Frequency Of Surgical Complications Research Articles

Surgical Complications of Live Related Renal Transplantation

AbstractIntroduction:Renal transplantation is the treatment of choice for patients with end stage renal disease. It offers marked improvement in the quality of life of patients who undergo this form of treatment. Surgical complications are important in the sense that they can lead to loss of allograft and in severe cases loss of patient life. The aim of this study is to determine the frequency of surgical complications after renal trans-plantation in our population.Materials and Methods:We retrospectively reviewed the surgical complications in 350 patients who had live related renal transplantation performed at Postgraduate Medical Institute, Shaikh Zayed hospital Lahore from January 2007 to December 2013.Results:Among 57 (16.1%) surgical complications 18 (5.1%) had urological complications. Urinary fistulae, ureteral stenosis, ureteral stricture and hematuria occurred in 9 (2.5%), 4 (1.14%), 4 (1.14%) and 1 (0.28%) patients respectively. Vascular complications occurred in 5 (1.42%) patients in total. 2 (0.57%) patients had renal artery thrombosis and 1 (0.28%) patient had renal vein thrombosis. 2 (0.57%) patients had thrombosis of external iliac artery. Lymphocele occur-red in17 (4.8%) of patients and wound infection developed in 19 (5.4%) patients.Conclusion:Surgical complications after kidney transplantation may be reduced or minimized if basic surgical principles of transplantation are followed. We conclude that kidney transplantation is a safe procedure with fewer surgical complications. The most important thing is the early diagnosis and prompt treatment of the complications in order to save the graft and the patient.Keywords:Transplantation, Complications, Live related.

Total thyroidectomy as a method of choice in the treatment of Graves' disease - analysis of 1432 patients.

BackgroundGraves’ disease represents an autoimmune disease of the thyroid gland where surgery has an important role in its treatment. The aim of our paper was to analyze the results of surgical treatment, the frequency of microcarcinoma and carcinoma, as well as to compare surgical complications in relation to the various types of operations performed for Graves’ disease.MethodsWe analysed 1432 patients (221 male and 1211 female) who underwent surgery for Graves’ disease at the Centre for Endocrine Surgery in Belgrade during 15 years (1996–2010). Average age was 34.8 years. Frequency of surgical complications within the groups was analyzed with nonparametric Fisher’s test.ResultsTotal thyroidectomy (TT) was performed in 974 (68%) patients, and Dunhill operation (D) in 221 (15.4). Carcinoma of thyroid gland was found in 146 patients (10.2%), of which 129 (9%) were a microcarcinoma. Complication rates were higher in the TT group, where there were 31 (3.2%) patients with permanent hypoparathyroidism, 9 (0.9%) patients with unilateral recurrent nerve paralysis and 10 (1.0%) patients with postoperative bleeding. Combined complications, such as permanent hypoparathyroidism with bleeding were more common in the D group where there were 2 patients (0,9%), while unilateral recurrent nerve paralysis with bleeding was more common in the TT group where there were 3 cases (0,3%).ConclusionsFrequency of complications were not significantly statistically different in relation to the type of surgical procedure. Total thyroidectomy represents a safe and efficient method for treating patients with Graves’ disease, and it is not followed by a greater frequency of complications in relation to less extensive procedures.

Outcomes of immediate perforator flap reconstruction after skin-sparing mastectomy following neoadjuvant chemotherapy

BackgroundThe impact of neoadjuvant chemotherapy (NACT) on immediate free flap breast reconstruction remains controversial. Furthermore, the oncological outcomes of immediate free flap breast reconstruction after skin-sparing mastectomy (SSM) following NACT remain unclear. This study aimed to investigate the surgical complications and oncological outcomes of immediate perforator flap reconstruction after SSM following NACT. MethodsA total of 201 consecutive patients with indications for immediate perforator flap reconstruction after SSM were included between 2004 and 2012. Surgical and oncological outcomes were compared between patients with and without NACT. ResultsThere were 38 patients in the NACT group and 163 in the non-NACT control group. The median age of the NACT group was 39.5 years, which was significantly younger than the control group (43.0 years; P < 0.05). Patients in the NACT group also had more advanced and aggressive disease (P < 0.05). There was no significant difference in the frequency of surgical complications between the groups, no difference in the type of complications, and no significant difference in the frequencies of major and minor complications. No patients in the NACT group had delayed adjuvant therapy. Eight patients (4%) developed recurrences, with a median follow-up time of 3.0 years. Local recurrences occurred in three control patients but no patients in the NACT group. ConclusionNACT does not affect short-term or interim outcomes after immediate perforator flap reconstruction and may thus represent a safe and practical treatment option for the multidisciplinary treatment of breast cancer.

