Randomized clinical trial of laparoscopic versus open donor nephrectomy

Background

This randomized controlled trial was designed to determine the safety and efficacy of laparoscopic donor nephrectomy (LDN) in comparison with short-incision open donor nephrectomy (ODN).

Methods

Eighty-four live kidney donors were randomized in a 2 : 1 ratio to LDN (56 patients) or short-incision ODN without rib resection (28). Primary endpoints were pain relief and duration of inpatient stay.

Results

There was no donor death or allograft thrombosis in either group. The first warm ischaemic time median (range) 4 (2–7) versus 2 (1–5) min; P = 0·001) and the duration of operation (160 (110–250) versus 150 (90–200); P = 0·004) were longer for LDN. LDN led to a reduction in parenteral morphine requirement 59 (6–136) versus 90 (35–312) mg; P = 0·001) and hospital stay (4 (2–6) versus 6 (2–9) days; P = 0·001), and earlier return to employment (42 (14–84) versus 66·5 (14–112) days; P = 0·004). Postoperative respiratory function was improved after LDN. There were more postoperative complications per donor in the ODN group (0·6(0·7) versus 0·3(0·5); P = 0·033). At a median follow-up of 74 months, there were no differences in renal function or allograft survival between the groups.

Conclusion

LDN removes some of the disincentives to live donation without compromising the outcome of the recipient transplant.

Case-matched comparison of long-term results of non-heart beating and heart-beating donor renal transplants

BACKGROUND

Function and survival of non-heart-beating donor (NHBD) renal transplants have been shown to be comparable to those from heart-beating donors (HBDs) up to 10 years after transplantation. However, there are few data on outcome after 10 years, particularly from uncontrolled NHBD donors.

METHODS

All NHBD renal transplants (predominantly uncontrolled) performed between April 1992 and January 2002 were retrospectively matched with HBD renal transplants performed over the same period.

RESULTS

Some 112 NHBD renal transplants were compared with 164 HBD renal transplants. Delayed graft function was significantly higher in the NHBD group (83.9 versus 22.0 per cent respectively; P < 0.001). Primary non-function rates were similar (5.4 versus 1.8 per cent respectively; P = 0.164). Overall serum creatinine was significantly higher in NHBDs (P < 0.001). Median graft and patient survival was 126 months for NHBD and 159 months for HBD kidneys. Death-censored graft survival at 1, 5, 10 and 15 years was respectively 91.8, 77.5, 61.0 and 44.2 per cent for NHBD, and 91.1, 86.3, 71.7 and 58.5 per cent for HBD kidneys (P = 0.108).

CONCLUSION

Despite increased delayed graft function rates and serum creatinine levels, the long-term survival of NHBD renal transplants was similar to those from HBDs. However, there was a trend to poorer function and survival from 10 years after transplant.

Paired exchange programmes can expand the live kidney donor pool

Background

Kidney paired donation (KPD) is an exchange of organs between two live donors, who are otherwise ABO incompatible or cross-match positive, and their intended recipients. The outcome is the generation of compatible transplants conferring an improvement in quality of life and longevity.

Methods

Medline was searched for articles on KPD using a combination of keywords. Publications focusing on protocols and policy, mathematical modelling, ethical controversies, and legal and logistical barriers were identified.

Results

Many are precluded from transplantation because of incompatibilities with their intended donors. KPD has the potential to increase the rate of transplantation by facilitating exchange transplants between otherwise incompatible donor–recipient couples. Ethical controversies surrounding paired donation include confidentiality, conditionality of donation, synchronicity of operations and the possibility of disadvantaging blood group O recipients. Logistical barriers hampering KPD programmes involve the location of donor surgery and organ transport.

Conclusion

Paired donation may expand the living donor pool by providing an alternative successful strategy for incompatible donor–recipient couples. Its widespread implementation will depend on resolving ethical and logistical constraints.

