Donald M. Jacobs

Initial experience with laparoscopic live donor nephrectomy.

BACKGROUND Advances in laparoscopic instruments and video technology have made laparoscopic donor nephrectomy (LDN) feasible. We report our initial experience with this technique. METHODS A retrospective review of 30 open donor nephrectomies and our first 30 LDNs was performed to assess donor and recipient outcome and resource usage. RESULTS LDN was successfully completed in 26 donors (87%). The increased operative time and costs were balanced by less postoperative pain, earlier discharge, earlier return to normal activity and work, fewer incision problems, and less personal financial loss. Recipient outcome was not affected. CONCLUSION LDN is technically feasible and safe, and recipient graft outcomes are equivalent. Convalescence is shortened, and there is less personal financial loss. LDN offers significant benefit to the donor and may result in increased organ donation.

Malignancy, mortality, and medicosurgical management of Clostridium septicum infection

BACKGROUND Necrotizing Clostridium septicum infections (CSI) have a strong association with malignancy or immunosuppression. To clarify this relationship and determine how it impacted mortality, the experience with CSI at a single institution was reviewed. METHODS Records of all patients admitted to our hospital with culture proven clostridial infection from 1966 through 1993 were reviewed. RESULTS Among patients presenting with clinical gas gangrene, 281 had culture proven clostridial infection and 32 (11.4%) had CSI. The mortality among CSI patients was 56%, whereas 26% of all patients with clostridial infections died (p = 0.001). An associated malignancy was found in 50% of patients with CSI, whereas this was seen in only 11% of patients with other clostridial infections (p = 0.0001 for CSI versus clostridial infection overall). The remaining patients with spontaneous CSI all had evidence of immunosuppression. CONCLUSIONS The high mortality and likelihood of associated malignancy or hematologic disease underscore the importance of a high index of suspicion and the need to search for and treat associated conditions in all patients with CSI.

Anatomical and Morphological Evaluation of Pacemaker Lead Compression

In recent years, pacemaker lead failure due to compressive damage has been reported with increasing frequency. To document the mechanism of this failure, we evaluated explanted mechanically damaged leads with electrical testing, optical microscopy, and in some cases, scanning electron microscopy (SEM) In addition, we performed an autopsy study to measure the compressive loads on catheters placed percutaneously through the costoclavicular angle, as well as by cephalic cutdown. Of the 49 explanted compression damaged leads with enough clinical data for analysis, all had been placed by percutaneous subclavian puncture. Our autopsy data confirmed the significant increase in pressures generated in the costoclavicular angle for medial percutaneous subclavian catheterization (126 ± 26 mmHg) compared to a more lateral percutaneous subclavian puncture (63 ± 15 mmHg) or a cephalic cutdown (38 ± 13 mmHg) (P < 0.01). In vivo coil compression testing documented loads up to 100 pounds per linear inch of coil and a compressive morphology by SEM identical to that seen in the clinical explants. Pacemaker leads appear to be susceptible to compression damage when placed by subclavian venipuncture. When possible, leads should be placed such that they avoid the tight costoclavicular angle.

The relationship of hemorrhoids to portal hypertension

Records of 188 patients with documented portal hypertension were reviewed to determine the incidence of hemorrhoids as well as bleeding complications associated with this condition. The incidence of hemorrhoids among these patients was not increased compared to the normal population. Six of the patients with portal hypertension did, however, bleed massively from hemorrhoids. Elevated portal venous pressure is an important factor in those patients having severe hemorrhoidal bleeding. The presence of coagulation defects may also be of considerable importance.

Civilian rectal trauma: A changing perspective

BACKGROUND Recently the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma developed a Rectal Injury Scaling System (RISS). Little data exist regarding its clinical utility. METHODS We retrospectively reviewed 45 patients with rectal injuries to assess the impact of the RISS on patient management and outcome. We compared RISS grade I patients (group I, partial-thickness injury) with patients with grades 2, 3, and 4 injuries (group II, full-thickness injury). RESULTS Group II underwent distal rectal washout and repair of the injury twice as often and had a significantly higher rate of diversion of the fecal stream. This was associated with a 3-fold increase in complications. The only complications in group I were in patients managed with diversion of the fecal stream and distal rectal washout. CONCLUSIONS Our data suggest that aggressive surgical management for RISS grade I injury may not be necessary. Implementation of therapy based on the RISS may improve outcomes of civilian rectal trauma.

