Rachel Bluebond-Langner

Laparoscopic live donor nephrectomy: Trends in donor and recipient morbidity following 381 consecutive cases

Objective:To review a single-institution 6-year experience with laparoscopic live donor nephrectomy detailing the technical modifications, clinical results, as well as the trends in donor and recipient morbidity. Summary Background Data:Since 1995, laparoscopic donor nephrectomy has had a significant impact on the field of renal transplantation, resulting in decreased donor morbidity, without jeopardizing procurement of a high-quality renal allograft. This technique has become the preferred method of allograft procurement for many transplantation centers worldwide but still remains technically challenging with a steep learning curve. Methods:Records from 381 consecutive laparoscopic donor nephrectomies were reviewed with evaluation of both donor and recipient outcomes. Trends in donor and recipient complications were assessed over time by comparing the outcomes between four equally divided groups. Results:All 381 kidneys were procured and transplanted successfully with only 8 (2.1%) open conversions. Mean operative time was 252.9 ± 55.7 minutes, estimated blood loss 344.2 ± 690.3 mL, warm ischemia time 4.9 ± 3.4 minutes, and donor length of stay was 3.3 ± 4.5 days. There was a significant decline in total donor complications, allograft loss, and rate of vascular thrombosis with experience. The rate of ureteral complications declined significantly when comparing our early (Group A) versus later (Groups B–D) experience. Conclusion:Laparoscopic donor nephrectomy has remained a safe, less invasive, and effective technique for renal allograft procurement. Over our 6-year experience and with specific refinements in surgical technique, we have observed a decline in both donor and recipient morbidity following laparoscopic live donor nephrectomy.

Recurrent abdominal laxity following interpositional human acellular dermal matrix.

Repair of large complex abdominal hernias with significant loss of domain requires component separation in combination with either a synthetic or biologic interpositional material. We previously described an algorithm for complex abdominal hernia repair, which incorporates Alloderm as an interpositional material and selective use of prolene mesh as an overlay. We now report recurrent laxity in a series of patients who were repaired with interpositional Alloderm alone without prolene mesh overlay. We reviewed all patients who underwent repair of massive ventral hernias and identified 7 patients who presented with abdominal wall laxity following component separation with interpositional Alloderm alone. All patients developed laxity within 12 months and required a secondary procedure. At the time of re-exploration, severe attenuation in the Alloderm was noted. The segment was excised, the edges closed primarily, and prolene mesh was placed as an onlay. Although Alloderm has been reported to be an effective biologic material for abdominal hernia reconstruction, we have noted significant laxity requiring secondary intervention.

Laparoscopic ablation of symptomatic parenchymal and peripelvic renal cysts.

OBJECTIVES To assess the safety and efficacy of laparoscopic ablation of symptomatic renal cysts as minimally invasive therapeutic techniques have largely supplanted open surgical intervention for the treatment of symptomatic renal cysts. METHODS The records of 32 consecutive adult patients who underwent laparoscopic ablation of renal cysts (11 peripelvic, 21 parenchymal) were retrospectively reviewed. All patients were symptomatic at presentation; 26 had a single cyst, 5 had two cysts, and 1 had four cysts. RESULTS Twenty patients underwent a transperitoneal laparoscopic approach, and 12 patients underwent a retroperitoneal laparoscopic approach. An average of 3.2 ports were used for each procedure, and no open conversions or transfusions were necessary. When comparing patients with parenchymal and peripelvic cysts, statistically significant differences were noted in the mean operative time (164 versus 233 minutes, respectively; P = 0.003) and mean operative blood loss (98 versus 182 mL, respectively; P = 0.04). Four patients (13%) had complications (one major and three minor), including a persistent ureteral stricture. One patient with negative preoperative aspiration cytology and negative intraoperative frozen section analysis was later found to have malignancy within the cyst wall, necessitating radical nephrectomy and trocar site excision. One patient (3%) developed a recurrence. CONCLUSIONS Laparoscopic ablation of symptomatic renal cysts is a safe and efficacious procedure. We report an overall complication rate of 13% and a recurrence rate of 3% with a mean follow-up of 18.1 months (median 10.0).

Predictable Patterns of Intracranial and Cervical Spine Injury in Craniomaxillofacial Trauma: Analysis of 4786 Patients

Background: Patients presenting with traumatic craniomaxillofacial fractures often have occult concomitant injuries. This study was designed to determine whether facial fracture patterns are associated with a particular constellation of concomitant head and neck injuries. Methods: A retrospective review of 4786 consecutive patients diagnosed with maxillofacial fractures at a dedicated urban trauma center from 1998 to 2005 was conducted; maxillofacial fractures and cervical spine injuries were grouped by dividing the craniomaxillofacial skeleton and cervical spine into thirds. Univariate and multivariate logistic regression analyses were used to identify associations between facial fractures and other traumatic injuries. Results: Among all patients with facial fractures, 461 (9.7 percent) also had cervical spine injuries and 2175 (45.5 percent) had associated head injuries. Fractures of the upper face were associated with increased likelihood of mid lower cervical spine injuries, severe intracranial injuries, and increased mortality rates. Unilateral mandible injuries were associated with an increased likelihood of having upper cervical spine injuries, whereas unilateral midface injuries were associated with basilar skull fractures and several intracranial injuries. Finally, bilateral midface injuries were associated with basilar skull fracture and death. Conclusions: Craniomaxillofacial fractures are commonly associated with head and cervical spine injuries that involve predictable patterns of force dispersion from the maxillofacial skeleton and transmission to the cranial vault and cervical spine. These results suggest that concomitant injuries should be investigated closely with distinct types of facial fractures.