A comparison of traditional open, minimal-incision donor nephrectomy and laparoscopic donor nephrectomy

Laparoscopic donor nephrectomy (LDN) and minimal-incision donor nephrectomy (MILD) are less invasive procedures than the traditional open donor nephrectomy approach (ODN). This study compares donor and recipient outcome following those three different procedures. Sixty consecutive donor nephrectomies were studied (n = 20 in each group). Intra-operative variables, analgesic requirements, donor recovery, donor/recipient complications and allograft function were recorded prospectively. Operating and first warm ischaemia times were longer for LDN than for ODN and MILD (232+/-35 vs 121+/-24 vs 147+/-27 min, P < 0.001; 4+/-1 vs 2+/-2 vs 2+/-1 min, P < 0.01). Postoperative morphine requirements were significantly higher after ODN than after MILD and LDN (182+/-113 vs 86+/-48 vs 71+/-45 mg; P < 0.0001). There was no episode of delayed graft function in this study. Donors returned to work quicker after LDN than after ODN and MILD (6+/-2 vs 11+/-5 vs 10+/-7; P = 0.055). Donor and recipient complication rates and recipient allograft function were comparable. We concluded that MILD and LDN reduce postoperative pain and allow a faster recovery without compromising recipient outcome.

Nifedipine improves immediate, and 6- and 12-month graft function in cyclosporin A (CyA) treated renal allograft recipients

To investigate the effect of oral nifedipine, a calcium channel blocker known not to modify cyclosporin A (CyA) pharmacokinetics, on immediate transplant function and CyA nephrotoxicity, 68 adult renal transplant recipients were pre-operatively randomized to one of three regimes: A (high-dose CyA, initial dose 17 mg/kg per day, maintenance dose 7 mg/kg per day); B (regime A plus oral nifedipine); C low-dose CyA, initial dose 10 mg/kg per day, maintenance 4 mg/kg per day plus azathioprine 1 mg/kg per day). All three groups received identical steroid regimes. Calcium channel blockers of all types were avoided in groups A and C. Delayed graft function (dialysis dependence by day 4) was seen least frequently in group B (P < 0.02). Group B had improved graft function at 6 months compared with group A, identified by differences in serum creatinine (P < 0.05), GFR (P < 0.01) and ERPF (P < 0.05). Similar differences in serum creatinine (P < 0.05) and GFR (P < 0.05) were also identified at 12 months. Group C also had better 6- and 12-month GFR values than group A (P < 0.05 each). The three groups did not differ in donor or recipient age, HLA matching, ischaemic or anastomosis times, frequency of early rejection or whole-blood CyA levels. These results indicate that nifedipine significantly improves immediate and medium-term graft function.

Living kidney donation: a comparison of laparoscopic and conventional open operations

Laparoscopic donor nephrectomy has the potential to lessen the burden placed on live kidney donors. This study describes the first British comparison of donor morbidity and recovery following conventional open donor nephrectomy (ODN) and laparoscopic donor nephrectomy (LDN). An initial series of LDN (n=20) was compared to a historical control group of ODN (n=34). Laparoscopic operations were performed via a transperitoneal approach, the kidney being removed through a 6--12 cm Pfannensteil incision. Open operations were performed using a retroperitoneal flank approach with resection of the 12th rib. Postoperatively, donors were managed with a patient controlled analgesia system. LDN was associated with shorter mean (SD) inpatient stay (6 (2) v 4 (1) days; p=0.0001) and lower parenteral narcotic requirements (morphine 179 (108) v 67 (54) mg; p=0.0001). Laparoscopic donors started driving their cars sooner (2 (1.5) v 6 (4) weeks; p=0.0001) and returned to work more quickly (5 (3) v 12 (6) weeks; p=0.0001) than open nephrectomy donors. There were no differences in recipient serum creatinine levels at three months post-transplant but two recipients of transplant kidneys retrieved laparoscopically (10%) developed ureteric obstruction, whereas this complication did not occur after ODN (p=0.13). LDN is associated with less postoperative pain and a substantial improvement in donor recovery times. It is not yet clear whether or not the outcome of the recipient kidney transplants are the same after ODN and LDN and much more experience is required before the place of this new technique can be defined.

