Impact of center volume and the adoption of laparoscopic donor nephrectomy on outcomes in pediatric kidney transplantation

Reports for pediatric kidney transplant recipients suggested better outcomes for ODN compared to LDN. Contemporary outcomes stratified by donor type and center volume have not been evaluated in a national dataset. UNOS data (2000-2014) were analyzed for pediatric living donor kidney transplant recipients. The primary outcome was GF; secondary outcomes were DGF, rejection, and patient survival. Live donor nephrectomies for pediatric recipients decreased 30% and transitioned from ODN to LDN. GF rates did not differ for ODN vs LDN (P = .24). GF was lowest at high volume centers (P < .01). Donor operative approach did not contribute to GF. LDN was associated with less rejection than ODN (OR 0.66, CI 0.5-0.87, P < .01). Analysis of the 0- to 5-yr recipient group showed no effect of ODN vs LDN on GF or rejection. For the contemporary era, there was no association between DGF and LDN in the 0- to 5-yr group (OR 1.12, CI 0.67-1.89, P = .67). Outcomes of kidney transplants in pediatric recipients following LDN have improved since its introduction and LDN should be the approach for live donor nephrectomy regardless of recipient age. The association between case volume and improved outcomes highlights future challenges in organ transplantation.

Chest pain after kidney transplantation owing to pneumomediastinum: a case report

BACKGROUND

Chest pain in kidney transplant recipients can signify a life-threatening condition.

CASE REPORT

A patient with polycystic kidney disease who underwent living donor kidney transplantation with open bilateral native nephrectomy developed acute substernal chest pain 10 days post-transplantation. History, physical, and diagnostic studies identified no cardiac or pulmonary causes for the pain, but radiography showed mediastinal air. No vascular or thoracic injury explained the development of the pneumomediastinum. After 1 day on oxygen, the chest pain symptoms resolved. Repeat x-rays showed resolution of the pneumomediastinum.

DISCUSSION

Pneumomediastinum resulting from air migrating from the abdominal cavity to the thorax has not been described after open removal of diseased abdominal organs. This case illustrates that creation of a potential space in the abdominal cavity can be associated with the development of pneumomediastinum.

CONCLUSIONS

Conservative measures were sufficient to resolve the pneumomediastinum and symptoms in this patient.

Allocation policy for hepatocellular carcinoma in the MELD era: room for improvement?

Currently, liver transplantation is the optimal cure for hepatocellular cancer (HCC) limited to the liver. The requisite use of a scarce resource and the effective "competition" between transplant candidates with and without HCC necessitates an allocation policy that defines the subset of HCC patients appropriate for transplantation and their equitable waiting-list prioritization relative to non-HCC patients. Under Model for End-Stage Liver Disease (MELD) allocation, HCC candidates must meet the Milan criteria (single tumor < or =5 cm in diameter or 2 or 3 tumors, each <3 cm in diameter) to qualify for exceptional HCC waiting-list consideration. Their waiting-list prioritization is based on estimating progression risk beyond the Milan criteria (termed dropout), an event for HCC patients considered equivalent to death for non-HCC patients. Although the Milan criteria may be too restrictive, thereby denying deserving patients access to transplantation, high rates of understaging by pretransplantation radiographic imaging and concern for erosion of recurrence-free survival rates have dampened enthusiasm for relaxation of tumor guidelines. The efficacy of pretransplantation locoregional therapies to reduce dropout, downstage patients, and/or decrease posttransplantation recurrence remains to be determined. Genomic, molecular, or clinical criteria to accurately differentiate HCC patients whose disease will recur from those whose disease will not recur would resolve much of the current controversy regarding appropriate criteria for HCC patients to qualify for transplantation.

Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: report of a new technique and early results

BACKGROUND

Open inguinal hernia repair with high ligation is an excellent method of repair in the pediatric population. Advantages of endoscopic repairs include the ability to evaluate the contralateral side, avoidance of access trauma to the vas deferens and gonadal vessels, and decreased operative time. We now report our experience with subcutaneous endoscopically assisted ligation (SEAL),: a novel technique that has proved to be a safe and effective in the treatment of inguinal hernia in the pediatric population.

METHODS

The study is based on a retrospective review of 204 pediatric patients with 300 inguinal hernias treated with the SEAL technique from November 2001 to August 2003 at a tertiary referral center. Patient age ranged from 30 days to 16 years at the time of operation, with a mean follow-up of 235 days (median follow-up, 189 days). Statistical analysis was done with chi2 test, with the main outcome measures being intraoperative and postoperative complications including recurrence rate, suture abscesses, and postoperative hydroceles.

RESULTS

There were 13 recurrences in 300 SEAL repairs, for a recurrence rate of 4.3% (95% C.I. 2.01%-6.65%), with only two recurrences in the last 100 repairs (2%). There were 10 suture abscesses or granulomas and 7 postoperative hydroceles. There was no statistically significant association between recurrence and gender, age at operation, history of prematurity, bilaterality, or kind of suture used.

