery bypass grafting. Lower extremity computed tomography was suggestive of an oval and thick sac implying a hematoma or seroma. After using ultrasound scanning for the mass, an incision through the previous surgical wound showed a huge mass. Inspection after incision the mass revealed an old hematoma within the sac.Pathologic findings demonstrated chronic inflammation with the hematoma surrounded by a fibrotic sac. The patient's postoperative course was uneventful without recurrence.Our experience suggests the possibility of a huge hematoma within a thick fibrotic sac at the previous vein harvest site for coronary artery bypass grafting.

Robotic Versus Laparoscopic Donor Nephrectomy: A Retrospective Bicentric Comparison of Learning Curves and Surgical Outcomes From 2 High-volume European Centers.

BACKGROUND: Although laparoscopic donor nephrectomy (LDN) represents the gold-standard technique for kidney living donation, robotic donor nephrectomy (RDN) settled as another appealing minimally invasive technique over the past decades. A comparison between LDN and RDN outcomes was performed. METHODS: RDN and LDN outcomes were compared, focusing on operative time and perioperative risk factors affecting surgery duration. Learning curves for both techniques were compared through spline regression and cumulative sum models. RESULTS: The study analyzed 512 procedures (154 RDN and 358 LDN procedures) performed between 2010 and 2021 in 2 different high-volume transplant centers. The RDN group presented a higher prevalence of arterial variations (36.2 versus 22.4%; P = 0.001) compared with the LDN cohort. No open conversions occurred; operative time (210 versus 195 min; P = 0.011) and warm ischemia time (WIT; 230 versus 180 s; P < 0.001) were longer in RDN. Postoperative complication rate was similar (8.4% versus 11.5%; P = 0.49); the RDN group showed shorter hospital stay (4 versus 5 d; P < 0.001). Spline regression models depicted a faster learning curve in the RDN group ( P = 0.0002). Accordingly, cumulative sum analysis highlighted a turning point after about 50 procedures among the RDN cohort and after about 100 procedures among the LDN group.Higher body mass index resulted as an independent risk factor for longer operative time for both techniques; multiple arteries significantly prolonged operative time in LDN, whereas RDN was longer in right kidney procurements; both procedures were equally shortened by growing surgical experience. CONCLUSIONS: RDN grants a faster learning curve and improves multiple vessel handling. Incidence of postoperative complications was low for both techniques.

Current possibilities and risks of donating some tissues, cells, and organs from living donors.

Transfusion, transplantation, and regenerative medicine are rapidly developing fields. The authors of the text want to inform about upcoming legislative changes at the EU level and briefly describe and compare the difficulty of some donation procedures from the point of view of a living donor, as well as their risks, including psychosocial risks. The study is based on a qualitative expert investigation. Comparing the complexity of procedures from the perspective of donors is important, for example, for setting compensations. The tables show that the current compensations are disproportionate.

Comparison of pure laparoscopic donor right posterior sectionectomy versus right hemihepatectomy for living donor liver transplantation.

The right posterior section (RPS) graft for living donor liver transplantation is an alternative graft in a live liver donor with insufficient remnant left lobe volume and portal vein anomaly. Although there have been some reports regarding pure laparoscopic donor right posterior sectionectomy (PLDRPS), no study has compared PLDRPS versus pure laparoscopic donor right hemihepatectomy (PLDRH). The aim of our study was to compare the surgical outcomes of PLDRPS versus PLDRH at centers achieving a complete transition from open to laparoscopic approach in liver donor surgery. From March 2019 to March 2022, a total of 351 living donor liver transplantations, including 16 and 335 donors who underwent PLDRPS and PLDRH, respectively, were included in the study. In the donor cohort, there were no significant differences in major complication (≥grade III) rate and comprehensive complication index between the PLDRPS versus PLDRH group (6.3% vs. 4.8%; p = 0.556 and 2.7 ± 8.6 vs.1.7 ± 6.4; p = 0.553). In the recipient cohort, there was a significant difference in major complication (≥grade III) rate (62.5% vs. 35.2%; p = 0.034) but no significant difference in comprehensive complication index (18.3 ± 14.9 vs. 15.2 ± 24.9; p = 0.623) between the PLDRPS and PLDRH groups. PLDRPS in live liver donors with portal vein anomaly and insufficient left lobe was technically feasible and safe with experienced surgeons. The PLDRPS group might be comparable with the PLDRH group based on the surgical outcomes of donors and recipients. However, in terms of recipient outcomes, more careful selection of donors of the RPS graft and further research in a large number of cases are necessary to evaluate the usefulness of PLDRPS.

