Arnoud Gerardus Peppelenbosch

Acute ischemic injury to the renal microvasculature in human kidney transplantation

Increased understanding of the pathophysiology of ischemic acute kidney injury in renal transplantation may lead to novel therapies that improve early graft function. Therefore, we studied the renal microcirculation in ischemically injured kidneys from donors after cardiac death (DCD) and in living donor kidneys with minimal ischemia. During transplant surgery, peritubular capillaries were visualized by sidestream darkfield imaging. Despite a profound reduction in creatinine clearance, total renovascular resistance of DCD kidneys was similar to that of living donor kidneys. In contrast, renal microvascular perfusion in the early reperfusion period was 42% lower in DCD kidneys compared with living donor kidneys, which was accounted for by smaller blood vessel diameters in DCD kidneys. Furthermore, DCD kidneys were characterized by smaller red blood cell exclusion zones in peritubular capillaries and by greater production of syndecan-1 and heparan sulfate (main constituents of the endothelial glycocalyx) compared with living donor kidneys, providing strong evidence for glycocalyx degradation in these kidneys. We conclude that renal ischemia and reperfusion is associated with reduced capillary blood flow and loss of glycocalyx integrity. These findings form the basis for development of novel interventions to prevent ischemic acute kidney injury.

Tubular epithelial injury and inflammation after ischemia and reperfusion in human kidney transplantation.

Objective:To provide an integrated insight into the kinetics of tubular injury, inflammation, and oxidative stress after human kidney transplantation. Background:Tissue injury due to ischemia and reperfusion is an inevitable consequence of kidney transplantation. Tubular epithelial injury, inflammation, and oxidative stress play major roles in the pathophysiology of acute kidney injury in small animals, but it remains to be established whether this paradigm holds true for human kidney transplantation. Methods:Markers of tubular injury, inflammation, and oxidative stress were compared between recipients of kidneys from donors after cardiac death (DCD; N = 8) with prolonged ischemia and recipients of living donor kidneys with minimal ischemia (N = 8). Results:In the early postoperative period, creatinine clearance and tubular sodium reabsorption were profoundly reduced in DCD kidneys, coinciding with significantly increased urinary concentrations of tubular injury markers (neutrophil gelatinase-associated lipocalin, N-acetyl-&bgr;--glucosaminidase, and cystatin C) and an 18-fold increase in renal production of cytokeratin-18, indicating extensive necrotic cell death. Tubular injury in DCD kidneys was followed by greater systemic inflammatory activity and oxidative stress in the postoperative period (measured with 17-plex cytokine arrays and as plasma F2-isoprostanes, respectively). In contrast, no evidence of oxidative damage to either of the 2 kidney types was found in the early reperfusion period. Conclusions:These findings establish the relevance of observations in animal models for human kidney transplantation and form the basis for development of novel therapies to improve early graft function and expand the use of donor kidneys with prolonged ischemia.

Peritoneal dialysis catheter placement technique and complications

Background. This review describes the peritoneal dialysis (PD) catheter implantation techniques for the treatment of PD. The PD catheter-related complications still cause significant morbidity and mortality, resulting in the necessity to switch to haemodialysis (HD) treatment. Methods. Several catheter insertion techniques, using an open surgical approach, laparoscopic and percutaneous techniques have been employed, with their specific early and late complications and failure rates. Results. Despite the similar outcomes of open surgical versus laparoscopic techniques from randomized studies, the laparoscopic insertion has the major advantage of correct catheter positioning in the lower abdomen, with the possibility of adhesiolysis. The minimal invasive percutaneous insertion bears the risk of bowel perforation and catheter malpositioning, and the outcome of this technique is strongly related to the experience of the surgeon. The major complications of these implantation techniques, like bleeding, dialysate leakage and catheter malpositioning, and their management are discussed in our study. Late peritonitis remains the major drawback of PD treatment, with the need of temporary or permanent changeover to the HD treatment in 10% of the patients. Conclusions. Enrichment of the physicians interest and experience, along with a multidisciplinary approach to outline the optimal strategy of PD-catheter insertion and complication of the treatment, may improve the patients’ survival and decrease the morbidity.

Q fever (Coxiella burnetii) causing an infected thoracoabdominal aortic aneurysm

We report a patient, which we believe is the first, with a thoracoabdominal aortic aneurysm, Crawford type IV, caused by Q fever (Coxiella burnetii). Treatment consisted of antibiotic therapy started preoperatively and continued postoperatively and an open repair, including resection of the infected aneurysm, replacement with a rifampin-soaked polyester graft, and an omental wrap covering the grafts. After 13 months of follow-up, the patient had no signs of infection, and results of laboratory findings were normal.

