Urologic complications in more than 2500 kidney transplantations performed at the Saint Barnabas healthcare system.

We report our urologic complications based on one urologist's experience during a 17-year period on more than 2500 ureteral reimplantation operations performed at the time of kidney transplant. Among 2548 ureteroneocystostomies performed by the transplant urologist, a 5.5% urologic complication rate was observed. This included vesicoureteral reflux (3%), ureteral strictures (1.3%), urine leak (0.9%), and uteropelvic junction obstruction (0.3%). The factors for low urologic complication rates include the use of a shorter segment of ureter using the Lich-Gregoir technique (compared to the Politano-Leadbetter technique) and the routine use of indwelling stents. In addition, having one transplant urologist performing all ureteral reimplantations and managing all urologic complications provided consistency in results.

Appendicitis in pregnancy.

Appendicitis continues to be the most common nonobstetric surgical diagnosis in pregnancy. Historically, this diagnosis has been associated with an increased risk of fetal loss as well as maternal morbidity. The physiologic and anatomic changes in pregnancy have been thought to obscure and thus delay the diagnosis of acute appendicitis, contributing to its increased risk in pregnancy. Such increased risks have been well reported in literature. To further evaluate the overall incidence, to determine the factors contributing to delay in diagnosis, and to assess overall outcomes in appendicitis in pregnancy, we performed a retrospective contemporary evaluation of pregnant patients with the diagnosis of acute appendicitis during the period 1991-1998. Twenty-two patients had the combined admitting diagnoses of pregnancy and acute appendicitis among 44,845 deliveries for the same time period (incidence, 0.05%). Gestational stage at diagnosis was the first trimester in 5 patients (22%), second trimester in 6 patients (27%), and third trimester in 11 patients (50%). Nineteen patients (86%) had pathologically proven acute appendicitis. Sixteen patients (73%) presented with less than 24 hours of abdominal symptoms. Seventeen patients (77%) presented with findings of rebound and guarding on initial physical examination. Fifteen patients (68%) were taken to the operating room within 24 hours of presentation. Of these, 10 patients (68%) had acute perforated appendicitis. Overall, there were 12 cases of perforated appendicitis (55%), which is an incidence higher than what has been reported in literature. There were no instances of fetal mortality. Preterm labor occurred in 5 patients, all in their third trimester with perforated appendicitis. Our study found that our population paralleled the incidence of gestational appendicitis of 0.05-0.07 per cent; physical examination on presentation was the most reliable diagnostic tool for appendicitis; and there is a higher incidence of perforation with increased gestational age, which does not result in increased fetal mortality.

Basal cell carcinoma of the penis.

We report the case of an 87-year-old man with basal cell carcinoma (BCC) of the penis. Treatment was by excisional biopsy and there was no recurrence after thirty-four months. Although BCC is a common skin tumor, it rarely occurs on the penis. A review of the literature shows that most penile BCCs occur on the shaft in older men, have been present for more than a year, and are successfully treated with excisional biopsy. This is the nineteenth reported case of BCC of the penis and represents the oldest patient reported to date.

Increasing accuracy in the diagnosis of acute appendicitis with modern diagnostic techniques.

One hundred consecutive patients admitted to the hospital with the prospective diagnosis of appendicitis were evaluated retrospectively to determine the effect of the use of modern diagnostic techniques upon the accuracy of preoperative diagnosis. Appendectomy was performed on 48 patients. In three of these patients, the diagnostic process was assisted by the use of radiologic or ultrasound techniques. Of the 52 patients who did not undergo appendectomy, 13 patients clearly avoided surgery or were steered towards an other appropriate operative procedure due to findings on ultrasound or barium enema. Ultrasound was particularly useful in differentiating the etiology of right lower quadrant pain in the childbearing aged female. This study demonstrates that the traditionally expected 15% normal appendix rate can be narrowed (6.25% in this group of patients) without increasing morbidity, with the use of sophisticated diagnostic techniques in the evaluation of selected patients who present diagnostic dilemmas.

