O. Rossetti

Is lymphocele in renal transplantation an avoidable complication

BACKGROUND This study evaluated the impact of surgery in the incidence of lymphocele after kidney transplantation (KTx). METHODS A prospective randomized study was conducted during a 6-year period on a group of patients undergoing KTx and operated on by the same surgeon (CVS). A total of 280 patients undergoing KTx were randomly allocated into two groups: (1) group C (control group) was 140 patients who were submitted to KTx with standard technique: implantation of the kidney in the controlateral iliac fossa with vascular anastomoses on the external iliac vessels; and (2) group M (modified technique group) was 140 patients who underwent a modified technique with a cephalad implantation of the graft in the ipsilateral iliac fossa and vascular anastomoses in the common iliac vessels. Both groups were comparable for age, cold ischemia time, incidence of rejection episodes, presence of adult polycystic kidney disease, and source of donor graft. RESULTS Group M showed an incidence of lymphocele production (3 patients, 2.1%) significantly lower than group C (12 patients, 8.5%). Eight patients (1 in group M and 7 in group C) required surgical treatment by peritoneal fenestration. No allograft or recipient was lost as a result of fluid collection but the hospitalization was shorter in group M than in group C. CONCLUSIONS A cephalad implantation of the renal graft in the ipsilateral iliac fossa has been associated with a lower incidence of lymphocele, probably because vascular anastomoses on the common iliac vessels cause less lymphatic derangement than those performed on the external iliac vessels.

Early pancreas retransplantation for vascular thrombosis in simultaneous pancreas-kidney transplants.

Vascular thrombosis is still the leading cause of nonimmunologic, technical pancreatic transplant graft failures and usually occurs in the early postoperative period. Little data exist regarding the issue of pancreas retransplantation although it has been described for chronic rejection in pancreas transplant alone with poor results. From October 1993 to December 1996, 16 patients with type I diabetes mellitus and end-stage renal disease underwent to SPK at our Dept. of General Surgery and Adominal Organ Transplantation. Twelve were males and 4 females with a mean age of 36.8 (range 25 to 56). Therteen had bladder drainage (BD) and 3 enteric drainage (ED). One patient in the BD group and 1 patient in the ED group had vascular thrombosis of their pancreas graft 7 and 3 days after SPK respectively. Both patients presented hematuria, abdominal tenderness, pain and oedema of the ipsilateral lower limb. At operation, hemorragic necrosis involving the whole pancreas with thrombosis of portal vein extended in the external and common iliac veins was seen. Pancreasectomy and throm-bectomy associated to pancreas retransplantion was performed in 1 patient in the same time while in the other, pancreas retransplant was performed 1 day later. The postoperative course was uneventful and both patients were discharged 16 and 23 days p.o. They are alive and well 6 and 11 months with functioning grafts.

Renal Transplants from Older Deceased Donors: Use of Preimplantation Biopsy and Differential Allocation to Dual or Single Kidney Transplant according to Histological Score Has No Advantages over Allocation to Single Kidney Transplant by Simple Clinical Indication

Background Grafts from elderly donors (ECD) are increasingly allocated to single (SKT) or dual (DKT) kidney transplantation according to biopsy score. Indications and benefits of either procedure lack universal agreement. Methods A total of 302 ECD-transplants in period from Jan 1, 2000, to Dec 31, 2015, were allocated to SKT (SKTpre) on clinical grounds alone (before Dec 2010, pre-DKT era, n = 170) or according to a clinical-histological protocol (after Dec 2010, DKT era, n = 132) to DKT (n = 48), SKT biopsy-based protocol (“high-risk”, SKThr, n = 51), or SKT clinically based protocol (“low-risk”, SKTlr, n = 33). Graft and patient survival were compared between the two periods and between different transplant categories. Results Graft and overall survival in recipients from ECD in pre-DKT and DKT era did not differ (5-year graft survival 87.7% and 84.2%, resp.); equal survival in the 2 ECD periods was shown in both donor age ranges of 60–69 and >70-years, and in low-risk or high-risk ECD categories. Within the DKT protocol SKThr showed worst graft and overall survival in the 60–69 donor age range; DKT did not result in significantly better outcome than SKT from ECD in either era. One-year posttransplant creatinine clearance in recipients did not differ between any ECD transplant category. At 3 and 5 years after transplantation there were significantly higher total dialysis-free recipient life years from an equal donor number in the pre-DKT era than in the DKT protocol. Conclusions Use of a biopsy-based protocol to allocate grafts from aged donors to SKT or DKT did not result in better short term graft survival than a clinically based protocol with allocation only to SKT and reduced overall recipient dialysis-free life years in time.

Bovine pericardium for multiple artery reconstruction in kidney transplantation

Dear Editors, Multiple arterial reconstructions are often required in kidney transplantation (KT), and a variety of reconstruction strategies and implant techniques have been described [1,2]. When an aortic Carrel patch cannot be safely used in older deceased donors with severely atherosclerotic aortas, or in living donor kidney procedures, multiple artery reconstruction may represent a surgical challenge requiring time-consuming technical solutions. Glutaraldehyde-treated bovine pericardium (BP) is one of the preferred biological materials in cardiovascular and thoracic surgical procedures [3] and was recently used for major venous reconstruction in oncological liver and pancreatic surgery [4,5]. BP’s xenogeneic origin raises a number of immunological concerns, such as xenogeneic antigen epitopes (alpha-GAL epitopes), one of the main triggers of an immune response [6]. However, the use of chemically treated BP represents the clinical standard and the glutaraldehyde-fixing process should eliminate any antibody-mediated reaction to the relevant epitopes. Despite the potential advantages of using biological tissues like BP in terms of handling and a lower risk of infection and thrombosis compared to synthetic patching materials, little is known about their use in transplantation [2,7,8]. We report on the use of a glutaraldehyde-treated BP patch for reconstruction of multiple renal arteries procured from three elderly deceased donors with two arteries in which the aortic patch was judged too risky to use, and from five living donors (two distant small arteries in four cases, and three arteries in one). During bench surgery, the renal arteries were anastomosed to the BP patch using 7–8/0 prolene sutures in interrupted or running fashion according to the vessel diameter and were parallel to each other to avoid the risk of kinking (Figure 1). There were no acute or late complications related to graft thrombosis or infection, and the patch had a long-term patency demonstrated by Doppler ultrasound up to 36 months after we first used it in KT. No long-term anticoagulation was required. Commercially available BP is an acellular material mainly composed of collagen. Its 0.5 mm thickness makes the patch easy to perforate with a vascular punch to create the new arterial ostium and easily trimmed and tailored to match the shape and size of the recipient arteries with minimal suture line bleeding after graft revascularization. In the case of small polar arteries, implanting each artery with separate end-to-side

Transplantation Bench Surgery of the Abdominal Organs

Liver bench surgery: carefully dissect the donor inferior vena cava, especially in the suprahepatic region, where the adventitia is firmly adherent to the surrounding diaphragm, and on the posterior side to avoid uncontrollable posterior bleeding during implantation. Recognize hepatic artery variations (Michel’s classification) when examining the superior mesenteric artery. Dissect the hepatic artery from the aortic patch to the level of bifurcation of the gastroduodenal artery, cleaning off the celiac plexus and fibrofatty tissue enveloping the vessels. Do not ligate the small collaterals too near to the vascular ostia, especially in atheromasic arteries.