Hand-assisted laparoscopic splenectomy for hydatid cyst

Splenic hydatidosis is a rare condition. We performed a hand-assisted laparoscopic splenectomy for a large hydatid cyst localized in the center of the spleen. We discuss the advantages of the "helping hand."     

Hand-assisted laparoscopic vertical banded gastroplasty. Initial report

Laparoscopic approaches to surgery for morbid obesity offer to reduce the morbidity associated with conventional weight reduction surgery. This paper describes a hand-assisted laparoscopic technique for vertical banded gastroplasty, a method which shortens and simplifies the laparoscopic approach to this established open surgical procedure.     

Retroperitoneal laparoscopic nephrectomy in children

We present two cases of obstructive uropathy nefrectomy through a retroperitoneal approach was performed. Renal differential function by means of a 2,3 dimercapto-succinic acid renal scan showed less than 10% on the ipsilateral kidney to the diagnosis pathology. The size of the kidneys meant no hindrance during its nefrectomy. Morcellation within the organ bag was required for its removal without needing to broaden the 10 mm port opening. The patients were discharged home 48 hours after surgery and they returned to school within the first postoperative week.     

Complications and risks of living donor nephrectomy

BACKGROUND: Short- and long-term patient and graft survival rates are better for living donor (vs. cadaver) kidney transplant recipients. However, donor nephrectomy is associated with at least some morbidity and mortality. We have previously estimated the mortality of living donor nephrectomy to be 0.03%. In our present study, to determine associated perioperative morbidity, we reviewed donor nephrectomies performed at our institution from January 1, 1985, to December 31, 1995. METHODS: The records of 871 donors were complete and available for review. Of these donors, 380 (44%) were male and 491 (56%) were female. The mean age at the time of donation was 38 years (range: 17-74 years), and mean postoperative stay was 4.9 days (range: 2-14 days). RESULTS: We noted two (0.2%) major complications: femoral nerve compression with resulting weakness, and a retained sponge that required reexploration. We noted 86 minor complications in 69 (8%) donors: 22 (2.4%) suspected wound infections (only 1 wound was opened), 13 (1.5%) pneumothoraces (6 required intervention, 7 resolved spontaneously), 11 (1.3%) unexplained fevers, 8 (0.9%) instances of operative blood loss > or = 750 ml (not associated with other complications), 8 (0.9%) pneumonias (all of which resolved quickly with antibiotics alone), 5 (0.6%) wound hematomas or seromas (none were opened), 4 (0.5%) phlebitic intravenous sites, 3 (0.3%) urinary tract infections, 3 (0.3%) readmissions (2 for pain control and 1 for mild confusion that resolved with discontinuation of narcotics), 3 (0.3%) cases of atelectasis, 2 (0.2%) corneal abrasions, 1 (0.1%) subacute epididymitis, 1 (0.1%) Clostridium difficile colitis, 1 (0.1%) urethral trauma from catheter placement, and 1 (0.1%) enterotomy. At our institution, no donor died or required ventilation or intensive care. We noted no myocardial infarctions, deep wound infections, or reexplorations for bleeding. Analysis, by logistic regression, identified these significant risk factors for perioperative complications: male gender (vs. female, P<0.001), pleural entry (vs. no pleural entry, P<0.004), and weight > or = 100 kg (vs. < 100 kg, P<0.02). Similar analysis identified these significant risk factors for postoperative stay > 5 days: operative duration > or = 4 hr (vs. < 4 hr, P<0.001) and age > or = 50 years (vs. < 50 years, P<0.001). CONCLUSIONS: Living donor nephrectomy can be done with little major morbidity. The risks of nephrectomy must be balanced against the better outcome for recipients of living donor transplants.     

Role of CT angiography in the preoperative evaluation for laparoscopic nephrectomy

Laparoscopic nephrectomy (LN) was recently introduced as a minimally invasive alternative to open nephrectomy in living related renal donation. Because of the limited field of view available with laparoscopic techniques, the role of preoperative radiologic evaluation in LN has expanded to include anatomic definition of the renal arteries, collecting system, renal parenchyma, and renal venous anatomy. Computed tomographic (CT) angiography has proved to be a minimally invasive alternative to conventional angiography in the preoperative evaluation of living related renal donors. CT angiography has been shown to have an accuracy comparable to that of conventional angiography in predicting renal arterial anatomy. In addition, CT angiography provides comprehensive definition of the renal vascular anatomy including the location, size, and length of the renal, adrenal, gonadal, and lumbar veins. Dual-phase spiral CT combined with three-dimensional CT angiography constitute a single, minimally invasive procedure that can provide a complete preoperative evaluation of potential living related renal donors prior to LN. Comprehensive anatomic depiction of the renal arterial and venous supplies aids in surgical planning and helps avoid potential complications.     