Long-term Outcomes and Prognostic Factors for Trabeculectomy With Mitomycin C in Eyes With Uveitic Glaucoma

To elucidate the long-term outcomes and prognostic factors for trabeculectomy with mitomycin C (MMC) in eyes with uveitic glaucoma (UG). A retrospective, consecutive, comparative cohort study was conducted with 204 patients who underwent trabeculectomy with MMC between 1999 and 2008 at 2 Japanese clinical centers. The study group included 101 eyes with UG and 103 eyes with primary open-angle glaucoma (POAG). Surgical failure was defined as intraocular pressure levels of ≥21 mm Hg or an additional glaucoma surgery. Kaplan-Meier survival curves for surgical failure were compared between UG and POAG eyes, and prognostic factors for surgical failure of trabeculectomy in UG eyes were analyzed by the Cox proportional hazards model. Secondary outcome measures included comparisons of the frequency of additional cataract surgery and other surgical complications after trabeculectomy between UG and POAG eyes. The mean follow-up periods (±SD) were 34.7±37.9 and 37.7±34.7 months (median, 24.0 and 27.4 mo) for UG and POAG, respectively. The subtypes of uveitis were granulomatous uveitis (n=20) including sarcoidosis (n=12), Vogt-Koyanagi-Harada disease (n=5) and varicella zoster virus uveitis (n=3), Behçet disease (n=10), Posner-Schlossman syndrome (n=5), and other types of UG (n=12). Fifty-four eyes were diagnosed with idiopathic UG. The 3-year probabilities of success after trabeculectomy were 71.3% and 89.7% for UG and POAG, respectively (P=0.0171). A multivariable model showed that UG eyes with previous cataract surgery [relative risk (RR)=2.957, P=0.0344)] and granulomatous uveitis (RR=3.805, P=0.0106) were associated with surgical failure. UG eyes experienced more frequent cataract surgeries after trabeculectomy than POAG eyes: the 3-year probabilities of additional cataract surgery of 62.6% and 10.7% for UG and POAG, respectively (P<0.0001). There was no significant difference in the frequency of surgical complications such as bleb leakage, hypotensive maculopathy, severe anterior-chamber hemorrhage, and infectious endophthalmitis. Trabeculectomy with MMC was less effective in maintaining intraocular pressure reduction in UG eyes than in POAG eyes. The prognostic factors for surgical failure of trabeculectomy in UG eyes were previous cataract surgery and granulomatous uveitis. In addition, UG eyes after trabeculectomy more frequently required additional cataract surgery.

An institutional based study of post-operative surgical complications of live related renal transplant recipients

Abstract Objectives This study was done to know the frequency of surgical complications among the live related renal transplants at our institution and to analyze the different factors that may influence the occurrence of such complications. Settings and design A prospective study of 182 live related renal transplants from August 2006 to December 2008 done at our institution was designed and conducted. All patients received their kidneys from living donors who were first degree relatives. All patients were followed for a minimum one year period. Surgical complications were reported and their incidence was correlated with several pretransplant, technical and post-transplant risk factors by both univariate and multivariate analyses. Results Among the 182 patients, 27 surgical complications were encountered. These complications included ureteric stricture in 1 patient, lymphocele in 13 patients, deep vein thrombosis in 1 patient, vascular complications in 4 patients, wound infection in 6 patients with dehiscence in one patient in one patient and pyocoele in one patient. The incidence of urological complications was 0.5%, vascular complications 2.2% lymphocoele was 7.1% and wound infections was 3.3%. On univariate analysis, the factors that significantly affected the incidence of surgical complications were occurrence of post-transplant ATN for lymphocoeles and the number of graft renal arteries for vascular complications. On multivariate analysis, the number of graft renal arteries significantly affected the occurrence of vascular complications. Conclusion Surgical complications in live renal transplantation can be minimized if basic principles of careful transplant techniques are used. Prompt identification and treatment of any complication is paramount to graft and patient survival.