Endoscopic-assisted intrathoracic oesophagogastrostomy without thoracotomy for tumours of the lower oesophagus and cardia

AIMS

This study aimed to evaluate the efficacy of a novel technique enabling a trans-hiatal oesophagectomy with intrathoracic anastomosis under direct vision, without thoracotomy.

METHODS

Trans-hiatal dissection of the oesophagus was performed using direct and laparoscopic visualization. The oesophagus was transected above the tumour with a linear endo-GIA-2 60 mum stapler. The stomach was transected and a gastric tube fashioned. The anvil of an appropriately sized CEEA circular stapler was modified enabling it to flatten. It was attached to a novel delivery system introduced under direct vision along a guidewire into the stapled oesophagus. The anvil was realigned to its original position in the distal oesophagus, docked with the body of the stapler and an intrathoracic anastomosis performed.

RESULTS

Ten patients (female n=3, male n=7) aged from 39--77 years (mean age 65 years), ASA 2--3 with distal third tumours were treated. Duration of procedure ranged from 2--5 hours (mean 4 hours). One patient suffered a post-operative chest infection and an anastomotic leak treated successfully with a self-expanding metal stent. Hospital stay ranged from 6--28 days (mean 17 days). There was no mortality.

CONCLUSION

This technique allows a safe intrathoracic anastomosis to be performed trans-hiatally under direct vision, avoiding the need for thoracotomy in patients with high comorbidity.

A case-control comparison of the results of renal transplantation from heart-beating and non-heart-beating donors

INTRODUCTION

The decline in heart-beating brainstem dead organ donors has necessitated the search for other organ sources. In the field of renal transplantation one alternative source currently available, but little used, is that of kidneys from non-heart-beating donors (NHBD). Reticence to use NHBD kidneys is in part due to concerns over the effect that warm ischemic may have subsequent graft function. Presented here are the results of the NHBD renal transplants at the Leicester transplant unit, and compared with matched heart-beating donor transplants as a case control analysis.

METHODS

In order to analyze any differences in graft performance between the two organ sources, the confounding effect of other variables known to influence the outcome of renal transplantation was minimized by matching NHBD and HBD transplants for the following criteria: donor age and sex, first or re-transplant, anastomosis and cold times, tissue match and PRA sensitisation. Transplant performance was assessed primarily by graft survival, the statistical evaluation of which was by log rank analysis of Kaplan-Meier curves.

RESULTS

72 NHBD and 192 HBD transplants were performed over an eight year period. Of the 192 HBD transplants, 105 matched one or more of the NHBD by the criteria outlined above, and thus constituted the control group for comparison. There was no significant difference in overall graft survival between the two groups. The 5 year survival for the NHBD was 73% compared with 65% for HBD kidneys. When death with a functioning graft is treated as censored data, then these figures become 75% and 81% respectively, again without statistical significance.

CONCLUSION

NHBD kidneys are a valuable additional source of organs for transplantation, with long-term survival, comparable to transplants from HBD.

A comparison of the results of renal transplantation from non-heart-beating, conventional cadaveric, and living donors

BACKGROUND

In an attempt to address the shortage of conventional kidney donors, a non-heart-beating donor (NHBD) organ retrieval program has been established. We compared the results of kidney transplants from NHBDs (N = 77) with those from heart-beating cadaveric (HBD; N = 224) and living donors (LD; N = 49), performed in the same eight-year period.

METHODS

Patients dying after failed attempts at resuscitation in the accident department or after intracerebral hemorrhage/anoxia were considered as potential NHBDs. After death, in situ kidney perfusion and cooling were achieved using an intra-aortic catheter inserted via a femoral artery cut down. Kidney retrieval and transplant operations were performed using standard techniques.

