Biliary Complications After Single- and Dual-Graft Living-Donor Liver Transplantation Using a Right Posterior Section Graft of Donor with a Type III Portal Vein Variation.

BACKGROUND: When the donor's left lobe volume is <30%, donor selection for the right posterior section graft (RPSG) is based on the type III portal vein (PV) anatomic variation. Herein, we validated the selection of a donor with a type III PV variation for RPSG to prevent biliary complications (BCs) after single-graft (SG) and dual-graft (DG) living-donor liver transplantation (LDLT). METHODS: The clinical data of recipients and donors with a type III PV variation for LDLT using an RPSG performed between January 2004 and June 2018 were retrospectively collected and analyzed to determine the occurrence of BCs. RESULTS: The 26 LDLTs performed using an RPSG, including 20 DG LDLT cases, accounted for 0.6% of all LDLT cases (n=4292). BCs developed in 6 recipients (23.0%), including biliary stricture in 4 (15.3%) and bile leakage in 2 (7.6%). No vascular complications occurred. The RPSG volume was significantly smaller in recipients with BCs than in those without BCs (400.8±79.9 vs 504.1±96.5 mL, P = .015). The bile duct types were A, B, C1, C2, and D in 6 (18.8%), 5 (15.6%), 3 (9.4%), 13 (40.6%), and 5 (15.6%) patients, respectively. All the RPSGs had a single-orifice bile duct. The bile duct size of the RPSG was relatively smaller in recipients with BCs than in those without BCs (2.8±1.0 vs 3.6±1.4 mm, P = .237). CONCLUSIONS: When the left liver volume is disproportionately small, selection of a donor with a type III PV variation can prevent BCs after SG and DG LDLTs using an RPSG.

Transplantation of a Kidney With Duplicated Ureter Harvested From a Donor With Vascular Anomaly in the Form of Double Inferior Vena Cava: A Case Report.

During the organ procurement procedure, a surgeon encounters anatomic anomalies not very often but also not uncommonly. These changes may put the success of the transplant into question. Despite the thorough diagnosis of the potential donor, these anomalies are often diagnosed during organ donation. In our paper we present a case of kidney transplantation with duplicated ureter. The organ was collected from a donor with duplicated inferior vena cava. After transplantation, the kidney functioned immediately. Taking into consideration the well-being of the recipient, organs with anatomic abnormalities should be carefully considered for transplantation. This is especially important when there is a constant shortage of organs for transplantation.

Troubleshooting Complex Vascular Cases in the Kidney Graft: Multiple Vessels, Aneurysms, and Injuries During Harvesting Procedures.

PURPOSE OF THE REVIEW: To update the most relevant literature regarding complex vascular cases in kidney transplant setting involving the graft, especially during the harvesting procedure and back-table preparation from the subsequent implant. RECENT FINDINGS: Challenging situations affecting the kidney graft such as multiple vessels, renal artery aneurysms, kidney anatomical anomalies, or major injuries do not contraindicate the transplant, but require an exhaustive graft viability assessment and several bench surgery techniques. Graft vessel conditioning in the back-table might include simple anastomosis between them, enlarging with venous patch or reconstruction with donor or synthetic grafts. Compared with conventional transplant, literature reports longer warm ischemia time (40 vs 32 min) and slightly increased rates of delayed graft function (10.3% vs 8.2%) and vascular complications (10.8% vs 8.1%), but similar graft and patient survival. Kidney graft vascular complex cases require exhaustive assessment, meticulous harvesting, good surgical technique in the bench table, and proper surgery in the recipient. Despite its complexity, vascular complex kidney transplant offers comparable outcomes in the long term to conventional population when technically well performed, with slightly increased rates of vascular complications and delayed graft function.

Geographic Distribution of Multiple Arteries and Veins of 878 Kidney Donors From a Transplant Center in Turkey.