CONCLUSIONS

Our 4.3% (95% C.I. 2.01-6.65%) recurrence rate is comparable to prior series of laparoscopic repairs citing recurrence rates of 0%-5.7%. The majority of recurrences occurred within the first 4 months of developing this new procedure, with only two recurrences in the last 100 repairs. These pilot data suggest that SEAL is a safe and effective technique for inguinal hernia repair in the pediatric population. A prospective study is planned to compare this laparoscopic technique with open herniorrhaphy.

Hook needle-guided excision of recurrent differentiated thyroid cancer in previously operated neck compartments: a safe technique for small, nonpalpable recurrent disease

CONTEXT

As a result of more sensitive techniques to detect recurrent thyroid cancer, the number of patients presenting with small, nonpalpable recurrent thyroid cancer in cervical lymph nodes is increasing. Surgical excision of nonpalpable recurrent thyroid cancer can be difficult, particularly in a previously operated area.

OBJECTIVE

The objective of this study was to investigate whether preoperative insertion of a hook needle under ultrasound guidance is useful in neck reoperations for recurrent thyroid cancer.

PATIENTS

Ten consecutive patients presenting over a 4-month period with nonpalpable, ultrasound-visible, fine needle biopsy-proven recurrent thyroid cancer in previously operated neck compartment(s) were studied.

MAIN OUTCOME MEASURES

We measured whether it was technically possible to insert a hook needle preoperatively, rate of negative neck exploration, and complication rate.

RESULTS

The hook needle was inserted in seven patients. In three patients, the hook needle was not inserted; one patient had palpable disease 4 months after the preoperative clinic visit, one patient had a tumor too close to the carotid artery, and one patient had multiple bilateral foci of recurrent disease in the central neck. One patient had bleeding after insertion of the needle due to a penetration of an anterior jugular vein that was easily managed at neck reexploration. No other complication occurred during the hook needle insertion, and the only surgical complication was a transient recurrent nerve palsy. All pathology reports showed malignant disease.

CONCLUSION

Hook needle-guided excision of recurrent thyroid cancer is feasible and appears to be a promising tool for safe and successful reoperation of patients with small recurrent thyroid cancer in cervical lymph nodes.

Surgery in developing countries: essential training in residency

HYPOTHESIS

A surgical elective in a developing country setting is an essential new component in academic residency training.

DESIGN

A survey of residents and faculty within the Department of Surgery at the University of California-San Francisco, and a collaborative program piloted between the Department of Surgery at the University of California-San Francisco and Makerere University in Kampala, Uganda, including a 6-week clinical elective.

SETTING

Mulago and Nsambya hospitals in Kampala, Uganda.

PARTICIPANTS

Two residents and three faculty advisors at the University of California-San Francisco.

INTERVENTION

Development of a 6-week pilot clinical surgical elective.

MAIN OUTCOME MEASURES

Assessment of the level of interest in international health in an academic surgery program; pathology and case variety, diagnostic methods, and surgical and anesthetic resources and techniques in a pilot developing country.

RESULTS

Forty percent of residents enter residency with prior international health experience whereas 90% express interest in a developing country elective. Twenty-five percent of faculty participate in voluntary international surgical service and research projects. As a result of the survey and the level of interest in our program, two visits to Uganda were made and a residency elective rotation was successfully created. This resulted in exposure of residents to the educational benefits of learning in a resource-constrained setting: a broader scope of surgical conditions and pathology, greater reliance on history-taking and physical examination skills in a low-technology environment, and sociocultural aspects of care provision. Greater questions about global health equity, access to information, and the role of surgery in public health are raised along with potential challenges in international collaboration.

CONCLUSIONS

A developing country surgical experience complements the academic mission of service, training, and research, and should be an essential component of surgical training programs. There is interest among residents and faculty in such a program as well as a need for greater commitment to north-south collaborations among academic surgical institutions and societies, as has been successfully implemented abroad. More generally, surgery is an integral part of public health and health systems development worldwide.

The G alpha protein ODR-3 mediates olfactory and nociceptive function and controls cilium morphogenesis in C. elegans olfactory neurons

The Gi/Go-like G alpha protein ODR-3 is strongly and selectively implicated in the function of C. elegans olfactory and nociceptive neurons. Either loss of odr-3 function or overexpression of odr-3 causes severe olfactory defects, and odr-3 function is essential in the ASH neurons that sense noxious chemical and mechanical stimuli. In the nociceptive neurons, ODR-3 may interact with OSM-9, a channel similar to the mammalian capsaicin receptor implicated in pain sensation; in AWC olfactory neurons, ODR-3 may interact with another signal transduction pathway. ODR-3 exhibits an unexpected ability to regulate morphogenesis of the olfactory cilia. In odr-3 null mutants, the fan-like AWC cilia take on a filamentous morphology like normal AWA cilia, whereas ODR-3 overexpression in AWA transforms its filamentous cilia into a fan-like morphology.