Surgical Technique Notes of Arterial Vascular Reconstruction During Kidney Transplantation: Personal Experience and Literature Review

BACKGROUND

Arterial vascular anomalies in patients undergoing kidney transplantation (KT) are correlated with a higher incidence of early surgical complications, potentially causing graft loss. Arterial reconstruction allows patients to overcome these surgical challenges, thus minimizing the risk of poor outcomes. The aim of the present study is to retrospectively investigate the safety and effectiveness of the multiple arterial reconstruction technique with a Teflon patch in case of an unavailable aortic patch: to do so, surgical complications, graft function, and patient survival were evaluated.

METHODS

During the period January 2009 to August 2016, 202 adult deceased-donor KTs were performed at our center. Group A (n = 27; reconstruction of multiple arteries) and Group B (n = 175; control group) were compared.

RESULTS

No differences were observed between the 2 groups in terms of early postoperative course, with no vascular complication observed in Group A. No vascular patch infections were reported, nor longer cold ischemia time rates. Similarly, long-term survival rates were similar between the 2 groups.

CONCLUSIONS

The Teflon-patch arterial reconstruction technique appears to be safe and effective, with an acceptable balance of benefits and potential risks of using a prosthetic material. Studies based on larger series are needed to further validate this approach.

Transport of Human Organs in Italy: Location, Time, and Performances

INTRODUCTION

The outcome of transplantation activities depends on a variety of unpredictable factors. Up-to-date criteria on organ allocation foresee an efficient transport chain along with compliant performance parameters.

METHODS AND OBJECTIVES

The Centro Nazionale Trapianti and the Department of Civil, Chemical, Environmental, and Materials Engineering of the University of Bologna (respectively, CNT and DICAM) have been updating a national database of organ transplantation activities to investigate performance parameters and the main causes of disruption.

RESULTS

Between June 2015 and July 2016, 617 of 1061 organs have been shipped by air (making for 486 flight events), of which 407 were accompanied by medical equipment. Origin/destination and distance matrixes have been drawn for both road and air transport. Each airport node is ranked based on the n° of organs ingoing/outgoing and each route link on its frequency. Performance parameters such as average speed, distance covered, and time have been computed and compared with each organ's cold ischemia time (CIT). Average distance frontiers are rather homogeneous, but much effort is necessary to reduce the number of events performed with approximately 90% or more of CIT spent.

CONCLUSIONS

The monitoring of organ transplantation activities' performance is a standalone action within Europe to support strategic policies to optimize the system. Thus, a clearer awareness on performances and issues related to organ transport has been made possible: analyses show that the higher uncertainty associated with total time of displacement by air is due to the steps which take place by road (length and paths must be optimized) and lung transports generally perform weaker than heart transports due to longer average distances travelled and smaller average speeds, often resulting in a total displacement time greater than 90% of CIT.

Patients on liver transplantation waiting list with Model for End-Stage Liver Disease score ≥ 30: experience in the Organizzazione Centro Sud Trapianti macro area

INTRODUCTION

From 2011 a program was developed for liver transplant recipients with Model for End-Stage Liver Disease (MELD) score ≥30. We examined its effectiveness and impact on the other subjects on the waiting list.

MATERIALS AND METHODS

We analyzed requests received between January 2011 and May 2012 for the primary pathology, the outcome, the average waiting time, and the origin of the organ. We examined the ordinary waiting list for mortality rates and numbers of transplantations over this period (group A) versus a comparable preceding period (group B).

RESULTS

There were 38 requests for 33 patients. Their primary pathologies were cirrhosis associated with viral infection (n = 15), delayed graft failure (DGF; n = 5), biliary cirrhosis (n = 4), hepatocellular carcinoma (HCC; n = 3 including 2 with cirrhosis), cryptogenic cirrhosis (n = 3), postalcoholic cirrhosis (n = 2), metabolic disease (n = 2), and iatrogenic disease (n = 1). Of the requests, 25 were successfully dealt with, whereas 5 requests were temporarily suspended and 2 were permanently suspended because of better or worse patient conditions. There were 6 deceased patients. Transplanted organs came from the inter-regional area in 64% of cases. The average waiting time was 5.9 days. Within group A were a 311 transplantations among 723 waiting list patients on with a 13.7% mortality rate. Within group B were 305 transplantations among 871 wait-listed patients with a 14% mortality rate.

DISCUSSION

The liver transplantation program for recipients with MELD scores ≥ 30 allowed recipients in critical condition to receive grafts without altering substantially the opportunities for recipients on the elective waiting list.