A technique for removal of difficult stones of the common duct using the choledochoscope and biliary Fogarty catheter.

In our experience with several difficult instances, stones have been successfully retrieved where traditional methods had failed. The importance of this technique lies not only in less perioperative morbidity and frustration than when blind instrumentation is used, but also obviates the need for duodenotomy and sphincteroplasty.

Subclavian cannulation. Valuable dialysis access alternative.

The subclavian vein was used for temporary dialysis access in 67 patients. There were 733 dialysis treatments performed using a total of 87 catheters during the study period. The catheters were left in place for an average of 24.5 days per patient and 18.9 days per catheter. A mean of 10.9 dialysis treatments per patient, and 8.4 dialysis treatments per catheter were performed. Seven patients expired with their catheters indwelling. None of these deaths were related to the catheter. There were 21 associated catheter complications. Twelve of these catheter complications were corrected by changing the catheter over a guide wire. The technique for catheter insertion, proper catheter care including home care, and complications due to the catheters are discussed. Subclavian catheter dialysis access appears to be a valuable adjunct for dialysis and has replaced the use of Scribner shunts and repeated femoral catheterizations for temporary access in our institution.

Digital dermatoglyphics and breast cancer.

Fingerprints of one hundred nineteen Caucasian females were obtained. Of these females, thirty-four had histologically proven breast cancer, fifty-three were at high risk for development of breast cancer, and thirty-two comprised a control group. The digital pattern frequencies and the pattern intensity index were significantly different between the three groups. The presence of six or more whorls appears significant as noted by 32.4% of breast cancer patients possessing this number of whorls as compared to 3.1% controls. Also of note is that 95% of subjects with six or more whorls either had cancer or were at high risk.

Instant nutritional assessment in the intensive care unit.

Instant nutritional assessment of the critically ill patient using serum albumin level and total lymphocyte count is reported. When an intensive care unit population is compared to the general hospital population a 6-fold increase in albumin level depressions, a 2-fold increase in lymphocyte count depression, and an 11-fold increase in depression of both parameters was noted in the intensive care unit population. Surgical intensive care unit (SICU) patients with depressed albumin levels and total lymphocyte counts had twice the complication rate and 4.5 times the death rate of those SICU patients with normal albumin levels and lymphocyte counts. It is concluded that serum albumin levels and total lymphocyte count determinations are valuable tools for instant nutritional assessment of the critically ill patient.

Instant nutritional assessment.

Instant nutritional assessment of the hospitalized patient is described based upon admission serum albumin levels and total lymphocyte counts. Abnormalities of these parameters are associated with markedly increased morbidity and mortality in a series of 500 consecutively admitted patient. It is suggested that instant nutritional assessment be performed on all hospitalized patients with appropriate alterations and therapy being made to allow for nutritional repletion.

Gas-producing clostridial and nonclostridial infections.

Clostridial infections have always been treated promptly and aggressively on the basis of history and Gram's strain. We believe that nonclostridial infections with similar fulminating, septic courses also should receive as prompt and radical treatment and perhaps more so, as hyperbaric oxygen therapy is of far less benefit in a nonclostridial infection. It is particularly important to treat the high risk, obese, patient with diabetes and an infection of the perineum or groin promptly and aggressively if the current, high morality is to be decreased.

Ruptured abdominal aneurysms presenting with unilateral peripheral neuropathy.

Neurologic deficits uncommonly occur following successful aortic surgery for aneurysm. Two cases are presented in which peripheral neuropathy precipitated the diagnosis of ruptured aneurysm. Both patients had large retroperitoneal hematomas at operation, and the neuropathy was due presumably to compression of the femoral and obturator nerves. Neither patient has shown significant improvement in function in the affected muscles after operation. This represents an important diagnostic sign with leaking or ruptured abdominal aortic aneurysm.