A novel scheme for graft allocation in non-heart beating donor renal transplantation.

Patients waiting more than 3 years for a renal transplant were ranked according to our novel Bristol and Region Allocation by Non-heart beating Donor Score (BRANDS). One kidney from 40 non-heart beating donors was allocated to the highest BRANDS long-waiter and the other kidney allocated according to the UK National Allocation Scheme (NAS). The scheme reduced the number of patients waiting more than 3 years by 20%. Despite longer dialysis time, greater sensitization and more human leukocyte antigen mismatches, BRANDS patients had equivalent 3-year graft survival (BRANDS 91%, NAS 97%, P=0.264) and patient survival (BRANDS 94%, NAS 92%, P=0.99). Results were similar to 242 synchronous recipients from heart-beating donors. Renal function was significantly lower in BRANDS recipients (40 vs. 62 mL/min/1.73 m2, P<0.0001). Transplanting long-waiting patients with kidneys from non-heart beating donors has reduced waiting times without compromising early outcomes. It is unclear if equivalent survival will be sustained in the long term.

Fixation of the access-port is not required in gastric banding.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is increasingly performed in patients with morbid obesity. Suturing of the access-port in LAGB can be difficult and time consuming but is felt necessary by many surgeons to prevent migration and facilitate band adjustments. METHODS: Between 2003 and 2006, 226 patients underwent LAGB with the MIDband. All surgery was performed by the pars flaccida approach. The access-port was positioned in a subcutaneous pouch adjacent to the left hypochondrial port site and was not secured. Regular follow-up and band fills were offered. All band or port-related complications were duly recorded. A patient satisfaction survey was also conducted among 50 randomly selected post-banding patients. RESULTS: Mean age was 41.65 years (range 18-73 years) and mean BMI was 45.85 kg/m2 (range 34.0-74.93 kg/m2). The access-port was inaccessible at first attempt in 5 (2%) patients. 4 of these required radiological imaging to identify the port orientation and 1 required multiple attempts at port puncture with subsequent re-operation due to tube puncture. 91% of patients reported no significant trouble other than mild discomfort and prominence of the port. CONCLUSION: This study shows non-fixation of the access-port to be safe and effective with good patient acceptability. In addition, it avoids the need for regular X-ray localization of the port.

The Impact of Laparoscopic Adjustable Gastric Banding on an NHS Cohort of Type 2 Diabetics: a Prospective Cohort Study.

BACKGROUND: Obesity is an independent risk factor for diabetes, which is associated with significant morbidity and premature death. This study aims to evaluate the impact of laparoscopic adjustable gastric banding (LAGB) on a cohort of morbidly obese diabetics. METHODS: Inclusion and exclusion criteria were applied to consecutive diabetic patients undergoing LAGB. Demographic and disease-specific data were collected at baseline and 6-monthly intervals corresponding to follow-up assessments. Minimum follow-up was 24 months. Normally distributed variables were assessed with one-way analysis of variance/t tests; proportions were analysed with chi-squared/Fisher's exact tests. Follow-up was ≥90 % complete at each time point. RESULTS: One hundred twenty patients with a median age of 43.3 years, mean (± standard deviation (SD)) pre-op body mass index (BMI) of 48.7 (±8) kg/m2, and HbA1c of 8.6 (±2) % were included. BMI reduced significantly, with annual post-operative means of 41.4 ± 7.8, 39.9 ± 7.7, 39.5 ± 7.8, 39.3 ± 7.1 and 36.6 ± 5.4 kg/m(2) (p < 0.001). Corresponding percentage excess body weight lost was 32.8 ± 18, 39.8 ± 21.4, 38.5 ± 21.3, 37.0 ± 22.3 and 43.1 ± 14.1 %. HbA1c was significantly lower at each time point until 30 months post-operatively (p < 0.001). Thereafter, differences were insignificant, and HbA1c was comparable to pre-operative levels by 5 years. Seventy-six (63 %) patients achieved an HbA1c <7 % at 30 months (p < 0.001). Twenty-six (23 %) patients achieved remission from diabetes. The cumulative 5-year cost saving from reductions in anti-diabetes medications was £1650/patient. There were no mortalities, and 18 device explants. CONCLUSIONS: Modest but durable weight loss associated with significant improvements in glycaemic control and anti-diabetic medication use have been demonstrated. Peak effects occur within 24-30 months and diminish thereafter, possibly reflecting progression of pathological processes due to residual obesity.

Exposure to the field of renal transplantation during undergraduate medical education in the UK.

