Laparoscopic vs. Open Live Donor Nephrectomy: A Multivariate Patient Outcomes Analysis

Kidney transplantation is the best treatment for chronic renal failure patient (CRF), because in this treatment the patient will have normal life and also it is more cost effective than other methods for treatment of CRF.One of the major problems with the kidney transplantation is shortage of the kidney donor.Besides deceased donor, live kidney donors (related and unrelated) are selected for solving the problem of kidney donor shortage.Two approaches are used for removing kidney from live donors including: open nephrectomy and laparoscopic nephrectomy.The short stay at hospital is mentioned as one of the advantages of laparoscopic donor nephrectomy that is a factor for increasing live donor volunteer.At our center, we studied the issue: how long is the time of hospital stay of the kidney donor who has been operated as open nephrectomy and is it different with that reported for laparoscopic donor nephrectomy?Methods: The time of hospital stay of 326 kidney donors (35 females, 291 males) post operation have been studied as retrospectively at kidney transplant center of Imam Reza hospital from 2005 to 2011. Results:In 326 kidney donors, 48 donors after second day of operation, 276 donors after third day of operation, one donor after eight day of operation, and one donor after sixth day of operation had been discharged from the hospital, for all the kidney donors the operation had been done through trans flank incision and retroperitoneal and without the rib resection. Conclusion:In this study, considering the hospital staying time of open nephrectomy donors, it is understood that nearly one hundred percent of donors had been discharged from the hospital until third day of operation so it seems that the hospital stay of the open nephrectomy donors are comparable with the reported time for hospital stay of laparoscopic nephrectomy donors.

Open nephrectomy surgery in a kidney donor involves pain and many risks after the surgery, which leads to the inability to perform normal activities. For this reason, today the laparoscopic nephrectomy method is preferred in order to avoid complications and to return to normal life sooner. However, it is very critical to assess the impact of modifying the surgical technique on the outcome of kidney donation. Thus, the present study was undertaken with the following specific objective: a comparative study of the renal profile of live kidney donors who have undergone open and laparoscopic nephrectomy. The study in the present report was cross-sectional in nature. Participants included 91 kidney donors who had undergone either open nephrectomy (n = 46) or laparoscopic nephrectomy (n = 45). Data on the level of initial basic renal function, the duration of surgery, and the duration of hospitalization, together with the course of renal function in the 6 months after surgery, were collected. The data were analyzed using the Statistical Package for the Social Sciences, version 27 (SPSS version 27). The mean age of kidney donors was 29.4 ± 4.8 years, and all patients were male (100%). Body mass index and weight were comparable between the open and laparoscopic nephrectomy groups, with no statistically significant differences (P> 0.05). The mean duration of surgery in the open nephrectomy group (2.37 ± 0.30 hours) was significantly shorter than that in the laparoscopic group (3.37 ± 0.13 hours) (P< 0.001). The mean length of hospital stay was significantly shorter in the laparoscopic group (3.31 ± 0.31 days) compared to the open group (4.06 ± 0.04 days) (P< 0.001). GFR decreased significantly in both groups at discharge and 6 months postoperatively compared to baseline (paired t-test, allP< 0.001), but there was no significant difference in GFR between groups at any time point (P> 0.05). Both groups experienced a significant postoperative decline in hemoglobin, with a greater reduction in the open group (-1.59 ± 0.79 g/dL) compared to the laparoscopic group (-1.05 ± 0.95 g/dL) (P= 0.004). White blood cell counts increased postoperatively in both groups, with no significant difference between them (P= 0.118). Surgical complications included transection of the superior polar artery in 5.5% of cases. In laparoscopic nephrectomy, the time of surgery is longer, but the days of hospitalization after surgery do not differ and do not negatively affect the return of donor kidney function compared to the open method. Moreover, post-surgical problems have not been very frequent and are manageable in the best way possible.

Live-donor kidney transplants accounted for only 27% of all kidney transplants performed in the United States in 1995. Prolonged hospitalization, pain, extended convalescence, and related socioeconomic concerns associated with traditional open-donor nephrectomy surgery may discourage potential donors, contributing to a low percentage of live kidney donors. To remove such disincentives, the laparoscopic live-donor nephrectomy procedure was introduced. In this study, the postdischarge course of 10 laparoscopic nephrectomy donors was compared with that of 27 open nephrectomy donors over the same time period. Laparoscopic nephrectomy donors experienced significantly shorter hospitalizations, less pain, felt able to return to work and normal routines sooner, and needed significantly less assistance during the recuperation period than did open nephrectomy donors. The laparoscopic nephrectomy procedure may decrease many of the concerns of potential donors, thus making live kidney donation more attractive and increasing the kidney supply.