Clinical impact of replacing Minnesota antilymphocyte globulin with ATGAM.

In August 1992, we replaced Minnesota antilymphocyte globulin (MALG) with lymphocyte immune globulin, antithymocyte globulin (equine) (ATGAM) in our immunosuppression protocols. The clinical impression of increased graft rejection prompted our assessment of the effect of this change on patient and graft outcome. The initial study group consisted of 426 renal transplant recipients transplanted between October 1, 1987, and September 21, 1993. After exclusions, 388 transplant events, with a minimum 8-month follow-up, made up the final study cohort: 323 patients received MALG and 65 received ATGAM. Immunosuppression included intravenous methylprednisolone, oral prednisone, oral AZA, CsA in some cases, and intravenous MALG or ATGAM, 15 mg/kg/day, for 7 to 14 days. Acute rejection was treated with high dose intravenous steroids and steroid-resistant episodes were treated additionally with either MALG or OKT3. Statistical comparisons were stratified for multiple patient characteristics and treatment variations. There was a greater incidence of rejection in general, and a higher incidence of steroid-resistant episodes requiring subsequent antilymphocyte globulin therapy (P = 0.0073) in patients receiving ATGAM versus MALG. No difference was seen in the incidence of CMV infection or blood-borne sepsis. Lymphoma occurred in 3 MALG and 2 ATGAM recipients. MALG recipients were significantly less likely to experience rejection within the first 60 days after transplant (P = 0.0127 using unstratified data; P <0.0001 when data were stratified for patient characteristics). The relative risk of acute rejection for posttransplant days 5, 7, 10, and 14 was consistently higher for ATGAM-treated patients. We conclude that MALG and ATGAM are not equivalent drugs, and that MALG is a more effective immunosuppressant, and is just as safe as ATGAM in our protocol environment.

A randomized trial comparing cyclosporine induction with sequential therapy in renal transplant recipients

Abstract Calcium antagonists may reduce the nephrotoxicity of cyclosporine (CsA), allowing CsA to be introduced immediately after renal transplantation and thereby obviating the need for sequential induction therapy with a monoclonal or polyclonal antibody. To test this hypothesis, in a pilot feasibility trial 100 cadaveric or one-haplotype-mismatched living-related renal transplant recipients were randomized to either (1) sequential therapy with antithymocyte globulin (ATG) (ATGAM; Upjohn, Kalamazoo, MI) 20 mg/kg/d for 7 to 14 days until renal function was established and CsA (Sandimmune; Sandoz, East Hanover, NJ) was started, or (2) CsA 8 mg/kg/d begun immediately before surgery with diltiazem (Cardizem; Marion Merrell Dow, Kansas City, MO) 60 mg sustained release twice daily. Acute rejection episodes during the first 90 days were not different with ATG versus CsA induction (42% v 28%; P = 0.142 by chi-square analysis). Graft failures (10% v 16%; P = 0.372) and the incidence of delayed graft function (28% v 34%; P = 0.516) were also similar with ATG compared with CsA. ATG caused lower platelet counts (138 ± 59 × 103v 197 ± 75 × 103 at 7 days; P

Risk factors and patterns of injury in snowmobile crashes.

OBJECTIVE To evaluate risk factors for snowmobile injury and patterns of injury. METHODS We performed a retrospective analysis of patients with snowmobile injury at three trauma centers. Data were collected from trauma databases and patients charts from January 1988 through April 1996; we obtained statistics from the Minnesota Department of Natural Resources for comparison purposes. RESULTS There were 274 patients identified. The average age was 29 years (SD 12, range 1.6-77). The male:female ratio was 6.6:1. Helmets were used in 35%, not used in 10%, and not reported in 55%. Ethanol consumption was reported in 44% of patients. The average speed of the snowmobile at the time of the accident, when reported, was 47 mph/75 kph (n = 103, range 10-100 mph/16-166 kph). Of these patients, 26% (n = 27) reported a speed in excess of the legal limit (55 mph/88 kph). Accidents were more common in the afternoon and evening hours, and most accidents were caused by the snowmobile striking terrain or man-made objects. Mortality rate was 3.6% for this patient group (10 of 274). The average injury severity score (ISS) was 15 (SD 11). The average Glasgow Coma Score (GCS) was 14. The average number of patients who went to the intensive care unit and the total lengths of stay were 2 +/- 5 and 8 +/- 9 days, respectively. Neither GCS nor ISS correlated with reported speed. The frequencies of different types of injuries are as follows: fractures of upper and lower extremities (n = 184), serious head injury (n = 92), facial fractures or soft tissue injury to head or neck (n = 88), thoracic injury (n = 80), spine injuries (n = 50), intraabdominal injuries (n = 41), and pelvic fractures (n = 31). CONCLUSIONS Snowmobile injuries are related to ethanol use and the high speed attained by the newer generation of snowmobiles. Extremity fractures were a common component of snowmobile injury in this series, and rates of such injuries are similar to rates injuries in motorcycle accidents in states with helmet laws. Efforts at prevention of snowmobile injuries should be targeted at rider education and enforcement of alcohol restrictions.