Incisional hernia after laparoscopic nephrectomy with intact specimen removal: caveat emptor

The choline-containing phosphoglycolipid, MfGL-II, is the major polar lipid of Mycoplasma fermentans PG18. Anti-MfGL-II antisera raised in rabbits using the purified MfGL-II as an immunogen were employed in immunogold electron microscopic and immunofluorescence studies showing that MfGL-II is uniformly distributed and exposed on the cell surface of M. fermentans cells. The specificity of the antibodies was determined by immunostaining of lipid extracts separated by thin layer chromatography. The antibodies recognize lipids specific to M. fermentans but did not cross-react with lipid extracts of M. penetrans, M. capricolum, M. gallisepticum or Acholeplasma laidlawii. As phosphocholine almost completely abolished antibody interaction with MfGL-II in an ELISA assay it is suggested that the anti-MfGL-II repertoire is composed primarily of anti-phosphocholine antibodies. The anti-MfGL-II antisera inhibit the attachment of M. fermentans to Molt-3 lymphocytes suggesting that MfGL-II plays a major role in M. fermentans-host cell interaction.     

Effect of panel reactive antibody on live related donor kidney transplantation: Indian experience

Serum samples from 95 recipients, transplanted with kidneys from live related donors, were tested for the presence of panel reactive antibodies (PRA) in pre- and post-transplant serum samples by the extended microdroplet lymphocytotoxicity test. The immunoglobulin class of antibodies was tested by treatment of serum with dithiothreitol. A significant correlation was found between the high PRA found in the 75 pretransplant sera tested and the subsequent rejection episodes. In addition, the level of pretransplant PRA activity was associated with graft survival in that patients with low PRA had significantly superior graft survival than those with high PRA. Furthermore, the present data show that patients with historical high PRA, but current low PRA, had graft survival similar to that in recipients who had moderate PRA in their current sera. High PRA patients had more often a positive crossmatch than patients with low PRA. The PRA level was also associated with prolonged waiting period. Immunoglobulin class of antibodies was related to graft acceptance in that the presence of IgM antibodies was not detrimental to transplantation. The results in the present study suggest that PRA of < 10% is negligible, while more attention should be paid to patients with PRA > 10%.     

A review of our first 100 cases of laparoscopic nephrectomy: defining risk factors for complications

OBJECTIVE: To present the complications from our first 100 cases of laparoscopic nephrectomy, a technically demanding procedure requiring lengthy experience, and to define the risk factors. PATIENTS AND METHODS: Indications for laparoscopic nephrectomy included patients requiring nephrectomy for benign pathology and those requiring nephroureterectomy for upper tract transitional cell carcinoma confined to the upper ureter and/or renal pelvis. All patients were operated on by one surgeon (D.A.T.) via a transperitoneal route and data on diagnosis, outcome and complications collected prospectively. RESULTS: The overall complication rate was 18%, of which 3% were major and 15% minor complications. Five cases were converted to open surgery electively. Complications and conversions were associated with a history of pyonephrosis, previous renal surgery, staghorn calculi, polycystic kidney disease, and xanthogranulomatous pyelonephritis. While there was no discernible decline in the decrease in complications with experience, operative duration decreased from a mean of 204 min for the first 20 cases to 108 min for the last 20. Complications and conversions were more closely associated with diagnosis than with the surgeon's experience. CONCLUSION: Laparoscopic nephrectomy and nephroureterectomy can be undertaken for a variety of indications with reasonable complication and conversion rates. Although inflammatory conditions increase the difficulty of these procedures, we feel that patients requiring nephrectomy for benign disease should be offered a trial of laparoscopic surgery.     

Laparoscopy-assisted radical nephrectomy without pneumoperitoneum

Data presented here provide the first demonstration that circulating amylin regulates metabolism in vivo, and support an endocrine hormonal role that is distinct from its autocrine action at pancreatic islets. When rats were pre-treated with the potent amylin antagonist AC187 (n = 18), and then administered a 2 mmol glucose load, the rise in plasma lactate was less than in rats administered glucose only (n = 27; P < 0.02). When rats were treated so that plasma glucose and insulin profiles were similar (n = 8), the increase in plasma lactate in the presence of AC187 was only 50.3% as high as the increase when AC187 was absent (P < 0.001). These experimental results fit with the view that some of the lactate appearing in plasma after a glucose load comes from insulin-sensitive tissues. The experiments also support the view that an important fraction of the increase in lactate depends on processes inhibited by a selective amylin antagonist, most likely amylin action in muscle.     