BACKGROUND: There is a lack of surgeons in the field of renal transplantation, with a predicted shortage of over 20 consultants by the year 2005. Early positive exposure to the field, commencing at undergraduate level, has been identified as being vital to improving rates of recruitment. This study was performed to assess the exposure of undergraduates to the field of renal transplantation during medical education in the UK. METHODS: In October 2004 a questionnaire was sent to the clinical deans of all UK medical schools regarding undergraduate exposure to renal transplantation. RESULTS: Twenty-five replies were received, giving a response rate of 96%. All but one school had a centre for renal transplantation in their region. Three schools (12%) gave no formal lecture or tutorial on the subject during the entire course. Of the remainder, between one to four formal sessions were provided, ranging from 15 minutes to 3 hours duration. Six medical schools (24%) provided no compulsory clinical exposure to renal transplantation, with a further five (20%) saying that students may receive exposure by chance. The average length of attachment was three weeks. Twenty-one medical schools (84%) provided between 1-10% of students a choice to study renal transplantation, as part of electives and special study modules. CONCLUSION: This study reveals a variation between, and within, medical schools in the levels of formal teaching. If the trends in recruitment to renal transplantation are to be reversed, we have an obligation to improve upon the medical education that students currently receive.

A survey of medical students to assess their exposure to and knowledge of renal transplantation.

BACKGROUND: Within the field of renal transplantation there is a lack of qualified and trainee surgeons and a shortage of donated organs. Any steps to tackle these issues should, in part, be aimed at future doctors. METHODS: A questionnaire was distributed to final year students at a single medical school in the UK to assess their exposure to and knowledge of renal transplantation. RESULTS: Although 46% of responding students had examined a transplant recipient, only 14% had ever witnessed the surgery. Worryingly, 9% of students believed that xenotransplantation commonly occurs in the UK and 35% were unable to name a single drug that a recipient may need to take. CONCLUSIONS: This survey demonstrates a lack of exposure to, and knowledge of, the field of renal transplantation. Recommendations to address the problems with the recruitment of surgeons and donation of organs, by targeting medical students are made.

Ethnic minorities have equal access to bariatric surgery in the UK and Ireland.

Under-representation of ethnic minority groups in bariatric surgery rates has been reported in the USA. Ethnic minorities form 7.9 % of the UK population, but comparable data on provision of bariatric surgery for these groups have not previously been reported in the UK. We calculated an estimate of rates of bariatric surgery amongst ethnic groups in the UK and Ireland using data from the National Bariatric Surgery Registry and census data from the UK and Ireland. The number of procedures recorded per 1,000 morbidly obese patients was 5.2 for Caucasian patients, 5.2 for Asian patients and 5.2 for Black patients. The identical rates across different ethnic groups suggest that bariatric services are provided equitably in the UK, with ethnic minority groups achieving equal access.

The effects of laparoscopic adjustable gastric banding on idiopathic intracranial hypertension.

The purpose of this study was to determine whether laparoscopic adjustable gastric banding has a role in the treatment of idiopathic intracranial hypertension. This pilot study was undertaken in a single, tertiary referral centre. Data on all patients with idiopathic intracranial hypertension that have undergone laparoscopic adjustable gastric banding in our unit were collected from our prospectively maintained bariatric database. Additional information was obtained via telephone questionnaires and review of medical records. Four female patient with a mean age of 32 years (range 29-39 years) and mean pre-operative body mass index of 46.1 kg/m(2) (range 38.2-54.0 kg/m(2)) underwent laparoscopic adjustable gastric banding between June 2006 and July 2009. At a mean follow-up of 19.8 months all four patients reported either total resolution of headache or significant improvement in headache, with a mean improvement in pain score of 76.3/100 (range 55-95) on a analogue pain score. Mean excess weight loss at follow-up was 64.1% (range 50.1-88.2%). There were no complications or mortality in this cohort. This study suggests that laparoscopic adjustable gastric banding represents an effective and safe treatment for idiopathic intracranial hypertension associated with morbid obesity. We have shown good results both in terms of symptom resolution and weight loss, whilst avoiding alimentary tract diversion procedures in these young female patients. A randomized, controlled trial can be justified on the basis of this initial pilot study.

The reporting of gastric band slip and related complications; a review of the literature.

Laparoscopic adjustable gastric banding is a safe and effective treatment for morbid obesity. Long-term complications include band slippage, gastric pouch dilatation and gastric erosion. Rates of band slippage reported in the literature range from less than 1% to over 20%. The aim of this review was to explore whether differences in the reporting of this complication contributed to the variability in this outcome measure. A full literature search was undertaken using EMBASE and MEDLINE search engines. Forty studies were selected for analysis based on inclusion and exclusion criteria. Each was scrutinised for outcome reporting methods and related fields. Accurate definitions for relevant terms were derived from the best available evidence. Considerable variations in device deployed, operative approach, band fixation technique, and outcome reporting mechanisms were seen between the studies. The explanation and definition of terms used within manuscripts were also seen to vary between studies. A consensus needs to be reached on how best to report complications such as gastric band slippage. We suggest which information should be included by authors to allow for accurate and reproducible reporting of such outcomes in the future.

