Electrosurgery: history, principles, and current and future uses.
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Biophysics↗
Biomedical subjects
Douglas P Slakey
Publications and source records attributed to Douglas P Slakey.
Transplantation of adult recipients by single cadaveric kidneys from pediatric donors weighing < or = 25 kg can be a reliable option.
The evidence in favor of transplanting single allografts from cadaveric pediatric donors into adult recipients is equivocal. This study was performed to assess the outcome of transplantation of single kidneys from pediatric donors weighing < 25 kg. Thirty-five adults transplanted by renal allografts from pediatric donors weighing < 25 kg were compared with 30 matched recipients of kidneys from adult donors. Donors in study group were aged 4.2 +/- 2.1 years weighing 16.0 +/- 5.3 kg. In the study group, surgical complications occurred in five of 35 patients, in the control group four of 30. Serum creatinine reached nadir in 47.5 days in study group versus 30 days in controls (P < 0.01). Serum creatinine at 1 and 3 years were comparable in both groups. A 38.9% had proteinuria at 1 year in the study group compared with 22.7% in controls (P = 0.36). One-year graft survival was 91.7% in the study group versus 92.8% for controls. The surgical complications and graft survival in the study group was comparable with that of controls. The incidence of proteinuria may be more frequent, but does not appear to impact graft function. The use of single, as compared with paired, pediatric donor kidneys would allow more patients to be transplanted with equivalent results.
Adult↗
High body mass index and short- and long-term renal allograft survival in adults.
BACKGROUND: The effect of recipient obesity on kidney allograft survival remains enigmatic. The purpose of this study was to evaluate the effect of donor and recipient body mass index on graft survival. METHODS: Retrospective study of 193 consecutive, adult renal transplants, with at least six months follow-up (mean 24+/-14.1 months). Patients were divided into two groups based upon body mass index (BMI), [weight (kg)/height (m)]: normal (<30.0, n=137) and obese (> or =30.0, n=56). Endpoints were graft loss, defined as either total loss of graft function (return to dialysis) or patient death with a functional graft. Unadjusted and adjusted multivariate analysis techniques, including Kaplan-Meier and Cox proportional hazards regression were used. RESULTS.: Individuals with a BMI > or =30 were not more likely to experience graft loss (O.R. 0.93, 95% C.I. 0.50, 1.72). Rates of acute rejection were not increased in obese recipients. While mortality was not increased in the BMI > 30 group, morbidity, especially surgical, had an increased incidence. The ratio of recipient to donor BMI did not influence graft survival. CONCLUSION: Obese recipients (BMI > or =30.0) were not at increased risk for graft failure. Additionally, matching donor and recipient BMI's would not appear to substantially improve transplant outcome. Obese recipients do have increased posttransplant morbidity and risk all the known health consequences associated with obesity. Careful evaluation and clinical management of obese patients allows for successful kidney transplantation with results equivalent to normal BMI patients.
Body Mass Index↗
Developing and testing competency levels for laparoscopic skills training.
HYPOTHESIS: Expert levels can be developed for use as training end points for a basic video-trainer skills curriculum, and the levels developed will be suitable for training. DESIGN: Fifty subjects with minimal prior simulator exposure were enrolled using an institutional review board-approved protocol. As a measure of baseline performance, medical students (n = 11) and surgery residents (n = 39) completed 3 trials on each of 5 validated video-trainer tasks. Four board-certified surgeons established as laparoscopic experts (with more than 250 basic and more than 50 advanced cases) performed 11 trials on each of the 5 tasks. The mean score was determined and outliers (>2 SDs) were trimmed; the trimmed mean was used as the competency level. Baseline performance of each subject was compared with the competency level for each task. SETTING: All research was performed in a laparoscopic skills training and simulation laboratory. PARTICIPANTS: Medical students, surgical residents, and board-certified surgeons. MAIN OUTCOME MEASURES: Expert scores based on completion time and the number of subjects achieving these scores at baseline testing. RESULTS: For all tasks combined, the competency level was reached by 6% of subjects by the third trial; 73% of these subjects were chief residents, and none were medical students. CONCLUSIONS: These data suggest that the competency level is suitably challenging for novices but is achievable for subjects with more experience. Implementation of this performance criterion may allow trainees to reliably achieve maximal benefit while minimizing unnecessary training.