Iron chelation with a deferoxamine conjugate in hemorrhagic shock

Oxygen-derived radicals are cytotoxic, highly reactive molecules that contribute to cellular death and injury in hemorrhagic shock. Iron released into the plasma in hemorrhagic shock may contribute to cellular damage by catalyzing lipid peroxidation of cell membranes. Deferoxamine (DFO) chelation of transitional metal ions prevents formation of these radicals and may diminish reperfusion injury. The conjugation of DFO to pentastarch (PS) decreases DFO toxicity and extends its half-life making it a potentially useful resuscitative fluid. A porcine hemorrhagic shock model was used to evaluate the effects of five resuscitative fluids on survival and hepatic function. Swine (11-16 kg) underwent splenectomy, liver biopsy, and placement of arterial and venous catheters. Awake animals were bled at 1 ml/kg/min to a MAP of 45 mm Hg, maintained for 1 hr, and resuscitated over 30 min with one of five fluids: Lactated Ringers (LR); LR + free DFO 2.5 mg/ml (LR + DFO) (n = 6); 5% PS in LR (PS) (n = 6); 5% PS + free DFO (PS + DFO) 7.5 mg/ml (n = 6); 5% PS/DFO conjugate (7.5 mg/ml) in LR (n = 6). LR and LR + DFO received 3 ml/ml shed blood; PS, PS + DFO, and PS/DFO received 1 ml/ml shed blood. No shed blood was returned to the animals. There was no significant differences between groups in MAP, HR, CVP, and T pre- and post-resuscitation. No LR lived to sacrifice at 24 hr. Thirty-three percent of LR + DFO and PS + DFO animals died within minutes of receiving the free DFO containing resuscitative fluid, presumably from acute DFO toxicity.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative intrinsic and extrinsic compliance characteristics of S, J, and W ileoanal pouches

Although compliance of the ileoanal reservoir pouch has been shown to affect function, previous compliance studies may have been influenced by the compliance of the small bowel proximal to the pouch and by supporting pelvic structures. The following study was designed to isolate the pouch and to compare intrinsic and extrinsic factors influencing pouch compliance. Thirty-three mongrel dogs underwent rectal mucosectomy and protocolectomy with S-pouch (S) in nine, stapled J-pouch (SJ) in nine, handsewn J-pouch (HJ) in nine and handsewn W-pouch (SW) in six. At 2 weeks, each dog underwent laparotomy, the small bowel 2 cm proximal to the pouch was clamped, andin vivo pouch compliance was measured using anal balloon occlusion and continuous saline infusion manometry. The pouch was then removed andex vivo measurements were repeated. Mean compliance slopes between 0 and 40 cm H2O were compared by ANOVA and pairedt-ests.In vivo andex vivo compliance in ml/cm H2O was 3.1±1.2 and 3.8±1.6 (P=0.25) for the S-pouch, 3.1±0.6 and 5.2±1.7 (P<0.01) for the SJ-pouch, 2.3±0.5 and 4.8±0.7 (P<0.001) for the HJ-pouch, 3.6±0.6 and 6.0±0.7 (P<0.001) for the W-pouch. Pearsons correlation coefficient forin vivo andex vivo measurements of the S, SJ, HJ, and W pouches were r2=0.066, 0.001, 0.039, and 0.379, respectively. It is concluded that: 1) Isolated pouch compliance can be accurately measured in experimental animals with proximal and distal occlusion and inflow manometry. 2)In vivo compliance is significantly less in the HJ compared with S, SJ, and W pouches. 3) Differences betweenin vivo andex vivo compliance of SJ, HJ, and SW pouches are significant. 4)In vivo andex vivo compliance determinations correlate poorly. 5) Extrinsic factors contribute significantly to pouch compliance.