The use of neoplastic donors to increase the donor pool

The aim of the study was to evaluate the experience of the Centre-Sud Transplant Organization (OCST) area using cadaveric donor with neoplastic diseases to evaluate the possibility of transmission to recipients. From January 1, 2003, to December 31, 2010, the neoplastic risk has been reported to be 5.4% (377/4654 referred donors). In 2003, the number of donors with a tumor and their mean age were respectively: 60 (10.3%) and 59.6 ± 19.9; 2004: 33 (5.2%) and 61.4 ± 15.9; 2005: 32 (6%) and 62.8 ± 15.5; 2006: 46 (7%) and 60.7 ± 19.1; 2007: 51 (7%) and 58.9 ± 16; in 2008: 58 (7%) and 59.7 ± 19.6; 2009: 47 (7%) and 57 ± 26; 2010: 49 (7%) and 64 ± 16. The organ most affected by tumor has been the central nervous system (18%). The tumor was diagnosed before in 325 (86%) cases, versus during organ retrieval in 48 (12.7%) donor operations but before, which four cases (1%) occured after transplantation. According to the histological types and grades, 28 evaluated donors (8.2%) were suitable for transplantation. The histological types were: thyroid carcinoma (n = 3); prostate carcinoma (n = 8), renal clear cell carcinoma (n = 7), oncocytoma (n = 1), meningiomas (n = 2), dermofibrosarcoma (n = 1); verrucous carcinoma of the vulva (n = 1), colon adenocarcinoma (n = 1), grade II astrocytoma (n = 1), adrenal gland tumor (n = 1), gastric GIST (n = 1), oligodendroglioma (n = 1). Forty-five organs were retrieved (22 livers, 19 kidneys, 3 hearts, and 1 pancreas) and transplanted into 44 recipients with 1 liver-kidney combined transplantation. Four recipients died due to causes not related to the tumor. No donor-transmitted tumor was detected among the recipients. Donation is absolutely not indicated in cases of tumors with high metastatic potential and high grades. Performing an accurate evaluation of the donor, taking into account the histological grade, currently can allow, organ retrieval and transplantation with an acceptable risk.

Living organ donation, a therapeutic possibility, is still poorly used in Italy: a national analysis

Validity of living donor kidney transplantation is universally accepted. In contrast, after enthusiastic adoption in the 1990s, living donor liver transplantation has decreased in recent years. The aim of the present study was to evaluate retrospectively the current use of this form of donation in Italy by comparing liver and kidney cadaveric and living donations from 2002 to 2010. The number of liver transplantations from living donors has decreased from 34 in 2002 (3.9% of total) to 13 in 2010 (1.3% of total). In contrast, kidney transplantation from living donors increased from 126 (7.9% of total) to 186 (11% of total). We observed that living donations for kidney transplantation are still underused, especially with unrelated donors. Living donor liver transplantation has decreased in recent years; this procedure should be reserved to centers with particular expertise. It would be appropriate to implement programs to increase the attention of health professionals and the general population and to integrate living donations into programs of deceased organ donation.

Strategies to increase heart transplantation in centre-sud transplant organization

The 21 heart transplantations in Centre-Sud Transplant Organization (OCST) is a stable number despite increasing donations, especially among subjects aged 50 to 60 years. The aim of the present study was to evaluate the possibility to increase the usage of marginal hearts through dipyridamole ecostress. From 2008 to 2010 we analyzed OCST donors at 74 donation sites for echocardiography (31 yes versus 43 no) and heart utilization: (1) principal sites (n > 13) versus (2) minor sites (n < 13). Among 2145 signaled donors, there were 900 (42%) effective donors, including 816 (38%) utilized organs from 387 subjects of age <50 years; 189, 50 to 60 years and 240, >60 years with 217 (90%); 24 (10%), and 3 (1%) utilized hearts respectively to the analyzed sites, the utilized donors with echocardiography were 373: 259 (69.4%) versus 114 (30.5%) from those without such a service. Utilized donors between 50 and 60 years came from principal sites (n = 50), minor sites (n = 7) or those without an echocardiagram (n = 16). Utilized heart donors in each type of site were eight, one, and six, respectively. We believe that it may be possible to increase the total number of heart transplantations using dipyridamole stress-test echocardiography at the sites with major retrieval activity to increase heart transplantation among donors in the age range of 50 to 60 years.

Risk management systems for health care and safety development on transplantation: a review and a proposal

Starting from the report on medical errors published in 1999 by the US Institute of Medicine, a number of different approaches to risk management have been developed for maximum risk reduction in health care activities. The health care authorities in many countries have focused attention on patient safety, employing action research programs that are based on quite different principles.

MATERIALS AND METHODS

We performed a systematic Medline research of the literature since 1999. The following key words were used, also combining boolean operators and medical subheading terms: "adverse event," "risk management," "error," and "governance." Studies published in the last 5 years were particularly classified in various groups: risk management in health care systems; safety in specific hospital activities; and health care institutions' official documents. Methods of action researches have been analysed and their characteristics compared. Their suitability for safety development in donation, retrieval, and transplantation processes were discussed in the reality of the Italian transplant network.