Long‐term outcomes of living donor kidney transplants in pediatric recipients following laparoscopic vs. open donor nephrectomy

We compared long-term outcomes of LDKT in pediatric recipients following either laparoscopic (LDN) or ODN. In our retrospective single-center study, we compared 38 pediatric LDKT recipients of a laparoscopically procured kidney with a historic ODN group comprising 17 pediatric recipients. In our center, the first pure laparoscopic non-hand-assisted LDN for a pediatric LDKT recipient was performed in June 2001. Demographic data of donors and recipients were comparable between groups. Mean follow-up was 64 months in the LDN group and 137 months in the ODN group. Patient survival was comparable between groups. Graft survival at one and five yr was 97% (LDN) vs. 94% (ODN) and 91% (LDN) vs. 88% (ODN; p = n.s.), respectively. Serum creatinine at one and five yr was 1.16 ± 0.47 mg/dL (LDN) vs. 1.02 ± 0.38 mg/dL (ODN) and 1.38 ± 0.5 mg/dL (LDN) vs. 1.20 ± 0.41 mg/dL (ODN), respectively. The type and frequency of surgical complications did not differ between groups. DGF and acute rejection rates were similar between groups. In the ODN group, a higher proportion of right donor kidneys was used. In the ODN group, all kidneys had singular arteries, whereas in the LDN group five kidneys had multiple arteries. Arterial multiplicity was associated with a higher incidence of DGF. In our experience, LDN does not compromise long-term graft outcomes in pediatric LDKT recipients. Arterial multiplicity of the donor kidney may be a risk factor for impaired early graft function in the pediatric population.

An Optimized Method of Vessel Dissection in Establishment of the Rat Aortic Transplantation Model

The high demand for microsurgical skills in those without a strong microsurgery background limits the application of the rat aortic transplant model to transplantation research. In this study, we established a rat aortic transplant model using a hydrodissection technique as a minimal-touch technique in vessel dissection. Eighty male Sprague Dawley rats were randomly divided into two groups with equal numbers. In the experimental group, abdominal aortas were harvested using hydrodissection; in the control group, instrumental dissection was used. The harvested aortas were transplanted orthotopically. The mean harvesting and implanting time in the experimental group was significantly lower than that of the control group (11.8 ± 1.51 versus 23.8 ± 3.38 minutes, P < 0.01; 46 ± 6.07 versus 58.85 ± 5.31 minutes, P < 0.01). Surgical complications in the control group included inferior vena cava injury (2/20), arterial vasospasm (3/20), and arterial wall hemorrhage (1/10). None of these complications were observed in the hydrodissection group. The overall frequency of surgical complications in the hydrodissection group was significantly lower than that in the control group ( P < 0.05). This study suggested that the hydrodissection technique is a fast and safe method of vessel dissection. This technique requires less microsurgical skills and optimizes the establishment of the rat aortic transplant model.

Ovarian cancer in the elderly: Outcomes with neoadjuvant chemotherapy or primary cytoreduction

Background Recent studies have suggested inferior outcomes for elderly women with ovarian cancer. Our goal was to evaluate neoadjuvant chemotherapy versus primary cytoreduction in elderly women. Methods A retrospective chart review was performed for women aged 65+ diagnosed with ovarian cancer at our institution between 1997 and 2007. Univariate and multivariate logistic regression models were used to evaluate complication rates. Survival was evaluated with Cox regression and the Kaplan–Meier method. Results One hundred seventy-five patients were identified, 34 (19%) of whom were aged 80+. Those aged 65–79 and those 80+ received neoadjuvant chemotherapy with equal frequency (19% vs. 21%, p = 0.92). Treatment with neoadjuvant chemotherapy was associated with odds ratios of 0.80 (95% CI 0.37–1.75) for surgical complications and 0.79 (95% CI 0.33–1.90) for chemotherapeutic complications. In those aged 80+, the frequency of surgical complications (OR 1.01, p = 0.62) and chemotherapeutic complications (OR 1.04, p = 0.78) did not differ compared to younger patients. Overall survival did not differ based on initial treatment regimen, with 34 months in the primary surgery group and 29 months in the neoadjuvant chemotherapy group ( p = 0.65). The median disease specific survival for those aged 65–79 was 35 months, and 24 months in those aged 80+ ( p = 0.15). Post-operative mortality for patients aged 80+ was zero. Conclusions In our patient population, those aged 80+ have similar surgical and chemotherapy-related complication rates and comparable survival to those aged 65–79. The choice of initial treatment modality does not appear to impact survival when the decision is made in a selective fashion.