Abdominal wall reconstruction following severe loss of domain: the R Adams Cowley Shock Trauma Center algorithm.

Background: Large, complex, posttraumatic and recurrent abdominal hernias present a reconstructive challenge. Multiple techniques have been described to restore the integrity of the abdominal wall, although the indications and applications can be difficult to navigate. The authors propose an algorithm that facilitates the assessment and treatment of secondary large ventral defects. Methods: The algorithm described involves a systematic approach to abdominal wall reconstruction and was applied to 23 consecutive patients at the R Adams Cowley Shock Trauma Center. Data collected from the chart review included age, body mass index, mechanism of injury, placement of skin graft and use of resorbable mesh before definitive reconstruction, size of defect, number of tissue expanders placed, length of follow-up, and complications. Results: There were six female patients and 17 male patients, with an average age of 36 years. The average follow-up was 7 months. Seventeen patients had posttraumatic laparotomies, five patients had aggressive abdominal wall debridement following necrotizing fasciitis, and one patient developed a large abdominal wall hernia following complications from gastric bypass surgery. All patients underwent delayed abdominal wall reconstruction, with an average time to initial reconstruction of 19.5 months. Sixteen patients had no postoperative complications. Seven patients had complications, including one with an enterocutaneous fistula, one with a partial small bowel obstruction, two with seromas, one with a superficial wound infection, and two with recurrent abdominal wall laxity. Conclusions: The reconstructive ladder for large, complex abdominal hernias is poorly defined. The proposed algorithm provides a systematic staged approach that incorporates available techniques used for delayed reconstruction of the abdominal wall.

Functional outcomes of posttraumatic lower limb salvage: a pilot study of anterolateral thigh perforator flaps versus muscle flaps.

BACKGROUND Functional outcomes of lower extremity reconstruction compared with amputation have been evaluated. However, there are little comparative data among the different reconstructive options. With the recent increase in perforator flaps, we compared the functional outcomes of muscle and perforator flaps. METHODS We conducted a retrospective review of 136 lower extremity trauma patients who underwent reconstruction with either a free muscle or perforator flap during a 7-year period. Forty-two of these patients completed the study. Patients answered the short musculoskeletal functional assessment form and supplemental questions. A physical therapist evaluated performance of physical tasks. Donor site sensation was measured with the pressure specified sensing device. Radiographic fracture union was evaluated by an orthopedic surgeon. RESULTS Of the 42 patients enrolled, 20 had coverage with perforator flaps and 22 with muscle flaps. Quality of life and functional outcomes demonstrate no difference (p > 0.05). Ninety-three percent of patients would go through the limb salvage process to avoid amputation. Sensation at the donor site was diminished in all patients; however, the perforator flap donor site had more significant sensory loss (p = 0.005). Time to bony union (p = 0.51), union in the presence of infection (p = 0.85), and infection after flap (p = 0.87) was not related to flap type. CONCLUSION Both muscle and perforator flaps provide vascularized coverage, which nourishes the fracture but muscle flaps pilfer a functional unit which may not be inconsequential in a patient trauma. This pilot study suggests that functional outcomes of perforator skin flaps are equal to muscle flaps and a larger prospective study is warranted.

Microsurgical Reconstruction of Posttraumatic High-Energy Maxillary Defects : Establishing the Effectiveness of Early Reconstruction

Background: Posttraumatic, high-energy defects of the midface can be challenging to reconstruct because they involve extensive composite tissue loss and result in significant permanent functional and cosmetic deformity. These injuries require replacement of the bony framework, external soft tissue, and intraoral mucosa. Local skin flaps and nonvascularized bone grafts have been used for reconstruction, but bony resorption and the associated soft-tissue collapse limit long-term viability. The authors present a classification of maxillary defects following high-energy trauma and a treatment algorithm using vascularized bone flaps. Methods: Fourteen patients with significant maxillary loss from high-energy trauma underwent reconstruction with composite vascularized bone flaps. Eight patients had fibula flaps and six had iliac crest flaps. There were five women and nine men, with a mean age of 36.3 years (range, 21 to 48 years) and a mean follow-up of 18 months (range, 5 to 54 months). Results: Thirteen of the 14 flaps survived. Nine patients had additional procedures. Nine patients had oronasal fistulas and eight were dependent on gastrostomy tubes preoperatively. All patients were able to feed orally without nasal regurgitation postoperatively. All patients achieved stable restoration of the midfacial architecture. Conclusions: The classification scheme presented centers on the missing maxillary subunits. The reconstructive algorithm is based on the type of defect, tissue requirement, and donor tissues necessary to restore facial projection and prosthodontic rehabilitation. Iliac crest and fibula bone free flaps are ideal for restoring a variety of traumatic maxillary defects. The authors advocate early reconstructive intervention using vascularized bone flaps to achieve superior functional and cosmetic outcomes.