AIM: The diagnosis and management of multiple renal arteries and veins have gained importance with the increasing number of kidney transplantations and improved techniques in interventional radiology and vascular reconstructions. The aim of this study is to define and to detect the rate of multiple renal arteries and veins in our living kidney transplant donors coming from all parts of our country. METHODS: Abdominal computed tomography angiogram findings of 878 kidney transplant donors were analyzed. The presence and the distribution of multiple renal arteries and veins in donors coming from 7 geographic regions in Turkey were noted. RESULTS: The presence of multiple renal arteries was observed in 34% (48/141) of patients in the Marmara Region, 36.7% (79/215) of patients in the Black Sea Region, 37.2% (64/172) of patients in the Central Anatolia Region and 36.1% (30/83) of patients in the Southeastern Anatolia Region. The highest incidences of multiple renal arteries were observed in the Mediterranean and Aegean regions, affecting 40% (32/80) and 41.9% (26/62) of patients, respectively, while East Anatolia was found to have the lowest incidence, affecting 28% (35/125) of patients. The incidence of multiple renal veins also varied across regions. The highest incidence was observed in the Central Anatolia Region, where 23.3% (40/172) of patients were affected; the lowest was seen in the Aegean Region, where 11.3% (7/62) of patients were affected. In Turkey as a whole, 35.8% (314/878) of patients presented with multiple renal arteries, while the rate of multiple renal veins was found to be 19% (167/878) among our donors. CONCLUSIONS: As 80% of the kidney transplantations performed in Turkey involve living donors, we think it will be useful to have knowledge of not only the presence of multiple renal arteries and veins, but also the distribution of this feature throughout the different regions of the country.

Urologic Complications After Transplantation of Kidneys With Duplicated Ureter: A Retrospective Study.

BACKGROUND: Duplication of ureters is a common anatomic abnormality and occurs in 0.7% to 1% of the general population. In this article we focus on the safety of using of kidneys with complete ureteral duplication, provided no hydronephrosis or ureterocele was present in the donor. METHODS: From 1998 to March 2018 there were 1965 kidneys transplanted at our institution, including 27 kidneys with duplicated ureter, which corresponds to incidence of 1.4%. Patients' medical records, surgery protocols, and Poltransplant registries were searched for urinary complications. RESULTS: In the double ureter group, urologic complications occurred in 4 patients (15.4%). Similarly, severe urinary complications developed in 4 patients from the control group (17.4%). CONCLUSIONS: Transplantation of kidneys with duplicated ureters appears to be a safe and feasible procedure.

Lung Transplant From Donor With Tracheal Bronchus: Case Report and Literature Review.

Donor lung abnormalities are quite rare; one of them is the presence of bronchial anomalies, whose incidence range is from 0.1% to 0.5%. The upper right tracheal bronchus is one of the most frequent anatomic variations. We present a case of successful double lung transplant in a young female patient affected by cystic fibrosis from a donor with upper right tracheal bronchus, emerging 2 rings before the tracheal carina. During implantation of the left lung, we performed a double apical segmentectomy on back table; therefore, the right lung was implanted with the standard technique. Four cases of graft transplant characterized by the presence of tracheal bronchus are reported in the scientific literature; the authors report 4 different technical solutions to tackle the problem of anatomic anomaly. We report the first case of graft segmentectomy at back table suggesting a simple, safe, and time-sparing procedure. In conclusion, provided that the team has sufficient skill in reductive surgery at the back table and the anthropometric data are permissive, we stress the opportunity to downsize the graft in order to minimize anastomotic risks and save time.

Ethical Issues in the Use of Suboptimal Kidneys for Transplants: An Italian Point of View.

