Renal transplantation remains the optimal treatment for end stage renal disease. Compared with dialysis, it is associated with increased patient survival and better quality of life, and is cost effective. Kidney transplantation requires a multi-disciplinary approach in the pre-operative assessment and work-up of donors and recipients, and subsequent post-operative care. The classical surgical procedure for renal transplantation has changed little from the original pelvic operation originally described in 1951, but the surgical complexity however has been magnified by the increasing age of recipients, frequently with other comorbidities, and impetus to utilise kidneys from extended criteria donors, either as single or dual transplants. There have also been tremendous advances in the technical aspects of live-donation. This chapter details the surgical aspects of kidney donation and transplantation, including preparation of the graft, vessel reconstruction, urinary drainage and identification and management of post-donation and transplantation complications. It is hoped the reader is provided with a comprehensive account of the technical aspects of renal transplantation, with a description of variation in procedure based on anatomical aberrations. An overview of current practise with a look to the future is provided.
Optimizing postoperative pain control is an important aspect in perioperative patient care. The aim of this study was to investigate the efficacy of preincision local anesthetic infiltration in postoperative pain management for thyroid surgery and its relationship to bruising and wound cosmesis. In a randomized single-blinded study, 39 consecutive patients listed for thyroid surgery were assigned into two groups. Group I (n = 19) received subcuticular preincision infiltration with 10 ml of bupivacaine (0.5%) and Group II (n = 20) received no infiltration. Postoperatively, the pain experienced was evaluated by two methods: verbal response scores and linear analogue scores (0–100 mm) at different time intervals following surgery. Bruising and cosmetic effects resulting from surgery were assessed using a linear analogue score at discharge. The two groups were well matched for confounding variables. Pain scores were significantly different at 6 hours post operatively (p = 0.0341) with mean scores Group I = 33 and Group II = 50, but this difference disappeared at 24 hours. No patients (0%) received IV morphine in Group I compared to 5 patients (25%) in Group II. There was no significant difference in the mean bruising scores (p = 0.8864) and mean cosmetic scores (p = 0.3339) at discharge. Preincision infiltration with bupivacaine provides easy and better analgesic control postoperatively in patients following thyroid surgery with no effects on bruising or wound cosmesis.
Tunnelled dialysis catheters (TDCs) are key as an interim for haemodialysis until an atrio-venous fistulae matures. Repeated ultrasound-guided insertion of medical TDCs causes stenosis of the vein warranting a surgical cut-down. In these narrow veins, a single cut-down renders them no longer suitable for further use. We devised a method permitting repeated insertions using the omohyoid muscle as a marker. The TDC can be initially inserted above the muscle (I), followed by dividing the muscle (II) and finally below this muscle (III) as shown in Figure 1. In our experience, this permits repeated successful insertions, as the next re-insertion is centrally more proximal to the previous insertion away from the stenosis.
Figure 1
Diagram illustrating proposed technique.
A prospective study aimed at assessing the effect of introduction of a fast-tract referral system for patients with suspected breast cancer and the quality of GP referrals in Barnsley.Between February and April 2001, 70 consecutive patients with symptomatic breast disorders were seen in the fast-access breast clinic. Mean age=46 years (range 18-84). Ten non-urgent referrals seen in the study period were included in the analysis to determine the appropriateness of such referrals. Three screening criteria were used to select high-risk patients and data were recorded prospectively. Patients were classified as urgent, soon or routine based on symptomatology.Of the 70 patients seen, 20 were considered as urgent, 20 as soon and 30 as routine. Forty patients were seen within the '2-week wait' period. Twelve were classified on clinical grounds as malignant. Mean waiting time to see the GP was 2.2 days. Mean waiting time to see the specialist breast surgeon was 6.6 days.A fast-track system for suspected breast cancer has led to a significant reduction in the time to diagnosis and initiation of a definitive treatment, with most made within 2 weeks. Fast-track referrals is not appropriate in all cases.
Introduction:The inhibitory Fc receptor, FcγRIIb, regulates innate and adaptive immunity by inhibiting activation of myeloid and B cells.The role of FcγRIIb in transplantation has not yet been studied.Methods: Acute and chronic cardiac allograft rejection were investigated using the BALB/c (H-2 d ) to Bl/6 (H-2 b ) and bm12 to Bl/6 (MHC class II-mismatched) mouse models and survival compared to FcγRIIb -/-Bl/6, and transgenic Bl/6 recipients bearing increased FcγRIIb on their macrophages (MPTG) or B cells (BTG).We have previously shown that bm12 heart graft rejection is characterised by chronic allograft vasculopathy with the development of antinuclear autoantibody (quantified by staining HEp-2 cells).In the acute model, alloantibody was assayed using ELISA and cytotoxic CD8 T cell responses by IFNγ ELISPOT.Results: WT Bl/6 mice rejected bm12 hearts slowly (MST = 95d, n = 13), while rejection in FcγRIIb -/-recipients occurred rapidly (MST = 28d, n = 8) and was associated with augmented graft vasculopathy and autoantibody responses.In contrast, BTG and MPTG mice had delayed bm12 heart graft rejection, suggesting that accelerated rejection in FcγRIIb -/-mice is due to loss of inhibitory signalling on both B cells and macrophages.In the acute model, FcγRIIb -/-recipient mice rejected BALB/c heart grafts at the same tempo (MST = 7d, n = 6), and with similar alloantibody and cytotoxic CD8 T cell responses, as WT recipients.Conclusions: FcγRIIb plays a role in chronic but not acute allograft rejection.Polymorphisms in FcγRIIb gene expression exist in humans and are thus likely to influence allograft survival.FcγRIIb is a potential target for immunomodulation in clinical transplantation.Take-home message: The inhibitory Fc receptor, FcγRIIb, regulates innate and adaptive immunity by inhibiting activation of myeloid and B cells.My work has demonstrated that FcγRIIb appears to play a role in chronic but not acute allograft rejection.FcγRIIb is therefore a potential target for immunomodulation in clinical transplantation.
Abstract The Annual Scientific Meeting of the Association of Surgeons of Great Britain and Ireland takes place this year at the Scottish Exhibition and Conference Centre, Glasgow, UK (13th–15th May 2009), under the presidency of Professor Michael Horrocks.
Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.
<b><i>Background:</i></b> Ischaemia-reperfusion injury (IRI) remains one of the leading causes of acute kidney injury (AKI). IRI is an underlying multifactorial pathophysiological process which affects the outcome in both native and transplanted patients. The high morbidity and mortality associated with IRI/AKI and disappointing results from current available clinical therapeutic approaches prompt further research. Stem cells (SC) are undifferentiated cells that can undergo both renewal and differentiation into one or more cell types which can possibly ameliorate IRI. <b><i>Aim:</i></b> To carry out a detailed literature analysis and construct a comprehensive literature review addressing the role of SC in AKI secondary to IRI. <b><i>Methods:</i></b> Evidence favouring the role of SC in renal IRI and evidence showing no benefits of SC in renal IRI are the two main aspects to be studied. The search strategy was based on an extensive search addressing MESH terms and free text terms. <b><i>Results:</i></b> The majority of studies in the field of renal IRI and stem cell therapy show substantial benefits. <b><i>Conclusions:</i></b> Studies were mostly conducted in small animal models, thus underscoring the need for further pre-clinical studies in larger animal models, and results should be taken with caution. SC therapy may be promising though controversy exists in the exact mechanism. Thorough scientific exploration is required to assess mechanism, safety profile, reproducibility and methods to monitor administered SC.
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)