Laparoscopic lymphocelectomy: a multi-institutional analysis

PURPOSE

Because symptomatic lymphoceles are infrequent, single center studies generally report small numbers of patients. We report a multi-institutional experience with and long-term outcome following laparoscopic lymphocelectomy in 81 patients.

MATERIALS AND METHODS

Data were obtained from 9 institutions at which at least 5 cases of laparoscopic lymphocelectomy had been performed. Baseline patient demographics, operative time and blood loss, special operative adjunct techniques, postoperative course, convalescence, complications and lymphocele recurrence data were collected and analyzed.

RESULTS

A total of 56 men and 25 women with a mean age of 41 years were included in the study. Lymphocele formed after renal transplantation in 78 patients (96%) and after pelvic lymph node dissection in 3 (4%). Average operating time was 123 minutes with a mean blood loss of 43 ml. Omentopexy was performed in 11 cases (13.6%). No intraoperative stenting of the transplant ureter was performed. Intraoperative complications consisted of laryngospasm, bladder injury, inferior epigastric artery injury and mild renal capsule hematoma in 1 patient each. Conversion to open surgery was required for repair of bladder injury in 1, repair of preexisting hernia in 1, unusually thickened lymphocele wall in 1 and inaccessible lymphocele location in 4 cases. Mean time to ambulation and resumption of regular diet was 1 day, and mean hospital stay was 1.5 days. Postoperative complications included trocar site hernia in 1 and urinary retention in 2. Convalescence averaged 2.5 weeks. During a mean followup of 27 months 5 patients (6%) had lymphocele recurrence.

CONCLUSIONS

Laparoscopic lymphocelectomy is safe, minimally invasive and effective. It is an excellent alternative to the conventional open surgical approach.

Oxidative tryptophan metabolism in renal allograft recipients: increased kynurenine synthesis is associated with inflammation and OKT3 therapy

Serum concentrations of tryptophan (TRP) and kynurenine (KYN) were determined in renal allograft recipients (RAR) as an index of interferon-gamma-induced, indoleamine-dioxygenase-catalysed TRP degradation. Serum TRP and KYN in RAR during periods of stable graft function were typically within the normal range, however, the median values for serum KYN demonstrated significant increases 5-7 days prior to biopsy-confirmed acute rejection (1.6-fold, P less than 0.01) and on the day of biopsy (1.7-fold, P less than 0.001). Serum KYN was also markedly elevated in patients who contracted viral or Gram-negative bacterial infections in the absence of graft rejection. Serum KYN was not correlated with serum creatinine in RAR nor were serum TRP or KYN affected by antirejection therapy with high dose steroids. Retrospective analysis of intra-patient changes in serum KYN demonstrated that KYN monitoring was a useful adjunct to serum creatinine in the early detection of first acute rejection episodes. The first course of OKT3 therapy was associated with low serum TRP and significant increases in serum KYN (two- to three-fold) following the first three doses. The time course of these abnormalities corresponded to that over which many of the side effects of the OKT3 'first dose reaction' have been reported to occur. Significant changes in serum KYN were not observed in patients receiving repeat courses of OKT3 therapy. Significant decreases in serum TRP and significant increases in serum KYN were both prevalent and frequent in RAR during the first two postoperative months.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of chronic renal insufficiency on cyclosporine nephrotoxicity

Despite cyclosporine's efficacy in preventing rejection, its use has been hampered by nephrotoxicity. Questions remain concerning its application in patients with decreased renal function. The purpose of this study was to 1) establish a reliable animal model with chronic renal insufficiency (CRI) to study cyclosporine (CyA) nephrotoxicity, and 2) compare the long-term (50 day) severity of CyA nephrotoxicity in CRI versus normal animals. Fischer 344 rats were divided into six groups (15 to 22 each). In three groups, CRI was induced by a 5/6th nephrectomy (three groups were sham operated). After three wks., daily i.p. injections of olive oil, CyA at five mg./kg., or CyA at 30 mg./kg. daily were administered. Serum and urine were collected at 10 day intervals for the determination of biochemical indices of renal function. Animals were sacrificed after 50 days of treatment and renal histology was evaluated by light and electron microscopy. Chronic CyA treatment was well tolerated by both intact and CRI rats, suggesting that this is a reliable model for long-term CyA toxicity studies. CyA decreased renal function at day 50 in both CRI and intact animals. CRI of mild to moderate degree had little effect on the biochemical and histological indices of CyA induced nephrotoxicity. CRI does appear to potentiate the metabolic toxicity that occurs after chronic treatment with high dose CyA.