The shortage of organs leads to the need for utilizing suboptimal kidneys for transplantation. The distinction between optimal, marginal, and suboptimal kidneys leads surgeons to face not only technical problems but also ethical and legal issues related to clinical advantages offered by the transplant of a nonstandard kidney and the acquisition of consent. Between 1999 and 2015, we performed 658 transplants, 49 (7.5%) using suboptimal kidneys. All patients were alive and with vital graft throughout follow-up. We did not encounter any major surgical complications. From a technical point of view, our experience and literature review confirm that transplant of suboptimal kidney leads to good clinical results but exposes patients to a increased risks of surgical complications. Therefore, these interventions must take place in hospitals fully prepared for this type of surgery and performed by experienced transplant surgeons with proper matching between organ and recipient. Considering the insufficient resources available, from an ethical and legal point of view, doctors play an essential role in optimizing the use of these kidneys by avoiding wastage of organs, ensuring that transplants are done in suitable patients, and that patients are fully informed and aware of the risks and benefits associated with the specific suboptimal kidney being transplanted. We believe that, in highly specialized centers, the number of suboptimal kidney transplants should be increased, as their use has shown good clinical results and carries fewer ethical issues compared with marginal kidneys. Further, suboptimal kidneys may also be proposed for use in young patients with end-stage renal disease.

Arteriovenous Graft for Hemodialysis: Effect of Cryotherapy on Postoperative Pain and Edema.

BACKGROUND: Arteriovenous grafting offers an alternative for patients whose vessels are unsuitable for arteriovenous fistula. However, as a result of subcutaneous tunnel dissection, postoperative pain and edema of the operated limb present early after surgery. As a traditional therapeutic approach, cryotherapy has the ability to suppress postoperative pain and edema. AIMS: The purpose of the study was to investigate the feasibility of cryotherapy after arteriovenous graft surgery to decrease perioperative medication usage. DESIGN: This study was a randomized controlled trial. SETTING: A large integrated health care facility in South China. PARTICIPANTS/SUBJECTS: A total of 85 hemodialysis patients who received arteriovenous graft surgery from March 2011 to February 2017 were enrolled. METHODS: The participants were divided into an intervention group and a control group according to the postoperative management. Ice packs were applied covering the operative forearm for 120 minutes after wound closure in the intervention group. General information, pain score, analgesic consumption, wound inflammation, forearm edema, and participant satisfaction were compared between the two groups. RESULTS: Cryotherapy-treated patients required less analgesia (26.19% vs. 48.84%, p < .05), reported lower pain score from 30 minutes to 48 hours postoperative (p < .05), less wound inflammation (11.90% vs. 25.58%, p < .05), and higher participant satisfaction (8.92 ± 0.57 vs. 6.52 ± 0.63, p < .05), whereas the incidence of forearm edema was equivalent (p > .05). No adverse events were reported in either group. CONCLUSIONS: Cryotherapy is a preferable intervention for patients after arteriovenous graft implantation as a result of its favorable cost, convenience, and fewer side effects.

Anatomical Variants in Renal Transplantation, Surgical Management, and Impact on Graft Functionality.

INTRODUCTION: Chronic kidney disease (CKD) is a priority problem due to its high prevalence. According to the modalities of renal replacement therapy, kidney transplantation (TR) offers to be the best alternative. TR presents multiple factors of dependence of success; among them is the management of the anatomical variants of the graft and the surgical decision on the basis of these. Therefore, the objective of this study is to determine the frequency of variants in the graft, its surgical management, and the impact on the functionality of the transplanted kidney. MATERIAL AND METHODS: This was an observational, retrospective study of patients in the renal transplant unit of the Siglo XXI National Medical Center from 2002-2016. The analysis begins in the description of the population doing bivariate analysis to establish relative risks. For variables with a central tendency, the parametric tests analysis of variance, Student t paired, and unpaired will be used. In the case of nominal variables, the proportion's difference will be estimated using the chi-square test, establishing significance when P is ≤ .05. SPSS 21 software was used. RESULTS: There were a total of 773 patients, with 576 transplants from living donors and 197 from deceased donors. In the case of the artery, a greater number of variants is observed-27.8% being alive versus 17.3% of the variants found in deceased donors. For the renal vein, 12.7% of the kidneys were taken from living donor vs 6.1% from deceased donors. This required one more day of hospitalization (6 vs 7 days of single vs multiple vessels); likewise, increases in immediate post-transplant infections were 5% for single vessels vs 8% in the case of multiple variants. CONCLUSIONS: The importance of knowing the anatomical variants prior to the TR allows them to plan the potential surgical maneuvers, decreasing the times aimed at improving the immediate functionality of the renal graft, while also considering the increase in hospital expenses due to the greater number of days of hospitalization.