The Impact of Hospital-Acquired Infection on Outcome in Acute Pancreatitis

Mo1061 Analysis of Factors Predictive of Postoperative Complications in Whipple Procedure

Introduction: Protein Energy Malnutrition (PEM) is common among adults with chronic medical conditions, especially in patients with chronic heart, lung disease and malignancies. These conditions are associated with worse in hospital outcomes. However, the complex relationship between chronic medical conditions and PEM make the true effect of PEM on outcomes difficult to ascertain. This is compounded by the relative underdiagnosis of PEM in adults. Our study aimed to determine if PEM is an independent risk factor for adverse outcomes among patients with infective endocarditis (IE) who had mitral valve (MV) and /or aortic valve (AV) replacement surgery. Methods: Data was obtained from the National Inpatient Sample for 2016 &amp; 2017. Studied cohort were patients with IE who underwent AV and /or MV replacement. This group was divided by presence or absence of PEM using ICD-10 codes. Primary outcome was inpatient mortality. Secondary outcomes were total hospital charges, length of stay (LOS), NSTEMI, post procedural cardiac complications, acute kidney failure (AKI) and need for intra aortic balloon pump (IABP). Multivariate logistic and linear regression models were used to compare outcomes. Results: A total of 4275 hospitalizations met the inclusion criteria, of which about a fifth (20.12%) had PEM.Patients with PEM had higher adjusted odds of post procedural cardiogenic shock (aOR: 3.65, 95% CI: 1.724 - 7.746), and need for IABP placement (aOR: 4.01, 95% CI: 1.958 - 8.199), as well as significantly higher mean difference in total hospital charges and length of stay, relative to patients without PEM. There was however no significant difference in mortality, composite post procedural cardiac complications, NSTEMI or AKI between the PEM and non-PEM subgroup. Conclusion: PEM is associated with post procedural cardiogenic shock and intra-aortic balloon pump placement in patients with infective endocarditis who underwent valve replacement surgery but this impact did not translate to higher mortality. More research is needed to elucidate the role of PEM as a major comorbidity.

The General Public's Concerns about Clinical Risk in Live Kidney Donation

Modifications of Renal Blood Flow and Serum Interleukin Levels Induced by Laparoscopic and Open Living Donor Nephrectomies For Kidney Transplant: An Experimental Study in Pigs

Many autosomal dominant polycystic kidney disease (ADPKD) patients undergo nephrectomy and subsequent renal transplantation. We report our outcomes after hand-assisted laparoscopic nephrectomy (HALN) where a Rutherford-Morrison incision is used as a hand-port site and kidney extraction site, as well the future incision site for staged transplantation. A retrospective review was performed on all adult nephrectomies for ADPKD by the Transplant Surgery department at Westmead Hospital between June 2011 and June 2021. Outcomes were compared between HALN, laparoscopic nephrectomy (LN) and open nephrectomy (ON) including operation time, hospital length of stay (LOS), post-operative complications, subsequent transplantation and post-transplantation wound complications. Twenty-two HALN, 8 LN and 5 ON were performed during the study period. Median kidney weights for HALN, LN and ON were significantly different (1575, 403, 3420 g respectively, P= 0.001). There was a significant difference in LOS between the HALN and ON (5.8 versus 9.8 days, P= 0.04), but not between HALN and LN (5.8 versus 5.1, P= 0.06). There was no significant difference for operation time (P= 0.34) and major complication rates (P= 0.58). There were 8 HALN, 5 LN and 2 ON who have had subsequent renal transplantation with one wound complication, an incisional hernia in the HALN group. Our HALN is associated with a shorter LOS and similar complication rate to ON and can be efficiently performed for significantly larger kidneys than LN without a significant difference in operation time or LOS. The same Rutherford-Morrison incision site can be used for transplantation.