RESULTS

The median (range) warm ischemic time for NHBD kidneys was 25 minutes (5 to 53 min). The initial function rates for NHBD, HBD, and LD transplants were 6.5, 76.3, and 93%, respectively. Primary nonfunction occurred in 5 of 75 evaluable NHBD transplants (7%) compared with only 6 out of 224 (2.7%) HBD and 1 out of 49 (2%) LD transplants (P = NS). Eighty-four percent of NHBD kidney recipients required postoperative dialysis for a median of 19 days. The mean (SD) serum creatinine at 12 months was 179 (73) micromol/L in NHBD kidneys compared with 152 (57) micromol/L for HBD kidneys and 138 (44) micromol/L for LD kidneys. The actuarial five-year graft survival rates for NHBD, HBD, and LD transplants were 79, 75, and 78%, respectively. During the period under study, NHBD organs accounted for 22% of the total renal transplant program.

CONCLUSIONS

Despite being associated with poor initial graft function, the long-term allograft survival of NHBD kidneys does not differ significantly from the results of HBD and LD transplants.

A prospective randomized trial of three different sizes of core-cutting needle for renal transplant biopsy

BACKGROUND

Needle-core biopsy remains one of the most important investigations in cases of renal allograft dysfunction. The size and quality of the biopsy material are likely to be important factors in achieving an accurate diagnosis. The aim of this study was to compare the success and complication rates of renal transplant biopsy procedures using three differently sized needles.

METHODS

One hundred renal allograft recipients undergoing transplant biopsy using an automated needle core method were randomized to a 14, 16, or 18 gauge (G) needle. The size of each biopsy core was measured, and the presence or absence of renal cortical and medullary tissue and the number of glomeruli were recorded. Assessments of the ease with which the procedure was performed, the diagnostic usefulness of the biopsy material, and the discomfort associated with the procedure were made using verbal response and linear analog scales.

RESULTS

Fourteen G biopsy cores (N = 33) were larger than both 16G (N = 33) and 18G (N = 34) cores and contained more gomeruli (mean number for 14G, 16G, and 18G = 15, 11 and 9, respectively). There were no differences in the ease of use of the three needle types, but scores for diagnostic usefulness were higher for 14G versus 18G and 16G versus 18G. The 14G needle was associated with significantly more pain than the two smaller needles when this was assessed using a linear analog score. Macroscopic hematuria occurred in eight patients, but there were no differences in complications rates between the three groups.

CONCLUSIONS

All three needle sizes are safe for use in renal allograft biopsy using a semiautomated biopsy gun. The larger needles provide more tissue and glomeruli and, thus, are more diagnostically useful. Use of a 14G needle may be associated with more pain, and the 16G needle appears to offer the best compromise between diagnostic usefulness and patient acceptability.

A cost-benefit comparison of self-expanding metal stents and Atkinson tubes for the palliation of obstructing esophageal tumors

This retrospective study was undertaken to assess the cost-benefit aspects of self expanding metal stents (SEMS), versus Atkinson Tubes (AT) in the palliation of obstructing esophageal tumors. Over a 4 year period, 50 patients received palliative endoscopic intubation for inoperable esophageal malignancy. Patients either received an AT or a newer, but more expensive, SEMS, both inserted under general anaesthetic. Both patients cohorts were assessed in terms of the severity of their dysphagia and scored according to Atkinson and Fergusons' classification both pre- and post-operatively. Other factors that were considered included length of hospital stay, number of interventions, admission to the Intensive Treatment Unit (ITU), and rates of post-operative complication. The majority of tumors were either adenocarcinoma or squamous cell carcinoma. The location of the tumors (upper, middle or lower) were similar in each group as was the mean length of tumor being 7 cms in SEMS and 5 cms in AT. There were significantly more complications in the AT group compared to the SEMS group (p < 0.05). The most common complications in the AT group were tube displacement (21%), tumor overgrowth (26%) and esophageal perforation (13%). In contrast complications of the SEMS group were tumor overgrowth (15%) and esophageal perforation (8%). Mean hospital stay was 3 (1-30) days for SEMS and 8 (2-122) days for AT (p < 0.05). The median total cost of hospital stay was 1745 pounds (1027-5424) for SEMS versus 2349 pounds (1163-24,481) for AT.