Facial subunit composite tissue allografts in nonhuman primates: I. Technical and immunosuppressive requirements for prolonged graft survival.

Background: Widespread application of composite tissue allotransplantation has been impeded by risks of rejection and conventional immunosuppression. The authors have developed a nonhuman primate composite tissue allotransplantation model that demonstrated reliable and long-term success necessary to progress to preclinical studies. Methods: Composite facial subunits (e.g., skin, muscle, and bone) were transplanted between mismatched cynomolgus monkeys. Vascular supply was based on the common carotid artery and external and internal jugular veins. Facial allografts were heterotopically transplanted to the recipient’s lower abdomen with end-to-side anastomoses of the common carotid artery to the common femoral artery and of both the internal and external jugular veins to the common femoral vein. Animals received tacrolimus monotherapy. Grafts were inspected daily, submitted to biopsy regularly, and studied with magnetic resonance imaging. Results: Thirteen transplants were performed. Two grafts based on the common carotid artery and only the internal jugular vein failed within 3 to 5 days because of venous thrombosis not related to rejection. Subsequent transplants included anastomoses of both the internal and external jugular veins to the common femoral vein without thromboses. Immunosuppression consisted of tacrolimus monotherapy and was tolerated without complications. Long-term success was achieved with rejection-free graft survival (60 to 177 days). Conclusions: The authors have developed the first successful model of facial composite tissue allotransplantation in a nonhuman primate. Technical requirements include preservation of both internal and external jugular venous outflow. Tacrolimus monotherapy permitted prolonged rejection-free graft survival without early complications. This model provides a platform for further investigation of composite tissue allotransplantation tolerance and requirements for indefinite survival.

Occult carcinoma in 866 reduction mammaplasties: Preserving the choice of lumpectomy

Background: Occult breast carcinoma is occasionally found in reduction mammaplasty specimens. Historically, these patients were treated with mastectomy because the exact location of the tumor was unknown. Currently, breast conservation is the treatment of choice in 50 to 85 percent of breast cancers. The authors present a technique of routine specimen marking that allows localization of the tumor and preservation of the choice of lumpectomy. Methods: This is a retrospective review of 866 patients who underwent reduction mammaplasty performed by a single surgeon between 1990 and 2009. Data were collected for patients who had occult cancer found in their specimens, including age, cancer risk factors, abnormality, nodal status, selected treatment, and survival status. Specimens were marked and oriented and then sent in separate bags to the pathologist. Results: There were 10 cases of occult carcinoma among the 866 women (1.15 percent) who underwent reduction mammaplasty. Six cancers were found in patients undergoing reduction for symptomatic macromastia [n = 629 (0.95 percent)]. Four new cancers were found in the group of patients with a personal history of cancer [n = 237 (1.69 percent)]. All 10 patients had normal preoperative mammograms. Location, size, and margin status were easily identified and patients were offered the choice of lumpectomy or mastectomy. Conclusions: This article demonstrates that careful marking of reduction specimens in high-risk patients or in women older than 40 years allows the pathologist to orient, localize, and further section tissue for margin status. Communication among plastic surgeon, pathologist, oncologist, and radiation therapist preserves the choice of breast conserving therapy for early cancers.

Prolonged Survival of Composite Facial Allografts in Non-Human Primates Associated With Posttransplant Lymphoproliferative Disorder

Background. Composite tissue allotransplantation may have different immunosuppressive requirements and manifest different complications compared with solid organ transplantation. We developed a non-human primate facial composite tissue allotransplantation model to investigate strategies to achieve prolonged graft survival and immunologic responses unique to these allografts. Methods. Composite facial subunits consisting of skin, muscle, and bone were heterotopically transplanted to mixed lymphocyte reaction-mismatched Cynomolgus macaques. Tacrolimus monotherapy was administered via continuous intravenous infusion for 28 days then tapered to daily intramuscular doses. Results. Five of the six animals treated with tacrolimus monotherapy demonstrated rejection-free graft survival up to 177 days (mean, 113 days). All animals with prolonged graft survival developed posttransplant lymphoproliferative disorders (PTLD). Three animals converted to rapamycin after 28 days of rejection of their allografts, but did not develop PTLD. Genotypic analysis of PTLD tumors demonstrated donor origin in three of the five analyzed by short-tandem repeats. Sustained alloantibodies were detected in rejecting grafts and absent in nonrejecting grafts. Conclusions. Tacrolimus monotherapy provided prolonged rejection-free survival of composite facial allografts in a non-human primate model but was associated with the development of a high frequency of donor-derived PTLD tumors. The transplantation of a large volume of vascularized bone marrow in composite tissue allografts may be a risk factor for PTLD development.