Clinical Competence↗
Determining standards for laparoscopic proficiency using virtual reality.
Laparoscopic training using virtual reality has proven effective, but rates of skill acquisition vary widely. We hypothesize that training to predetermined expert levels may more efficiently establish proficiency. Our purpose was to determine expert levels for performance-based training. Four surgeons established as laparoscopic experts performed 11 repetitions of 12 tasks. One surgeon (EXP-1) had extensive Minimally Invasive Surgical Trainer-Virtual Reality (MIST VR) exposure and formal laparoscopic fellowship training. Trimmed mean scores for each were determined as expert levels. A composite score (EXP-C) was defined as the average of all four expert levels. Thirty-seven surgery residents without prior MIST VR exposure and two research residents with extensive MIST VR exposure completed three repetitions of each task to determine baseline performance. Scores for EXP-1 and EXP-C were plotted against the best score of each participant. On average, the EXP-C level was reached or exceeded by 7 of the 37 (19%) residents. In contrast, the EXP-1 level was reached or exceeded by 1 of 37 (3%) residents and both research residents on all tasks. These data suggest the EXP-C level may be too lenient, whereas the EXP-1 level is more challenging and should result in adequate skill acquisition. Such standards should be further developed and integrated into surgical education.
Clinical Competence↗
Hand-assisted laparoscopic donor nephrectomy: a low rate of complications.
BACKGROUND: Laparoscopic donor nephrectomy is associated with a higher incidence of ureteral complications. Hand-assisted dissection minimizes the use of instruments for intraoperative retraction and handling of periureteric tissue, and may reduce posttransplant complications. OBJECTIVE: To assess the outcome of hand-assisted laparoscopic donor nephrectomy, in particular ureteral complications. METHODS: Records of 143 kidney transplant recipients who received allografts removed using the hand-assisted laparoscopic technique were retrospectively studied. RESULTS: Total operating time was 2.0 +/- 0.55 (range 1.08-4) hours. Warm ischemia time was 1.45 +/- 0.60 (range 0.58-3.00) minutes. Length of artery, vein, and ureter was 2.4 +/- 0.5 cm, 3.0 +/- 0.5 cm, and 10.3 +/- 2.1 cm, respectively. Estimated blood loss averaged 86.3 +/- 55.6 mL. Intraoperative suction was not needed in 65% of patients. Two donors developed incisional hernias and 1 had a postoperative ileus. Four of 143 (2.8%) recipients developed ureteral complications: reoperations for ureteral necrosis (1), stenting for ureteral stenosis (2), and urethral catheterization for ureterovesical leak (1). Graft loss in the first year after transplantation occurred because of renal vein thrombosis, thrombosis of revised arterial anastomosis, arterial thrombosis due to myocardial infarction, vasculitis, focal segmental glomerulosclerosis, and chronic rejection. Delayed graft function developed in 3 recipients. The acute rejection rate was 14.6%. Mean serum creatinine levels at 1 and 3 years were 134 +/- 61 micromol/L (1.52 +/- 0.69 mg/dL) and 121 +/- 35 micromol/L (1.37 +/- 0.40 mg/dL), respectively. CONCLUSIONS: Hand-assisted laparoscopic donor nephrectomy is associated with a low incidence of ureteral complications; may reduce the technical difficulty of the operation and minimize retraction with instruments, resulting in fewer complications for donors and recipients; and minimizes donor blood loss.
Adolescent↗
Umbilical hernia repair in cirrhotic patients: utility of temporary peritoneal dialysis catheter.