Ultrasound-guided central venous catheter placement by surgical trainees: a safe procedure?

Background Central venous catheters (CVCs) are widely used to create a temporary or long-term access to the central venous system. A variety of treatments require a functional central venous access, including hemodialysis, administration of drugs, plasmapheresis and parenteral nutrition. The aim of this study was to evaluate the results of CVC placement performed by surgical trainees, according to a strict protocol of ultrasound-guided puncture and fluoroscopy-guided catheter insertion in a large teaching hospital in an outpatient setting. Methods Between 1 January 2006 and 31 December 2008, 539 CVCs were placed, of which 486 were primary inserted by surgical trainees. All placements were ultrasound- and fluoroscopy-guided. After every placement operators recorded type of catheter, type of anesthesia, subcutaneous tunneling, technique of insertion and complications. Results The study population consisted of 52% males. Access sites of CVCs were the internal jugular vein (91%), subclavian vein (5%) and other veins (3%). Technical success rate was 96.5%. Complication rate was 8.4%, of which 93% were arterial punctures. Pneumothorax occurred in three patients. Conclusions CVC placement by surgical trainees is a safe procedure when using a strict protocol of ultrasound-guided vessel puncture and fluoroscopic-guided catheter placement.

Revision techniques for failed PD catheters: outcome in a University Hospital

Purpose A disfunctioning peritoneal dialysis (PD) catheter has been reported in upto 35%. We report different salvage techniques used and its outcome. Methods We retrospectively reviewed our database on PD patients from 2009 to 2014. Operational data and data on PD catheter function were checked. Results From 2009 to 2014, we operated on 32 patients. Malfunction of their PD catheter was found in 23 patients and hernias in nine patients. Different laparoscopic techniques were used, including reposition of the catheter, fixation of the catheter, removal of adhesions and omentectomy. Of these 23 patients, 18 (78%) had a normal functioning catheter after the operation. Nine patients of the total of 32 patients had a correction of their hernia. In all cases, a non-absorbable mesh was used. Of those nine patients with a hernia, eight (89%) had a normal functioning catheter after the procedure. Conclusions The salvage of the catheter by means of a laparoscopic procedure or correction of a hernia is worthwhile and can save up to 81% of the catheters.

Open Thoracic and Thoraco-abdominal Aortic Repair in Patients with Connective Tissue Disease

Retrospective cross-border, single centre study February 2000 to April 2016 72 aortic operations on 65 patients with CTD 41 male, median age 41 years [range 19–70 years] 56 patients (86%) with previous aortic repair (71 open, 4 endovascular) 33 patients (51%) operated before at the site of the procedure reported here Procedures: 8 emergency operations (11%) Aortic arch revision (n = 1; 1%) Descending thoracic aortic repair (n = 11; 15%) TAAA type I repair (n = 12; 17%), Type II repair (n = 29; 40%) Type III repair (n = 12; 17%) Type IV repair (n = 5; 7%). Ascending aorta and/or the aortic arch (n = 2; 3%) and (n = 8; 11%) 7 patients (10%) underwent staged procedures Median follow-up: 42 months (0.5–180 months)

Randomized Controlled Trial Comparing Open Versus Laparoscopic Placement of a Peritoneal Dialysis Catheter and Outcomes: The CAPD I Trial

Objective: To determine the best operation technique, open versus laparoscopic, for insertion of a peritoneal dialysis (PD) catheter with regard to clinical success. Clinical success was defined as an adequate function of the catheter 2 – 4 weeks after insertion. Methods: All patients with end-stage renal disease who were suitable for PD and gave informed consent were randomized for either open surgery or laparoscopic surgery. A previous laparotomy was not considered an exclusion criterion. Laparoscopic placement had the advantage of pre-peritoneal tunneling, the possibility for adhesiolysis, and placement of the catheter under direct vision. Catheter fixation techniques, omentopexy, or other adjunct procedures were not performed. Other measured parameters were in-hospital morbidity and mortality and post-operative infections. Results: Between 2010 and 2016, 95 patients were randomized to this study protocol. After exclusion of 5 patients for various reasons, 44 patients received an open procedure and 46 patients a laparoscopic procedure. Gender, age, body mass index (BMI), hypertension, current hemodialysis, severe heart failure, and previous an abdominal operation were not significantly different between the groups. However, in the open surgery group, fewer patients had a previous median laparotomy compared with the laparoscopic group (6 vs 16 patients; p = 0.027). There was no statistically significant difference in mean operation time (36 ± 24 vs 38 ± 15 minutes) and hospital stay (2.1 ± 2.7 vs 3.1 ± 7.3 days) between the groups. In the open surgery group 77% of the patients had an adequate functioning catheter 2 – 4 weeks after insertion compared with 70% of patients in the laparoscopic group (p = not significant [NS]). In the open surgery group there was 1 post-operative death (2%) compared with none in the laparoscopic group (p = NS). The morbidity in both groups was low and not significantly different. In the open surgery group, 2 patients had an exit-site infection and 1 patient had a paramedian wound infection. In the laparoscopic group, 1 patient had a transient cardiac event, 1 patient had intraabdominal bleeding requiring reoperation, and 1 patient had fluid leakage that could be managed conservatively. The survival curve demonstrated a good long-term function of PD. Conclusion: This randomized controlled trial (RCT) comparing open vs laparoscopic placement of PD catheters demonstrates equal clinical success rates between the 2 techniques. Advanced laparoscopic techniques such as catheter fixation techniques and omentopexy might further improve clinical outcome.

