Right Living Donor Nephrectomies: Retroperitoneoscopic vs Laparoscopic Transperitoneal Approach.

Retroperitoneoscopic right living donor nephrectomy (RLDN) provides direct access to the renal hilum without the need to mobilize the colon. However, factors such as lack of anatomic landmarks to guide orientation, smaller working space, and steep learning curve provided a debate against this approach. In this retrospective study, we reviewed our single-center experience of retroperitoneoscopic RLDN. MATERIALS AND METHODS: Between January 2015 and January 2017, 10 patients underwent retroperitoneoscopic RLDN by a single surgeon at the National University Hospital, Singapore. Baseline demographics, intraoperative parameters, and both donor and recipient outcomes were retrieved from the database. RESULTS: Mean (SD) age was 52.7 (13.8) years, mean (SD) body mass index was 25.2 (2.9) kg/m2, mean (SD) operating time was 196.8 (38.0) minutes, mean (SD) warm ischemic time was 5.1 (2.1) minutes, and mean (SD) blood loss was 43 (25.0) mL. Mean (SD) renal vein length was 10 (2.5) mm, and mean (SD) renal artery length was 6 (1.8 mm). One patient had to be converted to laparoscopic transperitoneal nephrectomy. No donors developed complications. Mean (SD) hospital stay was 3.5 (1.1) days. All transplanted right kidneys had immediate graft function with no complications. Mean (SD) serum creatinine (at 1 year) was 103.6 (20.3) µmol/L. There is no graft loss among the recipient after 1 year. CONCLUSIONS: Right donor nephrectomy can be performed safely using retroperitoneoscopic approach. Retroperitoneoscopy offers advantages, especially in a patient who previously had transabdominal surgery or high body mass index. However, transperitoneal approach may be preferable in anomalous situations because it provides instinctive orientation from anatomic landmarks and a greater working space.

Challenges faced by international nurses when migrating: an integrative literature review.

AIM: Results from this literature review were used to identify the challenges faced by international nurses in their host countries following migration. BACKGROUND: The increasing strain of nursing shortages in the healthcare system has led to the recruitment of international nurses among many countries. However, following migration, international nurses are faced with challenges that may result in poor integration with their host countries. METHODS: Using Cooper's five stages for integrative research reviews, a literature search was conducted across seven databases using a PRISMA search strategy. Additional manual searches were also conducted on the end-references of the retrieved articles. The authors then independently reviewed the selected articles using the Joanna Briggs Institute appraisal form to extract and generate the themes for the review. FINDINGS: Twenty-four articles were selected for the review. The themes generated included: (i) difficulty orientating; (ii) a longing for what is missing; (iii) professional development and devaluing; (iv) communication barriers; (v) discrimination and marginalization; (vi) personal and professional differences; and (vii) a meaningful support system. IMPLICATIONS FOR POLICY AND PRACTICE: By identifying the challenges faced by international nurses, interventions that ensure equal treatment (e.g. multifaceted transition programmes and culturally sensitive 'buddy' systems) can be implemented to help international nurses adapt to their new environments. Adequate communication can be achieved by encouraging international nurses to speak English and learn the colloquial language and non-verbal behaviours used by native nurses. CONCLUSION: With good integration international nurses may be able to reach their full career potential as professional nurses in their host countries. The adaptation process is a dynamic process that requires effort from both international and native nurses. Thus, any strategies that are developed and implemented must be multifaceted.

Compensatory Hypertrophy After Living Donor Nephrectomy.

BACKGROUND: Previous studies have shown that kidney volume enhances the estimation of glomerular filtration rate (eGFR) in kidney donors. This study aimed to describe the phenomenon of compensatory hypertrophy after donor nephrectomy as measured on computerized tomographic (CT) scans. METHODS: An institutional Domain Specific Review Board (DSRB)-approved study involved approaching kidney donors to have a follow up CT scan from 6 months to 1 year after surgery; 29 patients participated; 55% were female. Clinical chart review was performed, and the patient's remaining kidney volume was measured before and after surgery based on CT scans. eGFR was determined with the use of the Modification of Diet in Renal Disease equation. RESULTS: Mean parenchymal volume of the remaining kidney for this population (mean age, 44.3 ± 8.5 y) was 204.7 ± 82.5 cc before surgery and 250.5 ± 113.3 cc after donor nephrectomy. Compensatory hypertrophy occurred in 79.3% of patients (n = 23). Mean increase in remaining kidney volume was 22.4 ± 23.2% after donor nephrectomy in healthy individuals. Over a median follow-up of 52.9 ± 19.8 months, mean eGFR was 68.9 ± 12.4 mL/min/1.73 m(2), with 24.1% of patients (n = 7) in chronic kidney disease grade 3. Absolute and relative change in kidney volume was not associated with sex, race, surgical approach, or background of hypertension (P = NS). There was a trend of decreased hypertrophy with increasing age (P = .5; Spearman correlation, -0.12). CONCLUSIONS: In healthy kidney donors, compensatory hypertrophy of the remaining kidney occurs in 79.3% of the patients, with an average increment of about 22.4%. Older patients may have a blunted compensatory hypertrophy response after surgery.