Anatomy problems in the radical resection for hilar cholangiocarcinoma

To analyze the clinical data, surgical strategies and results from the patients with hilar cholangiocarcinoma (HCCA), and to explore the anatomic factors related to the radical resection. The data from 52 patients with HCCA who underwent radical resection between January 1984 to December 2008 were investigated retrospectively, which included clinical diagnosis, Bismuth-Corlette classification, pathologic features, surgical procedures and follow-up results. According to the Bismuth-Corlette classification, 5, 12, 6, 16 and 13 patients belonged to type I, II, IIIa, IIIb and IV respectively. There were 24 cases underwent combined hepatic lobectomy. The 1-, 3- and 5-year survival rates were 78.8%, 36.4% and 12.1% respectively. Postoperative complications rate was 30.8% with the 3.8% mortality rate. The frequency of surgical complications was significantly higher in patients with higher level of serum total bilirubin (> 340 micromol/L) than that in patients with a relatively lower one (170 micromol/L) before operation (P < 0.05). Some anatomical factors should be considered during the radical resection of hilar cholangiocarcinoma, especially evaluation of potential hepatectomy, resection of caudate lobe, hepatic artery resection and/or reconstruction. The prognosis of the patients underwent R(0) radial resection could be significantly improved.

Abdominal Wall CT Angiography: A Detailed Account of a Newly Established Preoperative Imaging Technique

Institutional review board approval was obtained for this study, and all patients gave written informed consent. Autologous surgical breast reconstruction with use of abdominal wall donor flaps based on the deep inferior epigastric artery (DIEA) and one or more of its anterior musculocutaneous perforating branches (DIEA perforator flap) is being used with increasing frequency instead of breast reconstruction with use of traditional transverse rectus abdominus musculocutaneous and modified muscle-sparing flaps. Preoperative mapping of the DIEA perforators with abdominal wall computed tomographic (CT) angiography may improve patient care by providing the surgeon with additional information that will lead to optimization of the surgical technique, shorter procedure time, and reduction in the frequency of surgical complications. The branching patterns of the DIEA, the segmental anatomy of the anterior adipocutaneous perforating branches of the DIEA, and the importance of these features in pre- and intraoperative surgical planning necessitate a different approach to abdominal wall CT angiography than that used with other abdominal CT angiographic techniques. In abdominal wall CT angiography, the common femoral artery is used as the bolus trigger, CT scanning is performed in the caudocranial direction, the automatic exposure control feature is disabled, a scaled grid overlay tool is used to present information to the surgeons, and radiation dose is minimized (average dose, 6 mSv). The anatomic accuracy of abdominal wall CT angiography has been investigated in cadaveric and surgical studies, with sensitivity of 96%-100% and specificity of 95%-100%. This detailed description will allow other radiologists and surgeons interested in free DIEP flap surgery to incorporate this useful tool into their practice.

The retroperitoneal approach combined with epidural anesthesia reduces morbidity in elective infrarenal aortic aneurysm repair

In elective open infrarenal aortic aneurysm repair the surgical approach and the use of epidural anesthesia (EDA) may determine patients' outcome. Hence we analyzed our results after elective open aneurysm repair in the light of the surgical approach and the use of EDA. Retrospective analysis of a prospective data base. From December 2005 to April 2008, 125 patients with infrarenal aortic aneurysm underwent elective open repair. Patients were divided into four groups: retro- and transperitoneal approach with and without epidural anesthesia (RP+/-EDA and TP+/-EDA). In terms of age, sex, aneurysm diameter, ASA score and clamping time all groups were comparable. In the retroperitoneal groups significantly more tube grafts were implanted (63 vs. 27; P=0.001). The rate of surgical complications did not differ between the groups. The RP+EDA group had the lowest rate of postoperative assisted mechanical ventilation (5.1% vs. 35.7%; P=0.002) and medical complications (17.9% vs. 42.8%; P=0.032). Concerning frequency of surgical complications, the retroperitoneal incision was comparable to the transperitoneal approach in infrarenal aortic reconstruction. Supplementation with EDA resulted in a decreased rate of postoperative assisted mechanical ventilation and in lower morbidity rates.

