Niels F.M. Kok

Comparison of laparoscopic and mini incision open donor nephrectomy: single blind, randomised controlled clinical trial.

Abstract Objectives To determine the best approach for live donor nephrectomy to minimise discomfort to the donor and to provide good graft function. Design Single blind, randomised controlled trial. Setting Two university medical centres, the Netherlands. Participants 100 living kidney donors. Interventions Participants were randomly assigned to either laparoscopic donor nephrectomy or to mini incision muscle splitting open donor nephrectomy. Main outcome measures The primary outcome was physical fatigue using the multidimensional fatigue inventory 20 (MFI-20). Secondary outcomes were physical function using the SF-36, hospital stay after surgery, pain, operating times, recipient graft function, and graft survival. Results Conversions did not occur. Compared with mini incision open donor nephrectomy, laparoscopic donor nephrectomy resulted in longer skin to skin time (median 221 v 164 minutes, P < 0.001), longer warm ischaemia time (6 v 3 minutes, P < 0.001), less blood loss (100 v 240 ml, P < 0.001), and a similar number of complications (intraoperatively 12% v 6%, P = 0.49, postoperatively both 6%). After laparoscopic nephrectomy, donors required less morphine (16 v 25 mg, P = 0.005) and shorter hospital stay (3 v 4 days, P = 0.003). During one years follow-up mean physical fatigue was less (difference - 1.3, 95% confidence interval - 2.4 to - 0.1) and physical function was better (difference 6.2, 2.0 to 10.3) after laparoscopic nephrectomy. Function of the graft and graft survival rate of the recipient at one year censored for death did not differ (100% after laparoscopic nephrectomy and 98% after open nephrectomy). Conclusions Laparoscopic donor nephrectomy results in a better quality of life compared with mini incision open donor nephrectomy but equal safety and graft function.

Randomized clinical trial of the impact of early enteral feeding on postoperative ileus and recovery

Postoperative convalescence is mainly determined by the extent and duration of postoperative ileus. This randomized clinical trial evaluated the effects of early oral feeding on functional gastrointestinal recovery and quality of life.

A meta-analysis of safety and effectiveness of perioperative beta-blocker use for the prevention of cardiac events in different types of noncardiac surgery

ObjectivePerioperative &bgr;-blocker therapy has been proposed to improve outcome. Most of the trials conducted, however, lacked statistical power to evaluate the incidence of hard cardiac events and the relationship to the type of surgery. Therefore, we conducted a meta-analysis of all randomized controlled trials in which &bgr;-blocker therapy was evaluated. MethodsAn electronic search of published reports on Medline was undertaken to identify studies published between January 1980 and November 2004 in English language journals. All studies reported on at least one of three endpoints: perioperative myocardial ischemia, perioperative nonfatal myocardial infarction, and cardiac mortality. Type of surgery, defined as low, intermediate, and high risk according to the American College of Cardiology/American Heart Association guidelines, was noted. ResultsIn total, 15 studies were identified, which enrolled 1077 patient. No significant differences were observed in baseline clinical characteristics between patients randomized to &bgr;-blocker therapy and control/placebo. Beta-blocker therapy was associated with a 65% reduction in perioperative myocardial ischemia (11.0% vs. 25.6%; odds ratio 0.35, 95% confidence interval 0.23–0.54; P<0.001). Furthermore, a 56% reduction in myocardial infarction (0.5% vs. 3.9%, odds ratio 0.44, 95% confidence interval 0.20–0.97; P=0.04) and a 67% reduction (1.1% vs. 6.1%, odds ratio 0.33, 95% confidence interval 0.17–0.67; P=0.002) in the composite endpoint of cardiac death and nonfatal myocardial infarction were observed. No statistical evidence was observed for heterogeneity in the treatment effect in subgroups according to type of surgery (P for heterogeneity 0.2). ConclusionThis meta-analysis shows that &bgr;-blocker use in noncardiac surgical procedures is associated with a significant reduction of perioperative cardiac adverse events.