A necessary step toward kidney donor safety: the transition from locking polymer clips to transfixion techniques in laparoscopic donor nephrectomy.

Donor safety is of paramount importance in addressing end-stage renal failure through living kidney transplantation. The United States Food and Drug Administration (FDA) issued a Class II recall on the use of Hem-o-lok (Teleflex, Limerick, Pennsylvania, United States) polymer clips on the renal artery in laparoscopic donor nephrectomy (LDN) in June 2006 following 3 reported cases of donor deaths secondary to slipped ligature. The National University Hospital of Singapore made the transition regarding hilar control in minimally invasive donor nephrectomy, from using polymer and titanium clips to transfixion techniques (pure or hand-assisted laparoscopic) via laparoscopic staples or intracorporeal suturing, respectively. This study assessed safety during the transition in arterial transfixion techniques in minimally invasive donor nephrectomy for both donors and recipients. Forty-five consecutive kidney donors underwent donor nephrectomy over a 2-year period starting from June 2010. A total of 37 donors who underwent LDN (pure laparoscopic or hand-assisted laparoscopic) were included in the analysis. Of the 37 patients, 23 kidney donors had renal arterial control using Hem-o-lok while 14 patients from November 2011 onward underwent transfixion of the renal artery. The 2 groups of donor who underwent renal arterial control by either clips ligature or transfixion technique were comparable. The outcomes for the recipients in each group were similar with no statistical difference between postoperative creatinine level, incidence of delayed graft function, or graft survival at 1 year. We conclude that the transition in renal arterial control technique to transfixion techniques in LDN in line with FDA recommendation is feasible and affords equivalent donor and recipient outcomes.

Transradial percutaneous coronary intervention in acute ST elevation myocardial infarction and high-risk patients: experience in a single centre without cardiothoracic surgical backup.

INTRODUCTION: Primary transradial percutaneous coronary intervention (TRI) is shown to be efficacious in stable patients with acute coronary syndrome. We aimed to evaluate the application of primary TRI for acute ST elevation myocardial infarction (STEMI), including among high-risk patients from our registry. METHODS: This was a single-centre case series comprising 138 patients who underwent primary TRI for STEMI between May 2007 and June 2008. TRI was attempted with a 6-Fr guiding catheter in all patients regardless of Killip class status. Outcome measures were success rates of primary TRI, door-to-balloon time, procedure duration and volume of contrast used. All patients were followed up for major adverse cardiac events in-hospital, at 30 days and six months. RESULTS: A total of 138 patients had primary TRI attempted for STEMI. Four patients failed primary TRI and required a femoral approach. The remaining 134 patients underwent primary TRI. The mean patient age was 56.4 years. Most patients with acute STEMI presented in Killip class I and II (91.8 percent). Only 8.2 percent were in Killip class III or IV on admission. 50 percent of patients presented with anterior STEMI. The median door-to-balloon time for this group was 92 (interquartile range [IQR] 77-121) minutes, with a median procedure time of 39 (IQR 29-51) minutes. The success rate of primary TRI was 97.1 percent. CONCLUSION: Success rate, procedural and radiation time for TRI are comparable to those achieved via the femoral approach. Primary TRI is therefore a feasible and effective approach for acute STEMI, even in high-risk patients.

Anterior mediastinal masses: an anaesthetic challenge.

A patient with a large anterior mediastinal mass with minimal respiratory symptoms presented for a diagnostic biopsy of the mass. A pre-operative thoracic computed tomographic scan demonstrated narrowing of the distal trachea, and right and left main stem bronchi. An awake intubation was done. Thiopentone and muscle relaxant were given and surgery commenced. High airway pressure developed and ventilation became difficult, although oxygenation remained satisfactory throughout. Anaesthetic implications are discussed. We recommend that patients with more than 50% obstruction of the airway at the level of the lower trachea and main bronchi have their femoral vessels cannulated in readiness for cardiopulmonary bypass.