Paediatric non-heart-beating renal transplantation.

Expanding donor numbers for paediatric transplantation is an urgent, difficult issue. The use of non-heart-beating donor renal transplants has seen a revival in adult practice, with encouraging results. The authors present the first two cases in the UK of paediatric renal transplant from non-heart-beating donors.

The use of porcine dermal collagen implants in assisting abdominal wall closure of pediatric renal transplant recipients with donor size discrepancy.

Children may have kidneys transplanted from donors larger than themselves. Abdominal wall closure may be difficult, with risks of abdominal compartment syndrome and graft compromise. Meshes used to facilitate closure may cause dense intra-abdominal adhesions, making further surgery or peritoneal dialysis difficult. We present five cases in which abdominal wall closure was facilitated by porcine dermal collagen implant. Five children (2-15 yr) received transplanted kidneys from adult donors of significantly greater weight. In four recipients, the kidney was transplanted onto the aorta and vena cava intra-abdominally using a midline incision. In the fifth, the kidney was anastomosed onto the iliac vessels. The skin overlying the implant was closed normally. Maximum follow-up was three yr. In all cases, primary closure was achieved. One child received a second intra-abdominal transplant as an emergency, which later failed. The other kidneys are functioning well. One recipient developed a small incisional hernia three yr post-transplant. Another developed a skin dehiscence over the implant 23 days post-operatively. The implant was removed and skin closed. The other two recipients recovered well. Porcine dermal collagen implant is a helpful adjunct to abdominal wall closure following organ transplantation in children with donor size discrepancy.

Radiocephalic and brachiocephalic arteriovenous fistula outcomes in the elderly.

BACKGROUND: A recent meta-analysis has suggested that patients aged >65 have worse outcomes with radiocephalic arteriovenous fistulas (RCAVFs) compared with brachiocephalic arteriovenous fistulas (BCAVFs). We hypothesized that outcomes in patients aged > or = 80--a rapidly expanding cohort within this elderly group--might be skewing the results, and that age >65 may not be a contraindication to RCAVF formation. This study examined the effect of age group (<65, 65 to 79, >or =80) on functional outcomes (use; primary and secondary functional patency) in RCVAFs and BCAVFs. METHODS: We identified the outcomes of all patients undergoing a first surgical access procedure for a RCAVF or BCVAF between January 1, 2000, and December 31, 2005. We examined the effect of age and other factors including sex, diabetes mellitus, hypertension, late referral (<3 months before dialysis), dialysis before surgical access, preoperative duplex ultrasound imaging, and ethnicity on non-AVF use and primary and secondary functional AVF patency. Logistic regression and Cox proportional hazards regression models were used. RESULTS: From a total of 658 patients, 361 had a RCAVF, and 297 had a BCAVF. Their median age was 68.5 years (interquartile range [IQR], 54.4 to 76.5 years), and 288 (43.8%) were aged <65 years, 274 (41.6%) were 65 to 79, and 96 (14.6%) were > or =80. Age did not influence the site of the first surgical access (P = .874). Only 85.7% of patients actually progressed to hemodialysis, and the RCAVF or BCAVF in 45.7% of those was never used for dialysis. Female sex (hazard ratio [HR], 2.24; 95% confidence interval [CI] 1.387 to 3.643; P = .001) was the only factor associated with an increase risk of RCAVF nonuse, whereas diabetes (HR, 2.095; 95% CI, 1.261 to 3.482; P = .004) was the only factor associated with an increase risk of BCAVF nonuse. The respective primary patency rates at 1 and 2 years for RCAVFs were 46.0% and 27.1% for patients <65, 47.0% and 36.0% for those 65 to 79, and 45.7% and 38.1% for those >or =80. Only female sex (HR, 1.679; 95% CI, 1.261 to 2.236; P = .001) and prior hemodialysis (HR, 1.363; 95% CI, 1.0.29 to 1.804; P = .031) were associated with loss of patency of RCAVFs. The primary functional patency rates for BCAVFs at 1 and 2 years were 39.3% and 31.0% for those <65 years; 53.30% and 37.5% for those 65 to 79, and 46.3% and 42.6% for those >or =80. No factors analyzed were associated with loss of primary functional patency of BCAVFs. CONCLUSIONS: Age did not affect usability, primary or secondary patency of either RCAVFs or BCAVFs. Although patient selection is important, even patients > or =80 years who are considered suitable for surgical placement of access should not be denied a RCAVF solely because of age.