Unusual Exit Site of a Migrated Peritoneal Dialysis Catheter

Editor: A 68-year-old man presented to our peritoneal dialysis (PD) unit with a foreign object protruding from his anus. One year before, a PD catheter had been laparoscopically inserted for post-renal end-stage kidney disease. The surgery and postoperative course were uneventful, but dialysis was not started because renal function improved after desobstruction measures. The patient denied abdominal complaints, and a physical examination revealed no abnormalities except for the PD catheter protruding 2 cm from the anal sphincter (Figure 1). An abdominal radiograph showed the PD catheter elongated downward in the pelvis toward the anal sphincter (Figure 2). Under prophylactic antibiotic coverage, surgical removal of the catheter was performed by pulling, without opening the abdominal cavity. After careful monitoring for 1 week, the patient was discharged without complications. Dislocation of the PD catheter is a well-known complication (1,2). Some centers perform prophylactic peritoneal fixation of the catheter (3). However, a PD catheter perforating the bowel and exiting from the anus has, to our knowledge, never before been reported. The asymptomatic spontaneous migration through the CorrESPonDEnCE

Persistent Exit-Site “Infection” in a Peritoneal Dialysis Patient with Chronic Lymphocytic Leukemia

1. Cabtree JH. The use of the laparoscope for dialysis catheter implantation: valuable carry-on or excess baggage? Perit Dial Int 2009; 29:394–406. 2. Goh YH. Omental folding: a novel laparoscopic technique for salvaging peritoneal dialysis catheters. Perit Dial Int 2008; 28:626–31. 3. Xie JY, Ren H, Kiryluk K, Chen N. Peritoneal dialysis outflow failure from omental wrapping diagnosed by catheterography. Am J Kidney Dis 2010; 56:1006–11. 4. Numanoglu A, McCulloch MI, Van Der Pool A, Millar AJ, Rode H. Laparoscopic salvage of malfunctioning Tenckhoff catheters. J laparoendosc Adv Surg Tech A 2007; 17:128–30. 5. Varela JE, Elli EF, Vanuno D, Horgan S. Mini-laparoscopic placement of a peritoneal dialysis catheter. Surg Endosc 2003; 17:2025–7. 6. Harissis HV, Katsios CS, Koliousi EL, Ikonomou MG, Siamopoulos KC, Fatouros M, et al. A new simplified one port laparoscopic technique of peritoneal dialysis catheter placement with intra-abdominal fixation. Am J Surg 2006;192:125–9. 7. Oğünç G, Tuncer M, Oğünç D, Yardimsever M, Ersoy F. Laparoscopic omental fixation technique versus open surgical placement of peritoneal dialysis catheters. Surg Endosc 2003; 17:1749–55. 8. Yang PJ, Lee CY, Yeh CC, Nien HC, Tsai TJ, Tsai MK. Minilaparotomy implantation of peritoneal dialysis catheters: outcome and rescue. Perit Dial Int 2010; 30:513–18. 9. Yilmazlar T, Kirdak T, Bilgin S, Yavuz M, Yurtkuran M. Laparoscopic findings of peritoneal dialysis catheter malfunction and management outcomes. Perit Dial Int 2006; 26:374–9. 10. Crabtree JH. Selected best demonstrated practices in peritoneal dialysis access. Kidney Int Suppl 2006; 70:S27–37. doi:10.3747/pdi.2011.00121 Persistent Exit-Site “Infection” in a Peritoneal dialysis Patient with Chronic Lymphocytic Leukemia