Renal Transplantation in Patients With a Small Bladder

Background In patients undergoing kidney transplantation with a small bladder, many surgeons are faced with technical difficulties about the implantation as well as about satisfactory bladder rehabilitation. The objective of this study was to clarify the clinical outcomes of patients with end-stage renal disease who had a bladder capacity of less than 100 mL on preoperative voiding cystourethrogram after renal transplantation using extravesical ureteroneocystostomy. Patients and Methods We retrospectively studied 345 patients with end-stage renal disease who underwent renal transplantation between April 2002 and June 2006. These patients were classified into two groups according to their preoperatively estimated bladder capacity using a voiding cystourethrogram. Group A had a bladder capacity of less than 100 mL ( n = 23; 6.7%) and group B had a capacity of 100 mL or more ( n = 322; 93.3%). For each group, the clinical outcome, including serum creatinine level at 1 month and 1 year after transplantation, bladder capacity, surgical complications, and prevalence of urinary tract infection (UTI) requiring hospital admission were recorded and the graft survival rate calculated. Results Compared with group B, group A had undergone a longer duration of dialysis and required cadaveric kidney transplantation more frequently ( P < .05). Postoperative surgical complications occurred in nine cases. There was no difference in the frequency of surgical complications and UTI requiring hospital admission between group A and group B. At 1 year posttransplant, bladder capacity was 342.0 ± 43.8 mL (range, 300–400 mL) and 429.1 ± 75.9 mL (range, 200–500 mL), respectively ( P = .015). There was no statistical difference between the groups in the serum creatinine level and the graft survival rate at 5 years after transplantation (100% vs 92.4%). Conclusions Similar to patients with a normal bladder size, renal transplantation can be successfully achieved in patients with a small bladder. Attempts to increase the bladder capacity by programmed training of the bladder and bladder expansion by surgical intervention seem unnecessary.

Preoperative distal loop contrast radiograph before closure of an enterostomy in paediatric surgical patients. How much does it affect the procedure or predict early postoperative complications?

Before the closure of an enterostomy, a distal loop contrast radiograph (DLCR) is widely used to disclose pathology which may affect the performance of the procedure. We studied whether DLCR of paediatric patients caused actual alterations in the surgical plan and whether it predicted postoperative complications. Between 1991 and 2006, 105 patients (small bowel enterostomy, SBE; n = 51), (colostomy, CO; n = 54) underwent closure of an enterostomy. All 105 patients had preoperative DLCR. The indications for enterostomy included anorectal malformation (n = 38), neonatal intestinal perforation (n = 25), J-Pouch ileoanal anastomosis (n = 20), anorectal trauma (n = 5), and miscellaneous (n = 17). We recorded sensitivity, specificity, and positive and negative predictive value (PPV and NPV) of DLCR for complications within 6 postoperative weeks. DLCR was considered complete and interpreted as normal in 94 (90%) and abnormal (incomplete n = 3 or pathological n = 8) in 11 (10%) patients. None of the 11 abnormal findings caused cancellation of surgery, but in three (27%) patients it was possible to surgically correct a stricture seen in DLCR. The frequency of surgical complications was 17/105 (16%), SBE (15/51,29%) and CO (2/54, 4%), (P < 0.05). Most common complications (9/17, 53%) were those associated with the intestinal anastomosis. For postoperative complications DLCR had sensitivity, specificity, and PPV and NPV of 47, 97, 73 and 90% (SBE and 47, 97, 88 and 81%), (CO 50, 96, 33 and 98%). The pathology seen in DLCR, however, seldom directly hinted the complications which actually occurred. Abnormal DLCR changed the surgical plan in less than one-fifth of the cases. For surgical complications DLCR had poor sensitivity, good specificity and NPV, and moderate PPV. The pathology suggested by DLCR, however, correlated poorly with the actual complications. Poor sensitivity reflects the high frequency of anastomotic complications, which are practically unpredictable by preoperative radiographs.

Efectividad y eficiencia del uso de la anestesia en la cirugía descompresiva del síndrome del túnel carpiano

ObjectiveThe aim of this study was to evaluate the use of local anesthesia in the decompressive surgery of carpal tunnel syndrome from a clinical and economic point of view. Material and methodsA total of 229 releases of the median nerve, performed through classical open surgery, were evaluated. Local anesthetic was used in 138 patients, intravenous locoregional anesthetic was used in 71 patients, and brachial plexus anesthesia was used in the remaining 20 patients.Patients’ tolerance to the anesthetic technique was evaluated through the visual analogous scale referring to pain during the application of the anesthesia, to the pain from the tourniquet and to patients’ pain during the procedure. The final result of the intervention and its approximate costs were evaluated according to the anesthesia used. ResultsThe anesthetic technique did not influence the results of decompression or the frequency of surgical complications. None of the patients administered local anesthesia required a change of anesthetic technique.Brachial plexus block were associated with longer duration of the intervention. In patients undergoing local anesthesia, tolerance of the tourniquet was excellent, as was perception of pain during the procedure. ConclusionsThe use of local anesthesia in the surgery of the carpal tunnel syndrome is well tolerated by patients and reduces the cost of the intervention.