Vascular Graft Infection: Incidence and Potential Risk Factors.

PURPOSE: The purpose of this study was to identify factors that increase the risk of vascular graft infections (VGI) in patients following abdominal or lower extremity revascularization surgery. DESIGN: Retrospective, descriptive study. METHODS: We reviewed the electronic health records of 223 patients who had undergone abdominal or lower extremity revascularization procedures from July 2012 to November 2014, looking for factors associated with VGI. We reviewed 28 preoperative, intraoperative, and post-operative factors. Descriptive statistics (mean, range, and standard deviation) were used to describe the sample; χ was used to determine correlations between the risk factors and subsequent VGIs. The level of significance was determined at P = .05, with a confidence level of 95%. RESULTS: We identified 33 cases of VGIs for the 223 charts reviewed, yielding an incidence rate of 15%. Seventeen of the 33 patients with VGI (51.5%) were male. The average age of patients who experienced VGI was 60.9 years (standard deviation, 12.2 years, range, 29-81 years). Preoperative factors that were shown to show statistical significance for the development of VGI were sequential procedures (P = .003), diabetes mellitus (P = .002), hemoglobin A1c more than 7.0 (P = .0002), blood glucose more than 180 mg/dL (P = .0006), and lack of mobility (0.0097). Intraoperative factors associated with VGI were hemostatic agents applied to the surgical field intraoperatively (P = .003) and perioperative hypoxemia (P = .027). Postoperative factors associated with VGI were discharge from the hospital to skilled nursing facility or acute rehabilitation facility (P = .005) and unscheduled clinic visits (P = .008). CONCLUSION: We measured a 15% incidence of VGI and identified multiple pre-, intra-, and postoperative associated factors. Vigilance is required to prevent VGI and knowledge of specific risk factors is important.

Living-Donor Liver Transplantation With the Use of a Left-Lobe Graft From a Donor With Anomalous Biliary Anatomy in Which B4 Joins the Right Anterior Sectional Duct: A Case Report.

When there is an anatomic anomaly in the biliary tract of the donor for living-donor liver transplantation, the risk of postoperative biliary tract complications increases in both the donor and the recipient. We studied a case of living-donor liver transplantation with a left hepatic lobe graft that had anatomic anomalies, in which the medial segmental branch (B4) joined the anterior segmental branch and the posterior segmental branch formed a common trunk with the lateral segmental branch. A 40-year-old man visited our institution as a candidate organ donor for his mother, who had end-stage liver failure. An anomaly of B4 connecting the anterior segmental branch was suspected on magnetic resonance cholangiopancreatography. On intraoperative cholangiography, confluence of B4 with the anterior segmental branch and connection of the posterior and lateral segmental branches forming a common trunk were confirmed. Accordingly, individual anastomoses of the lateral segmental branch and B4 with the recipient jejunum were planned, and a left-lobe graft was excised. The postoperative recovery was smooth, and the donor was discharged with no complications. Even when an anatomic anomaly is present in the donor bile duct, in urgent cases, accurate evaluation through the use of various modalities may enable living-donor liver transplantation with the use of a graft with an anatomic anomaly.