Umbilical herniorrhaphy in cirrhotic patients with ascites is associated with a significant morbidity, recurrence rate, and mortality and therefore is often managed expectantly. Operative repair is indicated if an ascites leak or infection develops. Surgeons must consider the management of postoperative ascites to reduce recurrence rates and complications. We present a unique method using temporary peritoneal dialysis catheter placement (PD). Eight patients with moderate to massive ascites underwent umbilical herniorrhaphy with concomitant peritoneal dialysis placement. Patients have been followed for 8 to 30 months. All patients had successful repair of their hernia with 1 recurrence at 6 months and 1 late death (14 months). Patients were able to effectively control ascites using the PD catheter at home. There were no postoperative infections. The placement of a temporary PD catheter during umbilical herniorrhaphy provides a method for effective control of ascites in patients with cirrhosis. The technique has several advantages including outpatient management during the postoperative period and for easy removal of the catheter when no longer needed.
Adult↗
Cadaveric kidney transplant complicated by rupture of native kidney angiomyolipoma: a case report and review of the literature.
Kidneys with angiomyolipomas have been used for transplantation, but we are unaware of postoperative hemorrhage from a native kidney angiomyolipoma. A 49-year-old male who underwent a cadaveric renal transplant complicated by postoperative hemorrhage from a native kidney angiomyolipoma is presented. Evaluation and current management strategies are discussed.
Adult↗
Use of the LigaSure vessel sealing device in laparoscopic living-donor nephrectomy.
BACKGROUND: Laparoscopic living-donor nephrectomy has gained acceptance within the transplant community. The technique requires advanced laparoscopic techniques, and great care must be taken to ensure safety of the operation for the donor and transplantability of the donor kidney. Minimizing the risk of bleeding and trauma to the kidney are important features of a successful living-donor nephrectomy. Improved laparoscopic instrumentation has afforded greater safety and efficacy through technical advances. METHODS: The LigaSure device was used in 124 consecutive living-donor nephrectomies beginning in 1999. A transplant database was reviewed for operative statistics including intraoperative blood loss and operating time. RESULTS: The LigaSure device was used to dissect and seal all venous and arterial branches. Estimated blood loss was 90 +/- 53 mL. A suction device was required in only 40 (32%) of the cases. No patient experienced postoperative bleeding. There were two donor complications: one incisional hernia and one ileus. All kidneys functioned immediately upon reperfusion. CONCLUSIONS: The LigaSure device is an extremely effective tool for obtaining hemostasis by sealing both venous and arterial branches of the major renal vessels. This is also effective in sealing lymphatic tissues and thereby facilitating dissection. Avoiding the use of metallic clips simplified final division of the renal artery and vein. As with any laparoscopic instrument, the anatomic geometry of the operative field may limit use based upon port placement.
Adolescent↗
Factors affecting patient-physician communication via the Internet.
Patients with chronic diseases would potentially benefit greatly from more rapid communication with their health provider of their medical status, healthcare concerns, and personal medical information such as vital signs, blood sugar, and medication use. This study surveyed patients in a multidisciplinary transplant and liver disease clinic to determine whether they would consider using an Internet-based system for medical management of their illness, what specific factors would impact their use of such a system, and what limitations might be encountered with respect to patient education, socioeconomic status, and Internet access.
Attitude to Computers↗
Internet use by a multidisciplinary transplant clinic population.
BACKGROUND: This study was designed to determine patterns of patient Internet use and to define socioeconomic and other barriers that affect such use. METHODS: A 44-item questionnaire was distributed to patients seen in the transplant clinic during April 2001. RESULTS: A total of 170 patients completed the questionnaire. Fifty-six percent had access to the web. Seventy-two (42%) were African American, and 85 (50%) were Caucasian. Internet use was higher among Caucasian patients, but education level had the strongest correlation. Seventy-three percent of patients with a college education had Internet access compared with 38% of patients with a high school diploma. Twenty-two percent of patients used the Internet to find information about their doctor, and 35% searched for transplant survival results. CONCLUSIONS: Patients use the Internet to find information about their doctors and results of transplantation and other treatments. Physicians should consider establishing guidelines for use of Internet services by patients for education and communication.
Adult↗
Radiofrequency ablation of recurrent cholangiocarcinoma.