Intravascular extension of Wilms tumor.

To define the incidence and manifestations of and optimal therapy for children with intravascular extension of Wilms tumor. Children on a collaborative study of Wilms tumor who had intravascular extension into the inferior vena cava (IVC) or atrium were identified. Surgical checklists and surgical and pathology reports were reviewed. One hundred sixty-five of 2,731 patients had intravascular extension of Wilms tumor. The level of extension was IVC in 134 and atrium in 31. Sixty-nine had received preoperative therapy (55 with IVC extension and 14 with atrial extension) for a median of 8 weeks. Complications during preoperative chemotherapy were seen in five patients (tumor embolism and tumor progression in one each, and three with adult respiratory distress syndrome, one of which was fatal). The intravascular extension of the tumor regressed in 39 of 49 children with comparable pre- and posttherapy radiographic studies, including 7 of 12 in whom the tumor regressed from an atrial location, thus obviating the need for cardiopulmonary bypass. Surgical complications occurred in 36.7% of the children in the atrial group and 17.2% in the IVC group. The frequency of surgical complications was 26% in the primary resection group versus 13.2% in children with preoperative therapy. When all the complications of therapy were considered, including those that occurred during the interval of preoperative chemotherapy (one of the five also had a surgical complication), the incidence of complications among those receiving preoperative therapy was not statistically different from the incidence among those who underwent primary resection. The difference in 3-year relapse-free survival (76.9% for 165 patients with intravascular extension, 80.3% for 1,622 patients with no extension) was not statistically significant whether or not it was adjusted for stage and histology. Preoperative treatment of these children may facilitate resection by decreasing the extent of the tumor thrombus, but the overall frequency of complications is similar in both groups.

Surgical complications in children after liver transplantation

The frequency of surgical complications after liver transplantation remains high. Sixty transplants were done in 48 patients during years. Eleven patients were retransplanted (retransplant rate, 20%) for primary nonfunction (6), arterial thrombosis (3), warm ischemia (1), and rejection (2). Right pleural effusions were drained in 13 patients and left ones in 2. Forty-eight reexplorations excluding retransplantation were performed in 20 patients. Twelve laparotomies were for control of postoperative intraabdominal bleeding. The majority of these patients ( 8 10 , 80%) were transplanted with reduced-size grafts. Early postoperative vascular complications were detected in 12 grafts (5 portal vein occlusions, 7 arterial thromboses). All 5 patients with portal vein (PV) occlusions were reexplored, and PV flow was reestablished in all 5. Biliary leaks were diagnosed in 6 patients and were associated with arterial thromboses in 2 cases. Reoperation was required in 4 of 6 patients. Bowel perforation occurred in 4 patients: 2 small bowel, 1 duodenum, and 1 colon. There was 1 postoperative bowel obstruction requiring laparotomy. Two splenectomies were required in 4 patients with splenic infarction. Resection of part of a transplanted liver was done in 1 patient to exclude septic infarcts. Pancreatitis was diagnosed in 4 patients and one required laparotomy for control of pancreatic hemorrhage. Intraabdominal abscesses required open drainage in 2 patients and percutaneous drainage in 4. Seven thoracotomies were done in 6 patients: 5 open lung biopsies, 1 for control of hemorrhage, and 1 for diaphragmatic plication. The current high survival rates following liver transplantation require aggressive surgical management of a myriad of complications and numerous procedures are necessary both as treatment modalities and as diagnostic aids.