Organ donation in the UK: a survey by a British Transplantation Society working party

BACKGROUND

During the past few years the number of organ donors in the UK has declined after a slow but steady increase during the 1980s. Concern about the decline led to a survey by the British Transplantation Society. The report of this survey highlighted a number of reasons for the decline and this manuscript presents and discuss the main items in the report.

METHODS

Comprehensive information relating to organ donation was obtained by a combination of structured interviews during visits to intensive care units (ICUs) and neurosurgical units, the use of detailed questionnaires sent to all UK ICUs, and from the register held by the United Kingdom Transplant Support Service Authority.

RESULTS

The information obtained highlighted a number of reasons for the decline in organ donor numbers and these are presented and discussed. The pool of potential donors is shrinking as death rates from road traffic accidents and intracranial haemorrhage decrease. Also the increasing use of modern imaging techniques has improved predictive ability in patients with severe brain damage with the result that more patients whose prognosis is assessed as hopeless are not treated by ventilation. Inadequacies both in intensive care unit bed provision and the resourcing of the transplant co-ordinator service were also thought to be important.

CONCLUSIONS

Eight recommendations have been made, covering ICU bed provision, neurosurgical provision, transplant surgical staffing, the transplant co-ordinator network, reimbursement to donor units, asystolic donation, live donor transplantation, and interventional ventilation.

Urological complications in renal transplantation: impact of a change of technique

OBJECTIVE

To determine whether the change from the Leadbetter-Politano technique to a stented extravesical technique for the vesico-ureteric anastomosis in renal transplantation has altered the incidence of urological complications.

PATIENTS AND METHODS

Data were retrieved from a prospective computerized database and by case-note review on 248 consecutive renal transplants performed between January 1990 and June 1996. The characteristics of the donor. recipient and organ were noted, together with the technique used for the vesicoureteric anastomosis and the occurrence of major and minor urological complications.

RESULTS

The Leadbetter-Politano technique was used in 140 transplants and the stented extravesical technique in 108. There were no significant differences in the donor, recipient or organ characteristics between the groups. The stented extravesical technique was associated with a significantly lower rate of major complications (< 2%) and clinically significant haematuria than with the Leadbetter-Politano technique.

CONCLUSION

Changing from the Leadbetter-Politano technique to a stented extravesical technique for the vesico-ureteric anastomosis has been a major factor in reducing the incidence of urological complications in our transplant practice.

Recent advances in prophylaxis against deep vein thrombosis

The major development in DVT prophylaxis in recent years has been the introduction of low molecular weight heparins. Their main improvement compared with unfractionated heparin is in the convenience of a once daily dosage, but they have not yet convincingly been shown to be more effective or safer. A-V impulse boots may have an impact on knee and hip surgery but still face problems with patient acceptability. Probably the best way to ensure that more DVT are prevented is by clinicians maintaining a high level of awareness of the risk, and developing, and adhering to, local guidelines.

Preliminary results of the use of intraperitoneal carbon-adsorbed mitomycin C in intra-abdominal malignancy

Eleven patients suffering from intra-abdominal malignancy were treated with various doses of intraperitoneal mitomycin C adsorbed onto activated carbon particles. Seven of the patients underwent resection of their primary gastric tumour and all developed potentially life-threatening severe complications that proved to be fatal in four patients. The pattern of complications seen in these patients was unusual in patients undergoing gastrectomy and must be presumed to be secondary to the intraperitoneal mitomycin C. Intraperitoneal mitomycin C at a dose of 25 mg and 50 mg in the presence of an anastomosis or other suture line does not appear to be safe.