Determinants of late allograft nephrectomy

When loss of graft function occurs more than six months after transplantation, allograft nephrectomy is not routinely performed at the time of graft failure. It is usually performed only on those patients who subsequently develop specific complications. However, little is known about the characteristics that make patients more likely to require allograft nephrectomy. The purpose of our study was to identify risk factors for the subsequent need for allograft nephrectomy in patients with graft failure occurring more than 6 months after transplantation. Forty-one patients were studied. Inclusion criteria were: loss of graft function > or = 6 months after transplantation, resumption of dialysis and initiation of weaning from immunosuppression. Thirty patients were treated with cyclosporine + prednisone +/- azathioprine and 11 with azathioprine + prednisone. Mean follow-up time was 17.8 months, ranging from 6 months to 6.1 years. Recipient age, sex and race, original renal disease, donor, donor source (cadaveric vs living related), HLA compatibility, levels of panel reactive antibodies, occurrence of initial delayed graft function, causes of graft failure and tapering of immunosuppression were similar in patients with and without allograft nephrectomy. Using univariate analysis, allograft nephrectomy was found to be significantly more frequent in patients with a history of 2 or more episodes of acute rejection than in patients with no rejection episode: 83% vs 30% (p = 0.03). In addition, allograft nephrectomy was found to be significantly more frequent if the immunosuppressive regimen included cyclosporine (62% vs 27.3%; p = 0.04). Using multivariate analysis however, the number of previous episodes of rejection was found to be the only significant predictor for allograft nephrectomy. None of the other variables considered in the multivariate analysis, including the type of immunosuppressive therapy, was identified as a significant predictor for the need to perform allograft nephrectomy. In summary, the need for late allograft nephrectomy was correlated with the number of previous episodes of acute rejection. Patients with a history of numerous rejection episodes should thus be considered more likely to require allograft nephrectomy once immunosuppression is withdrawn. Possible interventions to reduce or prevent the need for nephrectomy include more gradual tapering of immunosuppression at the time of graft failure or indefinite low-dose immunosuppressive therapy.     

Adrenal insufficiency after unilateral radical nephrectomy

A case of adrenal insufficiency occurring after unilateral radical nephrectomy is presented. Recommendations for identification and treatment of this condition are discussed.     

Is adrenalectomy part of radical nephrectomy?

The spread of Classical Swine Fever (CSF) virus (strain Lorraine), originally isolated in the first CSF infected herd of the 1993-1994 Belgian epizootic, was examined in an isolation unit with three adjacent pens and 15 weaner pigs per pen. Virus was introduced through experimental inoculation of one weaner pig in the middle pen (pen 2). The experimentally inoculated pig became viraemic 4 days post-inoculation (dpi) and the pen mates at 12 (n = 9) and 14 dpi (n = 5). The first viraemia in pens 1 and 3 was observed 18 dpi. Pigs were found to be seropositive in pens 1, 2, and 3 from 24, 20, and 22 dpi onwards, respectively. The reproduction ratio (R0) for the pigs in pen 2, estimated according to the martingale method, was 81.3 (s.e. = 109.54). The rate ratio (Cox proportional hazard) of the first pigs to become viraemic in pen 3 (airborne contact plus contact via contaminated clothing and footwear with pen 2) versus pen 1 (airborne contact with pen 2 only) was 1.60 (P = 0.3342). Thus, the additional contact of contaminated clothing did not affect transmission of the CSF virus. The survivor function (Kaplan-Meier survival analysis) did not significantly differ per pen. The time from first detection of virus in plasma to death was not significantly different between pens. The mean rectal temperature of pigs in a pen increased 3 to 4 days prior to detection of virus. The proportion of seropositive pigs per pen (p) from the day the first weaner pig in a pen became viraemic (dpf) was examined as a function of time with a logistic regression model. The model parameter estimates did not differ between pens. Hence, the data from the three pens were pooled. The regression equation of the seroprevalence over time for the pooled data was p = 1/[1+e(4.65-0.39 *dpf)].     

Elevated des-AngI-angiotensinogen levels by nephrectomy and adrenalectomy

This study investigates the time course of plasma levels of angiotensinogen (Aogen) and of the Aogen metabolite des-AngI-angiotensiongen (des-AngI-Aogen) in nephrectomized rats with and without adrenals for 24 h. After nephrectomy the plasma Aogen levels increased 5-fold over the following 24 h. The increase is significantly lower after sham nephrectomy (3.7-fold, P < 0.05) and if the kidneys are withdrawn without decapsulization (2.4-fold, P < 0.05). A small and transient increase arise after nephrectomy plus adrenalectomy (1.6-fold after 8 h, P < 0.005). After adrenalectomy alone Aogen levels continuously shrink to 38% of control values after 24 h. Plasma des-AngI-Aogen levels increase 2.1- to 3.7-fold 24 h after the different nephrectomy procedures. In connection with recent findings these data support the notion that the increase in Aogen plasma levels after bilateral nephrectomy is triggered by renin, released during surgery. High plasma levels of des-AngI-Aogen after nephrectomy indicate that AngI is generated by tissue renin, e.g., in the adrenals. This suggests that after nephrectomy the plasma des-AngI-Aogen levels should be a valuable proof for the evaluation of the amount of generated angiotensin.