Case-orientated approach to the management of hepatocellular adenoma

Treatment of suspected hepatocellular adenoma (HA) remains controversial. The aim of this study was to evaluate the management of HA at a time when magnetic resonance imaging (MRI) and computed tomography (CT) are highly sensitive methods for diagnosing HA.

Live donor nephrectomy: a review of evidence for surgical techniques

Live kidney donation is an important alternative for patients with end‐stage renal disease. To date, the health of live kidney donors at long‐term follow‐up is good, and the procedure is considered to be safe. Surgical practice has evolved from the open lumbotomy, through mini‐incision muscle‐splitting open donor nephrectomy, to minimally invasive laparoscopic techniques. There are different minimally invasive techniques, including standard laparoscopic, hand‐assisted laparoscopic, hand‐assisted retroperitoneoscopic, pure retroperitoneoscopic, and robotic‐assisted live donor nephrectomy. At present, these minimally invasive techniques are subjected to clinical trials focusing on surgical outcome, quality of life, costs, long‐term follow‐up, and also morbidity of donor, recipient, and graft. In practice, many centers only perform donor nephrectomy on young healthy donors with normal weight. There is increasing evidence that donor nephrectomy with multiple arteries, right kidney and obese patients can be done with precaution. In this review, we address the surgical part of live kidney donation and the best level of evidence for all surgical techniques and issues surrounding the technique.

The current practice of live donor nephrectomy in Europe

Background. The increasing number of live kidney donors in the last decade has stimulated interest in the surgical technique of donor nephrectomy. In this study, we evaluated the current status of the surgical approach in European transplant centers. Methods. A questionnaire was sent to 131 centers in 12 European countries. Questions included the number of donors, the technique used, and the inclusion and exclusion criteria for a technique. Results. Ninety-two replies (70%) were included. In the responding centers, approximately 1450 live donor nephrectomies were performed in 2004 (more than 80% of all live kidney donations in these countries). The number of living donors ranged from 0 to 95 per center. Nineteen institutions (21%) removed kidneys using endoscopic techniques only. Twenty-two centers (24%) performed both open and laparoscopic donor nephrectomy. Vessel length, difficult anatomy and right-sided donor nephrectomy were common reasons to choose an open technique. Twelve centers had performed laparoscopic donor nephrectomy but quit their program for various reasons. In 51 centers (55%), only open donor nephrectomy was carried out. Lack of evidence that endoscopic techniques provide better results was the main reason for these centers to stick to an open approach. Incisional hernias occurred after all types of open surgery in up to 30% of the donors per center. Twenty-nine clinics still carry out the classic flank incision. Conclusion. The surgical technique of live donor nephrectomy varies greatly between transplant centers in European countries. To define the optimal surgical approach a European registration of donor nephrectomies would be helpful.

Living kidney donors: Impact of age on long-term safety

The safety of older live kidney donors, especially the decline in glomerular filtration rate (GFR) after donation, has been debated. In this study we evaluated long‐term renal outcome in older live kidney donors. From 1994 to 2006 follow‐up data of 539 consecutive live kidney donations were prospectively collected, during yearly visits to the outpatient clinic. Donors were categorized into two groups, based on age: <60 (n = 422) and ≥60 (n = 117). Elderly had lower GFR predonation (80 vs. 96 mL/min respectively, p < 0.001). During median follow‐up of 5.5 years, maximum decline in eGFR was 38%± 9% and the percentage maximum decline was not different in both groups. On long‐term follow‐up, significantly more elderly had an eGFR <60 mL/min (131 (80%) vs. 94 (31%), p < 0.001). However, renal function was stable and no eGFR of less than 30 mL/min was seen. In multivariate analysis higher body mass index (HR 1.09, 95%CI 1.03–1.14) and more HLA mismatches (HR 1.17, 95%CI 1.03–1.34) were significantly correlated with worse graft survival. Donor age did not influence graft survival. After kidney donation decline in eGFR is similar in younger and older donors. As kidney function does not progressively decline, live kidney donation by elderly is considered safe.

Laparoscopic donor nephrectomy: a plea for the right-sided approach.