Parathyroidectomy in chronic renal failure: comparison of three operative strategies

The efficacy of subtotal parathyroidectomy (n = 11), total parathyroidectomy+autotransplantation (n = 13) and total parathyroidectomy alone (n = 24) were compared in a series of renal patients with hyperparathyroidism. The principal indication for surgery was severe bone disease but other indications were uncontrolled hypercalcaemia, soft tissue calcification and grossly elevated parathyroid hormone (PTH) levels. The clinical success rates at 24 months follow-up for subtotal, total plus autograft, and total parathyroidectomy were 100, 89 and 97% respectively. Similar improvements in radiological changes and alkaline phosphatase levels were seen in all three groups. Recurrent hyperparathyroidism was recorded in three (27%) members of the subtotal parathyroidectomy group and two (16%) of the patients undergoing total parathyroidectomy and autotransplantation. Two patients required re-exploration of their forearm parathyroid autograft. No patients undergoing total parathyroidectomy only suffered persistent or recurrent hypercalcaemia. Vitamin D analogue requirements rates in patients undergoing subtotal, total plus autotransplant, and total parathyroidectomy at 24 months were 44, 70 and 81% respectively. An important finding is the demonstration of residual parathyroid function in 14/16 patients (87.5%) undergoing total parathyroidectomy without autotransplantation and followed-up for 2 years.

Palliation of oesophageal carcinoma using the argon beam coagulator

Oesophageal intubation occasionally fails to palliate inoperable carcinoma: some tumours are unsuitable for this procedure and others overgrow the tube. This study reports a series of nine patients (median age 79 (range 55-87) years) in whom the argon beam monopolar coagulator via a flexible endoscopic probe was used to ablate such tumours. Fourteen ablation procedures were performed. The endoscope was passed to the stomach at the end of each procedure. There were no complications; the median hospital stay was 2 (range 1-13) days. Thirteen procedures rendered the patients completely asymptomatic for a median of 6 (range 4-12) weeks. Six patients died a median of 14 (range 4-38) weeks after the first ablation, reflecting their limited life expectancy. The argon beam coagulator provides an effective alternative to laser ablation, being considerably cheaper and safer, while maintaining the minimally invasive nature of the palliation.

Work-load generated by the establishment of a non-heart beating kidney transplant programme

The work-load generated by a non-heart-beating donor (NHBD) kidney transplant programme over a 3-year period is reported. A total of 73 referrals were made, 64 from the Accident department and 9 from the wards. Organ procurement was performed in 24 cases (33%) and resulted in the retrieval of 44 kidneys. Reasons for failure to achieve organ procurement were; refused consent (n = 13; 18%), relatives unavailable to ask for consent (n = 9; 12%), technical problems with catheter insertion or perfusion (n = 10; 14%), transplant staff unavailable (n = 1; 1%), long asystolic period (n = 8; 11%) and donor unsuitable for other reasons (n = 8; 11%). Of the 44 kidneys retrieved, 30 were transplanted locally, 8 were transplanted at other United Kingdom centres and 6 were discarded. Locally transplanted NHBD kidneys represented 21% of the total transplant programme during the time period under study. We conclude that NHBD kidneys are a good source of additional organs for transplantation, but only one-third of referrals result in a successful procurement procedure. Moreover, the setting up of a successful programme is labour-intensive and requires a highly committed staff.

Laparoscopic hernia repair in Leicester General Hospital: a prospective audit of 94 patients

Conventional hernia repair is effective in terms of cure but is associated with considerable postoperative pain and delay in return to normal activity. Laparoscopic repair has the potential to reduce pain and speed return to normal activity, but there have been few published reports of the outcome of this operation in the UK. We present a prospective audit of 94 patients who underwent laparoscopic repair. Of the 94 patients, 87 (92.6%) were male and 7 (7.4%) were female. Thirteen of the repairs were bilateral and 12 were recurrent. Two had to be converted to open repair. The mean operating time for unilateral repair was 56 min and for bilateral repair 98 min. Sixty-three patients (67%) were discharged within 24 h and 21 (22.4%) were discharged within 48 h. There were minor complications in 20 patients (21%), eight of whom (8.5%) developed a haematoma. The other minor complications included seromas (2), bruising at the site of the entry port (2), hyperaesthesia in the groin (2), port hernia (1), shoulder tip pain after surgery (3) and postoperative urinary retention (2). Nine (9.5%) patients claimed to have had no pain or discomfort at all; 35 (37.2%) were pain and discomfort free in 2 weeks. Thirty-two (34%) patients returned to normal activities in 2 weeks. With a median follow-up of 8 months 3 (3.2%) recurrences were noted. It is emphasised that this series represents a learning curve and that the operation is developmental. We are now restricting laparoscopic repair to recurrent and bilateral hernias where the technique offers particular advantages.