Retroperitoneoscopic Donor Nephrectomy on the Right Side Provides Equivalent Outcomes and Donor Safety to That on the Left Side.

BACKGROUND: The left kidney is typically selected for laparoscopic donor nephrectomy. In contrast, right kidney donation raises concerns for donor safety, and venous anastomosis may be difficult to achieve due to the short renal vein. We investigated the safety and operative outcomes of right donor nephrectomy compared with those of the left. METHODS: We retrospectively analyzed the clinical records of living donor-kidney transplant donors and evaluated operative outcomes such as operative time, ischemic time, blood loss, and surgical complications in the donor. RESULTS: We identified 79 donors (left:right = 62:17 cases) between May 2020 and March 2023. There were no significant differences between the 2 groups regarding age, sex, body mass index, and number of renal arteries. Although the operative time (left and right: 190 and 225 minutes, excluding waiting time; P = .009) and warm ischemic time (left and right: 143 and 193 seconds, P = .021) were significantly longer on the right side, the total ischemic time (82 and 86 minutes, P = .463) and blood loss (left and right: 35 and 25 mL, P = .159) were comparable between the groups. There were no significant differences between the groups regarding the surgical complications. CONCLUSIONS: Operative outcomes were similar in both donor sides in the retroperitoneoscopic donor nephrectomies. The right side should be considered for donation in this operative procedure.

How Long Does It Take to Acquire Mastery of Performance in Laparoscopic Living Donor Nephrectomy? A Center-Based and Surgeon-Based Operative Time CUSUM Analysis.

BACKGROUND: The safety of laparoscopic donor nephrectomy (LDN) has been widely documented, but its challenging learning curve (LC) requires an insightful assessment to expand its application. The aim of this study was to evaluate LC of LDN in a high-volume transplant center. METHODS: Three hundred forty-three LDNs performed from 2001 to 2018 were evaluated. CUSUM analysis based on the operative time was used to assess the number of cases required to reach mastery in the technique for both the entire surgical team and for the 3 main surgeons considered separately. Analysis of association between demographics, perioperative characteristics, and complications within the different LC phases was conducted. RESULTS: Mean operative time was 228.9 minutes. Mean length of stay was 3.8 days and mean warm ischemia time (WIT) was 170.8 seconds. Surgical and medical complication rates were 7.3% and 6.4%, respectively. The CUSUM-LC showed a requirement of 157 cases (for surgical team) and 75 cases (for single surgeons) to reach competence in the procedure. Patient baseline characteristic showed no differences among the LC phases. Compared with the initial LC phase, hospital stay was significantly lower at the end of the LC whereas WIT results were longer in the LC descendent phase. CONCLUSIONS: This study confirms the safety and efficacy of LDN, with a low rate of complications. This analysis suggests that about 75 procedures are required to reach competence and 93 cases to achieve mastery level of skill for a single surgeon. It can be hypothesized that, in a high-volume transplant enter, the time to guarantee training in LDN is compatible with the duration of a clinical fellowship.

Wound healing dynamics, morbidity, and complications of palatal soft-tissue harvesting.

Palatal-tissue harvesting is a routinely performed procedure in periodontal and peri-implant plastic surgery. Over the years, several surgical approaches have been attempted with the aim of obtaining autogenous soft-tissue grafts while minimizing patient morbidity, which is considered the most common drawback of palatal harvesting. At the same time, treatment errors during the procedure may increase not only postoperative discomfort or pain but also the risk of developing other complications, such as injury to the greater palatine artery, prolonged bleeding, wound/flap sloughing, necrosis, infection, and inadequate graft size or quality. This chapter described treatment errors and complications of palatal harvesting techniques, together with approaches for reducing patient morbidity and accelerating donor site wound healing. The role of biologic agents, photobiomodulation therapy, local and systemic factors, and genes implicated in palatal wound healing are also discussed.