DISCUSSION

Some action researches and studies were dedicated to entire national healthcare systems, whereas others focused on specific risks. Many research programs have undergone critical review in the literature. Retrospective analysis has centered on so-called sentinel events to particularly analyze only a minor portion of the organizational phenomena, which can be the origin of an adverse event, an incident, or an error. Sentinel events give useful information if they are studied in highly engineered and standardized organizations like laboratories or tissue establishments, but they show several limits in the analysis of organ donation, retrieval, and transplantation processes, which are characterized by prevailing human factors, with high intrinsic risk and variability. Thus, they are poorly effective to deliver sure elements to base safety management improvement programs, especially regarding multidisciplinary systems with high complexity.

CONCLUSION

In organ transplantation, the possibility to increase safety seems greater using proactive research, mainly centred on organizational processes together with retrospective analyses but not limited to sentinel event reports.

Exchange of organs and patients with foreign nations during the first 15 months of activity of the Italian gate to Europe

The Italian Gate to Europe (IGE) was established in April 2005 to supply a single national coordinating center for the exchange of organs and patients with the rest of Europe. When an organ is offered from Italy, the IGE ascribes it to the first foreign organization that accepts it on a first-come, first-served basis. In the case of offers from abroad, the IGE allocates the organ to one of the three Italian Interregional Centres in rotation. On the basis of international agreements, the IGE also manages the transfer of foreign patients to Italian transplant centers. The first 15 months of activity have been compared with the previous period of the same length. The IGE managed 353 contacts. 53 organs were transplanted in Italy versus 19 in the previous period. Seven foreign patients received liver transplantations in Italy. The increase in imported organs could be a function of IGE creation, since it allowed a reduced response time to offers and guaranteed the participation of all Italian centers in the program of international exchanges with a subsequent increase in the pool of recipients and equitable distribution of transplanted organs. The drop in the number of exported organs was a probable a consequence of increased acceptance criteria of Italian centers. The mentioned international agreements have allowed us to better meet the health care needs of foreign citizens who live in countries with low per-million-population donation rates with no detriment to the probability of Italian citizens being transplanted.

Incidence of Neoplastic Donors in Organizzazione Centro Sud Trapianti Area During the 2003–2005 Period

The aim of this study is to evaluate the incidence of malignant tumors in cadaver donors and the possibility of neoplastic disease transmission to the recipients in the Organizzazione Centro Sud Trapianti (OCST) area. Among 1744 potential donors identified from 2003 to 2005, 125 (7.1%) showed an elevated malignant neoplastic risk. In 2003 a malignant tumor was diagnosed in 60 donors of mean age 59.6 +/- 19.9 years (median 62.5, M:36 F:24); in 2004, 33 donors of mean age, 61.4 +/- 15.9 years (median 63, M:19 F:14); in 2005, 32 donors of mean age of 62.8 +/- 15.5 years (median 65.5, M:20 F:12). Prostatic cancer was the most common tumor (23.2%). In 101 of 125 cases (80.8%) the tumor was diagnosed before organ retrieval, in 23 (18.4%) cases, during the donor operation but before the transplant, and in one case (0.8%) after transplantation. Each tumor was evaluated according to the histologic types and grades. From 12 of those donors with neoplasia, 24 organs were retrieved (10 livers, 11 kidneys, 3 hearts) transplanted in 23 recipients (one liver-kidney combined transplant). Three recipients died during the perisurgical period due to causes unrelated to the tumor and therefore were not considered in the follow-up evaluation. Among the remaining nine recipients who had a mean follow-up of 38.83 months (range 9-42), no donor-transmitted disease has become apparent by imaging control. A careful donor evaluation including histologic grading and strict application of Centro Nazionale Trapianti guidelines allowed us to use donors with malignant tumors in selected cases with an apparently reduced risk of transmitted neoplastic disease.

[The treatment of laparocele by means of a reticulo-laminar prosthesis (Composix Mesh). A technical note]

In this paper, the authors present a modified Rives' technique for the treatment of incisional hernias. This technique requires the use of a nonabsorbable prosthesis (Composix Mesh) made of a double-knit layer of monofilament polypropylene bonded with a single layer of low-porosity e-PTFE inserted behind the rectus muscles and fixed by metallic clips. The outer side (polypropylene) encourages complete host tissue incorporation to reduce recurrences, the inner side (e-PTFE) minimizes tissue attachment and, therefore, visceral complications.

Pubertal growth in children with chronic renal failure on conservative treatment

The pubertal growth spurt was followed for at least 3 years in 5 boys and 6 girls with chronic renal failure on conservative treatment. The peak height velocity averaged 8.6 cm/year (range 5.8-10.1 cm/year) in males and 8.2 cm/year (range 6.4-11.5 cm/year) in females. In none was the pubertal growth spurt below the 3rd percentile for chronological age. At the end of the follow-up period, all patients but 2 had stature within the normal limits of parental target. The relative variation of height averaged - 0.013 standard deviation scores per year. On the whole, the pubertal growth spurt was normal in subjects with chronic renal failure on conservative treatment.