ABSTRACT
INTRODUCTION: Delayed graft function (DGF) remains a significant and detrimental postoperative phenomenon following living-related renal allograft transplantation, with a published incidence of up to 15%. Early therapeutic vasodilatory interventions have been shown to improve DGF, and modifications to immunosuppressive regimens may subsequently lessen its impact. This pilot study assesses the potential applicability of perioperative non-invasive cardiac output monitoring (NICOM), transit-time flow monitoring (TTFM) of the transplant renal artery and pre-/perioperative thromboelastography (TEG) in the early prediction of DGF and perioperative complications. METHODS: Ten consecutive living-related renal allograft recipients were studied. Non-invasive cardiac output monitoring commenced immediately following induction of anaesthesia and was maintained throughout the perioperative period. Doppler-based TTFM was performed during natural haemostatic pauses in the transplant surgery: immediately following graft reperfusion and following ureteric implantation. Central venous blood sampling for TEG was performed following induction of anaesthesia and during abdominal closure. RESULTS: A single incidence of DGF was seen within the studied cohort and one intra-operative (thrombotic) complication noted. NICOM confirmed a predictable trend of increased cardiac index (CI) following allograft reperfusion (mean CI - clamped: 3.17 ± 0.29 L/min/m(2), post-reperfusion: 3.50 ± 0.35 L/min/m(2); P < 0.05) mediated by a significant reduction in total peripheral resistance. Reduced TTFM at the point of allograft reperfusion (227 ml/min c.f. mean; 411 ml/min (95% CI: 358 to 465)) was identified in a subject who experienced intra-operative transplant renal artery thrombosis. TEG data exhibited significant reductions in clot lysis (LY30 (%): pre-op: 1.0 (0.29 to 1.71), post reperfusion 0.33 (0.15 to 0.80); P = 0.02) and a trend towards increased clot initiation following allograft reperfusion. CONCLUSIONS: Reduced renal arterial blood flow (falling without the 95% CI of the mean), was able to accurately predict anastomotic complications within this pilot study. TEG data suggest the emergence of a prothrombotic state, of uncertain clinical significance, following allograft reperfusion. Abrogation of characteristic haemodynamic trends, as determined by NICOM, following allograft reperfusion may permit prediction of individuals at risk of DGF. The findings of this pilot study mandate a larger definitive trial to determine the clinical applications and predictive value of these technologies.
ABSTRACT
INTRODUCTION: Transhiatal oesophagectomy is a widely accepted technique for resection of tumours of the lower oesophagus. We present a life-threatening complication associated with the placement of a corrugated neck drain during this procedure. PRESENTATION OF CASE: Our patient underwent a transhiatal oesophagectomy for a lower oesophageal tumour. He developed persistent bilateral pneumothoraces despite chest drain insertions. Following removal of the corrugated neck drain, both lungs were successfully re-inflated. DISCUSSION: To the authors' knowledge, this serious complication has been described only once before in the medical literature; other surgeons should be made aware of this problem. CONCLUSION: Alternative drainage systems should be considered to help prevent this injury. Exercise caution if positioning corrugated drains in the neck.
ABSTRACT
The aim of this study was to determine the incidence of common bile duct (CBD) calculi patients undergoing laparoscopic cholecystectomy (LC) without routine intraoperative cholangiography (IOC) and the usefulness of risk stratification in guiding appropriate biliary tract imaging. Five hundred forty consecutive LCs were performed during the 12-month study period. Four hundred fifty-eight (84.8%) patients with low risk of CBD stones proceeded immediately to LC. Forty-four (8.1%) high-risk patients underwent endoscopic retrograde cholangiopancreatography (ERCP). Thirty-four (6.3%) moderate risk patients underwent magnetic resonance cholangiopancreatography. Four (0.7%) patients had an equivocal risk with 2 undergoing IOC. The preoperative incidence of CBD stones was 29/540 (5.4%), while 11 patients (2.04%) were readmitted with retained CBD calculi and underwent successful stone extraction with ERCP. The incidence of retained CBD calculi after LC without IOC is low. Risk stratification helps to accurately predict CBD stones and facilitates appropriate and cost-effective use of ERCP and magnetic resonance cholangiopancreatography.