Colonic complications of renal transplantation

Colonic complications of renal transplantation occur in 1.9 per cent of the cases. In our series of 587 consecutive renal transplants recipients 3 (0.51 per cent) had colonic complications, including 2 with ischemic colitis and 1 with pseudomembranous colitis. A review of 8 large series describing 2,539 additional renal transplant patients revealed 55 with significant colonic complications. The most common complication was ischemic colitis, which occurred in 29 patients, followed by diverticulitis in 17, pseudomembranous colitis in 5, appendicitis in 3, hemorrhagic proctitis in 1, a disrupted appendiceal stump in 1 and fecal impaction in 1. Etiological factors that may be important in the development of these colonic complications are uremia, blood volume redistribution, immunosuppressive therapy, antibiotic therapy, irradiation and previous retroperitoneal surgery.

Effect of warm ischemia on segmental pancreas transplantation in the rat

This study was performed to determine the effect of warm ischemia on post-transplantation endocrine function of rat segmental pancreas transplants. Diabetic (streptozotocin) rats were recipients of syngeneic vascularized grafts in all experiments. Thirty-, 60-, and 90-min periods of absolute ischemia at 37 C in addition to approximately 30 min of anastomosis time did not impair control of glucose metabolism as manifested by daily serum glucose values or response to intravenous glucose challenge when compared with control rats transplanted with freshly harvested pancreata. However, when the ischemic period was lengthened to 120 min, only one of five recipients had normal glucose values post-transplant. Islet morphology in the 30-, 60-, and 90-min ischemia groups was not different from controls. On the other hand, after 120 min of ischemia, islets were decreased in number, appeared smaller in size, and had undergone degeneration. For comparison, renal isografts using kidneys with 90 min of warm ischemia failed. These data suggest that in this model, islets in segmental pancreas transplants are more tolerant of warm ischemia than kidneys.

Gastroduodenal complications in kidney transplant recipients

Oral antacids taken every two hours while awake provided the only prophylaxis against gastroduodenal ulceration for 167 kidney transplant recipients between 1968 and July 1978. Either perforation or major hemorrhage occurred in eight patients within 30 days after transplantation. Between July 1978 and January 1981, bleeding occurred within 30 days in two of 147 recipients who were treated with both antacids and cimetidine. Of the 147 patients, eleven with a history of ulcers had undergone pretransplant vagotomy; neither perforation nor hemorrhage occurred in any of the eleven patients. Despite reports that cimetidine enhances certain types of immune responses, we observed slightly greater graft survival in the group treated with cimetidine.

Effect of splenectomy on first cadaver kidney transplants

A prospective study was begun in January 1975 to evaluate the effect of splenectomy on graft and patient survival in recipients of first cadaver kidney transplants. Ninety-two cases were evaluated. Splenectomy increased the survival of both grafts and recipients. The benefit from splenectomy compensated readily for the perioperative morbidity of splenectomy and the long-term increased risk of sepsis from certain bacteria for the asplenic patient. Splenectomy exerted its effect by reducing the incidence and intensity of rejection episodes. It was not clear whether the observation resulted from a direct immunosuppressive effect of splenectomy or from the increased tolerance to azathioprine observed in asplenic recipients. Finally, splenectomy negated an effect of race that had been observed earlier for survival of cadaver transplants and recipients.

Race as a risk factor in cadaver kidney transplantation

Recipients of 93 first-cadaver kidney transplants were studied for the effect of recipient and donor race on graft and patient survival. Both graft and patient survival were lower for black recipients than for whites. The difference was not explained by racial mismatch between donor and recipient. Black recipients had more rejection episodes and more instances of bacterial pneumonia. Pretransplant splenectomy reduced the likelihood of rejection episodes for black recipients and increased their rate of graft survival.

The fate of transplanted pancreatic islets in the rat

Syngeneic pancreatic islets transplanted into the liver or the spleen reverse streptozotocin-induced diabetes in the rat, but allogeneic islets function only briefly and are rejected. Shortly after transplantation, thrombi often form around transplanted tissue, particularly around nonislet tissue that contaminates islet preparations. These thrombi are a source of transient liver injury in recipients of intrahepatic grafts. A few days after transplantation, syngeneic islets injected into the portal vein are found at the periphery of portal tracts in direct contact with periportal hepatocytes, some of which become hypertrophied. Isografts remain situated in the portal tracts for prolonged periods without adverse effect on the surrounding liver. In contrast, allogeneic islets injected into the portal vein are infiltrated by small lymphocytes within 2 days of transplantation and are rapidly destroyed by the host. Syngeneic islets injected into the splenic pulp localize in the sinusoids and, 1 month or more after transplantation, are often surrounded by connective tissue or local collections of hemosiderin-laden macrophages. Allogeneic islets injected into the spleen are rejected with the same intensity and at approximately the same rate as allogeneic islets injected into the portal vein. Transplant rejection leaves no significant lasting morphologic effect on the host liver or spleen.

Successful renal vein reconstruction with bovine arterial heterografts

Extensive damage to a short right renal vein complicated transplant surgery in two patients. The use of a segment of modified bovine arterial heterograft permitted successful transplantation in both cases. These results are in contrast to the reported inability of bovine arterial heterografts to remain patent elsewhere in the systemic venous system.