Queratoplastia endotelial automatizada con pelado de membrana de Descemet (DSAEK). Revisión sistemática sobre efectividad y seguridad / Descemet's stripping automated endothelial keratoplasty (DEAEK). Systematic review of clinical-effectiveness and safety

OBJETIVOS: Realizar una revisión sistemática sobre la eficacia/efectividad, seguridad y costes de la queratoplastia endotelial automatizada con pelado de la membrana de Descemet (DSAEK) en pacientes con fracaso endotelial corneal. MÉTODO: Búsqueda exhaustiva de la bibliografía en las principales bases de datos biomédicas entre enero y mayo de 2012. RESULTADOS: De 485 artículos localizados se incluyeron 16 series de casos y un estudio de coste-efectividad. Se observó una mejoría tras la intervención en la agudeza visual corregida y sin corregir, alcanzándose valores de 0,6 a 0,8 y de 0,5 respectivamente. El astigmatismo no fue significativo en relación con los valores basales. Las principales complicaciones fueron la dislocación-desprendimiento del injerto (1,5-23%), el fracaso primario (0-12%) y el rechazo endotelial (0,8-8,5%). CONCLUSIONES: En la distrofia de Fuchs y en la queratopatía bullosa, la DSAEK mejora la agudeza visual corregida y sin corregir en relación con los valores preintervención. El astigmatismo originado tras la DSAEK no fue significativo. Las complicaciones más importantes están relacionadas con la viabilidad del injerto, siendo la más frecuente la dislocación-desprendimiento y en menor medida el rechazo endotelial. Los estudios que evalúan la DSAEK son series de casos, en su mayoría retrospectivas. La calidad de este tipo de trabajos no es elevada y presenta limitaciones

OBJECTIVE: To conduct a systematic review of the efficacy/effectiveness, safety and cost of Descemet's stripping automated endothelial keratoplasty (DSAEK) technique in patients with corneal endothelial failure. METHODS: Comprehensive literature search conducted in the main biomedical databases from January-May 2012. RESULTS: Following a critical perusal of the total of 485 abstracts retrieved, 16 case series and one economic evaluation study were included. Corrected distance visual acuity and uncorrected distance visual acuity improved after treatment with DSAEK, attaining values of 0.6 to 0.8 and 0.5 respectively. The degree of post-DSAEK astigmatism was not significant with respect to baseline values. The main complications were graft dislocation-detachment (1.5-23%), primary failure (0-12%) and endothelial rejection (0.8-8.5%). CONCLUSIONS: In Fuchs' dystrophy and bullous keratopathy, data on the effectiveness of DSAEK indicate post-intervention improvement in uncorrected and corrected distance visual acuity. Astigmatism arising after DSAEK was not significant. The most significant post-DSAEK complications are linked to the viability of the graft, with the most frequent complications being dislocation-detachment and, to a lesser extent, endothelial rejection. The studies that assess DSAEK are case series, and for the most part retrospective. The quality of this type of studies is both low and limited

Injertos y colgajos en pacientes sometidos a quimio o radioterapia: son seguros?: revisión de la literatura / Is it safe do grafts or flaps in a patient being treated with chemotherapy or radiation therapy?: literature review

Es conocido que la radiación ha sido asociada a una cicatrización disminuida de las heridas, necrosis grasa y decoloración. La quimioterapia, por otra parte, se ha descrito con efectos adversos como infección, necrosis, contractura o deformación de los colgajos. Los antecedentes previos son los causantes de cierta confusión al enfrentar pacientes oncológicos que durante su evolución requieren solucionar defectos de piel y tejidos blandos: es seguro realizar injertos o colgajos en un paciente que está siendo tratado con quimio o radioterapia? Por medio de la revisión de la literatura publicada buscamos dar respuesta a esta interrogante.

It is known that the radiation has been associated with decreased wound healing, fat necrosis and bleaching. Chemotherapy, on the other hand, has been described with side effects as infection, necrosis, contraction or deformation of the flaps. The previous history are causing some confusion that may arise when facing cancer patients that during their evolution require fix skin and soft tissue defects: is it safe do grafts or flaps in a patient being treated with chemotherapy or radiation therapy? Through the review of the published literature we seek to answer this question.