Evaluation of Pediatric Cadaver Kidneys Transplanted into Adult Recipients Receiving Cyclosporine

The major problem in clinical transplantation is the imbalance between the need for cadaveric organs and the available numbers of donors. If pediatric kidneys were transplanted into adult recipients when no pediatric recipient was available, the potential number of renal donors would be increased by 15 to 20%. Some centers are reluctant to use pediatric kidneys for adult recipients because of recent reports indicating poorer patient and allograft survival, increased delayed graft function, increased post-transplant hypertension and increased technical complication. (There also has been concern that the nephrotoxic effect of cyclosporine A would retard the organ growth that is necessary to provide normal renal function in adults.)A retrospective analysis was performed on 18 adult recipients who received kidneys from cadaver donors 14 months to 12 years old (group 1). These patients were compared to 106 adult recipients who received kidneys from donors greater than 12 years old (group 2). Actuarial patient survival at 1 year was 85% for group 1 and 95.8% for group 2 (p equals 0.13), while 1-year actuarial allograft survival was 83.1% for group 1 and 81.1% for group 2 (p equals 0.87). There was no significant difference between groups 1 and 2 in the frequency of delayed graft function, serum creatinine at 1, 3 and 6 months after transplantation, incidence of post-transplant hypertension or frequency of surgical complications. It is of interest that the pediatric kidneys had significant growth during the initial post-transplant month. Sonographic examination at postoperative days 1 and 30 demon¬strated a mean increase in size from 80.7 to 143.5cm. (p less than 0.001). In this series pediatric kidneys were safe and effective donor organs in adult recipients, and increased the available number of organs by 15%. (J. Urol., 142:1181-1185, 1989)

Extraperitoneal versus transperitoneal selective paraaortic lymphadenectomy in the pretreatment surgical staging of advanced cervical carcinoma (A Gynecologic Oncology Group study)

Two-hundred and eighty-eight patients with predominately stage IIB or IIIB cervical carcinoma underwent pretreatment surgical staging including selective paraaortic lymphadenectomy (SPAL), followed by pelvic irradiation with or without paraaortic irradiation (RT). Four patients were excluded from analysis (two received no RT and two were insufficiently documented). Of the remaining 284 patients, 128 underwent extraperitoneal (EP) SPAL and 156 transperitoneal (TP) SPAL procedures. Age, race, and stage (clinical and surgical), cell type, paraaortic nodal status, and peritoneal cytology findings were similar in both groups. Complications presumed to arise from operative staging were infection, which was similar for both groups, and vascular injury, which was higher in the TP group, although not statistically significant. Complications subsequent to RT fell into two categories: local—pelvic necrosis, vesicovaginal and rectovaginal fistulas, proctitis, etc., and regional—enterovaginal fistula, bowel obstruction, enteritis, bowel perforation, etc. The frequency of local complications was similar for both EP and TP patients. Utilizing univariant analysis, among regional complications, both bowel obstruction and nonobstructive enteric injuries were observed significantly more often in TP patients than in EP patients (11.5% vs 3.9%, P = 0.03, for both types). Multivariant analysis confirmed these observations. This report supports the conclusions that in advanced cervical carcinoma (1) EP- and TP-SPAL are of similar sensitivity in detecting nodal spread, (2) no significant differences in the frequency of surgical complications could be detected between EP- and TP-SPAL groups, and (3) TP-SPAL is associated with a higher frequency of certain postirradiation regional enteric complications.

Cryosurgical ablation of atrioventricular junction without extracorporeal circulation

A closed technique, using thoracotomy without cardiopulmonary bypass and atriotomy, for cryosurgical ablation of the atrioventricular node-His bundle junction is described. The technique was used in 34 patients selected from among 136 patients with disabling supraventricular tachyarrhythmias refractory to drug therapy in whom atrioventricular block was produced. After thoracotomy, four methods can be used to determine the site of cryoinstrument application: palpation of the internal anatomic landmarks, a "mechanical test," use of a cryoprobe, or recording of the His bundle electrogram. The cryoprocedure lasts 160 to 180 seconds at temperatures of -60 degrees to -80 degrees C and is repeated once or twice. Complete atrioventricular block was induced in 29 of the 34 patients. Paroxysmal tachycardia was terminated in 31. There were no operative deaths. The frequency of surgical complications was nearly three times lower than in the group of 77 patients subjected to open cryodestruction of the atrioventricular junction, and the length of hospital stay after the operation was an average of 4.7 days shorter. The follow-up for up to 6.5 years (mean 34 months) failed to show postoperative paroxysmal tachycardia or tachyarrhythmia in 31 patients. In my opinion, this rather safe method for ablation of the atrioventricular junction could be more widely used, especially if there are contraindications for extracorporeal circulation or if transvenous catheter ablation has failed.