Intrahepatic recurrence of cholangiocarcinoma after primary resection has traditionally been considered a contraindication to surgical management. Improvements in ablative technologies such as radiofrequency ablation (RFA) offer the surgeon additional alternatives in the management of selected intrahepatic tumors. We present a case report of a single intrahepatic recurrence of cholangiocarcinoma 12 months after primary resection of extrahepatic cholangiocarcinoma including right lobectomy for intrahepatic extension. The patient received operative treatment and RFA of the intrahepatic lesion. RFA successfully ablated the recurrent tumor, and the patient remains free of detectable disease 10 months later. A review of literature is presented. This is the first known report of the use of RFA for intrahepatic cholangiocarcinoma. In selected cases of primary or recurrent cholangiocarcinoma, RFA may increase the percentage of patients considered surgically treatable.
Aged↗
Single-center analysis of living donor nephrectomy: hand-assisted laparoscopic, pure laparoscopic, and traditional open.
CONTEXT: Laparoscopic living donor nephrectomy has been shown to be a safe method for removing kidneys for transplantation, but concerns have been raised regarding safety and long-term kidney function. OBJECTIVE: To compare safety and long-term kidney function in hand-assisted laparoscopic, pure laparoscopic, and traditional open living donor nephrectomy. METHOD: The charts of 48 patients with more than 1 year follow-up were reviewed. Thirty-four consecutive patients underwent laparoscopic live donor nephrectomy, and 14 had open donor nephrectomy. All kidneys functioned immediately at transplantation. In the laparoscopic group, 11 had the pure laparoscopic technique, and 23 patients had hand-assisted laparoscopic nephrectomy. RESULTS: Total operative and warm ischemic times were reduced with the hand-assisted technique when compared with pure laparoscopy. Operative and warm ischemic times were similar in open nephrectomy and hand-assisted laparoscopy. Long-term follow-up of serum creatinine levels revealed no significant differences between the 3 groups. Complication rates in the 3 groups were similar. CONCLUSION: Laparoscopic donor nephrectomy appears to be comparable to open donor nephrectomy in terms of safety and long-term graft function.
Adolescent↗
Dialysis access-induced superior vena cava syndrome.
Vascular thrombosis is a complication of dialysis access and thrombosis of the superior vena cava by indwelling dialysis catheters access can cause superior vena cava syndrome. We describe a case of superior vena cava syndrome resulting from a dialysis access catheter placed in the internal jugular vein. Although surgical intervention is often needed to treat dialysis access-related superior vena cava syndrome this patient required only conservative measures for resolution of the syndrome. In this paper we describe the presentation, diagnosis, and management of this case. A review of dialysis access thrombosis complications and treatment options is also presented.
Adult↗
Laparoscopic nonanatomic hepatic resection employing the LigaSure device.
BACKGROUND: Advancements in technology have allowed laparoscopic surgery to expand into advanced procedures such as liver resection; however, the value and safety of laparoscopic liver surgery is still a topic for debate. This study was designed to evaluate the feasibility and outcome of laparoscopic nonanatomic hepatectomy using the LigaSure device in a swine model. METHODS: Nonanatomic hepatic lobe resection was performed in 3 groups comparing the open finger-fracture method, the open method with the LigaSure device, and the laparoscopic method with the LigaSure device. The cut surfaces of the liver were evaluated for bleeding and biliary leakage at the time of the operation. The animals were inspected 48 hours later for hemorrhage and evaluated with cholescintigraphy (hepatobiliary iminodiacetic acid [HIDA] scan) for biliary leakage, in addition to histological evaluation of liver specimens. RESULTS: No hemorrhage or biliary leakage was noted in the groups where the LigaSure device was used, whereas 1 animal from the open finger-fracture method sustained a bile leak observed on HIDA scan. The operative blood loss was considerably less in the groups where the LigaSure device was used, and the shortest operative time was observed in the laparoscopic group. CONCLUSIONS: The LigaSure device can be safely and effectively used to perform a laparoscopic nonanatomic hepatectomy.
Animals↗