Background. Laparoscopic donor nephrectomy (LDN) has become the preferred procedure for live donor nephrectomy. Most transplant surgeons are reluctant toward right-sided LDN (R-LDN) fearing short vessels and renal vein thrombosis. Methods. In our institution, selection of the appropriate kidney for donation was based on the same criteria that traditionally governed open donor nephrectomy. All intraoperative and postoperative data were prospectively recorded. Results. One hundred fifty-nine R-LDNs (56%) and 124 left-sided LDNs (L-LDN, 44%) were performed. Demographics did not significantly differ. Complications occurred in 10 (6%) vs. 23 (19%) procedures (R-LDN vs. L-LDN, P=0.002), resulting in 2 and 11 conversions, respectively. Right-sided kidney donation was the only independent preventative factor for complications in multivariate analysis (P=0.008, Odds ratio 0.33). R-LDN was associated with shorter operation time (mean 202 vs. 247 min, P<0.001) and less blood loss (139 vs. 294 mL, P<0.001). Hospital stay was 3 days in both groups. With regard to the recipients, the second warm ischemia time was similar (29 vs. 28 min, P=0.699). Conclusions. R-LDN is faster and safer than L-LDN and does not adversely affect graft function. R-LDN may be advocated to allow donors to benefit from the advantages of laparoscopic surgery.

Complex vascular anatomy in live kidney donation: Imaging and consequences for clinical outcome

Background. Live donor kidneys with multiple arteries are associated with surgical complexity for removal and increased rate of recipient ureteral complications. We evaluated the outcome of vascular imaging and the clinical consequences of multiple arteries and veins. Methods. From 2001 to 2005 data of 288 live kidney donations and transplantations were prospectively collected. Vascular anatomy at operation was compared with vascular anatomy as imaged by magnetic resonance imaging (MRI) or subtraction angiography, and consequences of multiple vessels were investigated. Results. Simple renal anatomy with a solitary artery and vein was present in 208 (72%) kidneys. Sixty (21%) transplants had multiple arteries. Thirty (10%) transplants had multiple veins. Magnetic resonance imaging failed to predict arterial anatomy in 23 of 220 donors (10%) compared with 3 of 101 (3%) after angiography. The presence of multiple veins did not influence outcomes after nephrectomy in general. Multiple arteries did not affect clinical outcomes in open donor nephrectomy (n=103). In laparoscopic donor nephrectomy (n=185) multiple arteries were associated with longer operation times (245 vs. 221 min, P=0.023) and increased blood loss (225 vs. 220 mL, P=0.029). In general, neither multiple arteries nor vascular reconstructions influenced recipient creatinine clearance or ureteral complication rate. However, accessory arteries to the lower pole correlated with an increased rate of ureteral complications (47% vs. 14%, P=0.01). Conclusions. Multiple arteries may increase operation time. Accessory lower pole arteries are associated with a higher rate of recipient ureteral complications indicating the importance of arterial imaging. Currently, both magnetic resonance imaging and angiography provide suboptimal information on renal vascular anatomy.

Spinal or local anesthesia in lichtenstein hernia repair: a randomized controlled trial.

Background:With established protocols lacking, the choice of anesthetic technique remains arbitrary in inguinal hernia repair. Well-designed studies in this subject are important because of the gap or discrepancy between available scientific evidence and clinical practice. Methods:Between August 2004 and June 2006, a multicenter prospective clinical trial was performed in which 100 patients with unilateral primary inguinal hernia were randomized to spinal or local anesthesia. Clinical examination took place within 2 weeks postoperatively and at 3 months in the outpatient clinic. Results:Analysis of postoperative visual analogue scale scores showed that patients operated under local anesthesia had significant less pain shortly after surgery (P = 0.021). Significantly more urinary retention (P < 0.001) and more overnight admissions (P = 0.004) occurred after spinal anesthesia. Total operating time is significantly shorter in the local anesthesia group (P < 0.001). No significant differences were found between the 2 groups with respect to the activities of daily life and quality of life. Conclusions:Our study provides evidence that local anesthesia is superior to spinal anesthesia in inguinal hernia repair. Local anesthesia in primary, inguinal hernia repairs should be the method of choice.