The relative influence of delayed graft function and acute rejection on renal transplant survival

Three hundred and eight cadaveric renal transplants were analysed to establish the effects of acute rejection in the first 90 days and delayed graft function (DGF) on graft outcome. There were 120 patients (39%) with no DGF and no rejection (group 1), 101 patients (33%) with rejection but no DGF (group 2), 41 patients (13%) with DGF but no rejection (group 3) and 46 patients (15%) with both rejection and DGF (group 4). The actuarial 4-year graft survival rates for groups 1,2,3 and 4 were 78.3%, 65.4%, 60.1% and 40.4%, respectively. The acute rejection rate was 101/221 (46%) in patients with initial graft function compared with 46/87 (53%) for those with DGF (chi 2 = 1.02, P = 0.31). Cox stepwise logistic regression analysis demonstrated that DGF was a more powerful predictive factor for poor graft survival (P = 0.001) than acute rejection occurring in the first 90 days post-transplant (P = 0.034). Further efforts at improving graft outcome should concentrate on reducing the incidence of DGF.

A novel method for the treatment of localised intrathoracic anastomotic leakage

Images

No obvious advantages for thoracoscopic two-stage oesophagectomy

Thoracoscopically assisted Ivor-Lewis oesophagectomy potentially combines the pulmonary advantages of transhiatal oesophageal dissection, with the visibility and control permitted by thoracotomy. This study reviewed 17 patients who underwent this procedure with an intrathoracic anastomosis. Five patients required conversion to thoracotomy, four because of technical difficulties with the anastomosis. After operation 13 patients had radiological evidence of atelectasis, six developed a left pleural effusion and five had clinically significant pneumonia. Three patients developed an anastomotic leak, two of whom died giving an in-hospital mortality rate of 12 per cent. Median postoperative hospital stay was 12 days. Four patients developed benign anastomotic strictures requiring dilatation. The 1- and 2-year survival rates were 73 per cent (11 of 15 patients) and 63 per cent (five of eight) respectively. The use of minimal access techniques in this context does not appear to reduce the postoperative incidence of either pulmonary or anastomotic complications.

The beneficial effects of oral nifedipine on cyclosporin-treated renal transplant recipients--a randomised prospective study

The aim of this study was to test the hypothesis that nifedipine will improve graft survival in cyclosporin A (CyA)-treated renal transplant recipients. One hundred and forty-seven patients were randomised to one of three regimens. Group A received CyA, 7 mg/kg per day, and prednisolone; group B followed the same regimen as group A plus oral nifedipine and group C received CyA, 4 mg/kg per day, prednisolone and azathioprine. Calcium channel blockers were avoided in groups A and C. The crude 2-year (P = 0.0223) and 4-year (P = 0.0181) graft survival was significantly better in group B (86% and 81%, respectively) than in group A (75% and 63%, respectively). Delayed initial function was seen least frequently in group B (10.2%) compared to groups A (31%) and C (28%; P < 0.01). Group B also experienced fewer rejection episodes than groups A and C (P < 0.05). We conclude that the combination of oral nifedipine and CyA significantly improves initial graft function, rejection frequency and long term graft survival.

Technique for full-thickness muscle closure of laparoscopic port sites

Since the introduction of laparoscopic surgery there have been several case reports of incisional hernia at sites where laparoscopic trocars have been inserted through the abdominal wall1–5. These occur predominantly through port sites with a diameter of 10 mm or more, either through the linea alba at the umbilicus, or through more lateral defects. Fascial closure reduces the incidence but does not eliminate hernias entirely as they can occur into the subfascial space1,2. As complex laparoscopic surgery involving the use of several large ports becomes increasingly common, the incidence of this complication is likely to increase. The authors believe it is important to perform a full-thickness closure of all muscle defects 10 mm or greater in diameter.