For anatomical and technical reasons, many transplant centers restrict laparoscopic live donor nephrectomy (in contrast with open live donor nephrectomy) to left kidneys. This change in surgical practice increases procurement and transplantation rates of live donor kidneys with multiple renal arteries (RAs), without affecting donor and recipient outcomes. Retrospective review at an academic tertiary care referral center comparing laparoscopically procured single vs multiple-RA kidney grafts (April 1997 to October 2000). Seventy-nine consecutive left laparoscopic live kidney donors and 78 transplant recipients. Donor and recipient complications and postoperative length of stay; cold and warm ischemia time; operating time; short-term and long-term graft function; and survival. We noted multiple RAs in 21 (27%) of all kidneys. The proportion of donors with 1 or more perioperative complications was 19% in the single-RA group vs 10% in the multiple-RA group (P was not significant). For the recipients, we noted no significant differences between groups with respect to surgical complications, quality of early and late graft function, rejection rates, graft losses (all immunologic), and graft survival. Cold and warm ischemia time and length of stay were similar for donors and recipients in both groups. Median operating times were significantly longer for the multiple-RA vs single-RA group (difference, 41 minutes for donors and 45 minutes for recipients; P<.02). While the introduction of laparoscopic live donor nephrectomy has significantly increased the number of grafts with multiple RAs (compared with historical open controls), this change in practice is safe for both donors and recipients from a patient outcome-based perspective. However, from an economic perspective, the longer operating time associated with multiple-RA grafts provides strong added rationale for optimization of surgical instruments and techniques to make right-sided laparoscopic nephrectomy a routine intervention.

Numerous studies have demonstrated the feasibility of laparoscopy in the management of acute adhesive small-bowel obstruction (AASBO). However, comparative data with laparotomy are lacking. The aim of this study was to compare laparoscopy and laparotomy for the treatment of AASBO in terms of patient outcome and cost-effectiveness. A retrospective chart review of all patients who underwent surgery for AASBO from 1999 to 2005 was conducted. Data recorded included operative and postoperative course, among others. Operative and total hospital charges were estimated from the Patient Accounting System. Thirty-one patients who underwent laparoscopy were matched to a similar group of patients who underwent laparotomy. In the laparoscopy group, four patients (13%) had a laparoscopy-assisted procedure and ten patients (32%) were converted. The laparoscopy group was subdivided into laparoscopy, laparoscopy-assisted, converted, and assisted-converted subgroups. In the majority of the patients, AASBO was secondary to a single band. Overall morbidity was significantly higher in the laparotomy group (p = 0.007). Morbidity rates were statistically significant between the laparoscopy and assisted-converted subgroups (p = 0.0001) but not between the laparotomy group and assisted-converted subgroup (p = 0.19). Median hospital stay and median time to first bowel movement were significantly shorter in the laparoscopy group. Charge data were available for only the last three years of the study. Operative charges and total hospital charges were similar between the laparoscopy and the laparotomy groups (p = 0.14 and p = 0.10, respectively). There was a significant difference in total hospital charges between the laparoscopy subgroup and laparotomy group (p = 0.03). Laparoscopy for AASBO is associated with reduced hospital stay, early recovery, and decreased morbidity. Laparoscopy-assisted and converted surgeries do not differ significantly from laparotomy in regard to patient outcome. Operative and total hospital charges are similar for both laparoscopy and laparotomy.

Background Kidney transplantation is the preferred treatment for patients with end stage renal failure in industrialized countries, but its availability is very limited in Sub-Saharan Africa. In Ethiopia, this option was accessible for only those few who could afford to travel abroad with their living donors for donation and transplantation. In collaboration with faculty from the University of Michigan (UM), the Federal Democratic Republic of Ethiopia, National Kidney Transplant Center, the first Ethiopian kidney transplant program, was launched at Saint Paul’s Hospital Millennium Medical College (SPHMMC) in Addis Ababa in Sept 2015. This study reports on live donor and recipient kidney transplant outcomes to date. Methods This is a retrospective cross sectional qualitative study of live kidney transplant performed at Saint Paul Hospital Millennium Medical College. Results This study reports on live donor and recipient kidney transplant outcomes to date. From September 2015 through February 2018, a total of 70 live kidney transplants were performed at Saint Paul’s Hospital Millennium Medical College (SPHMMC). All procedures were performed by SPHMMC transplant team in collaboration with University of Michigan faculty and later experiences from Hospital Do Rim Sao Paulo Brazil was incorporated. All of recipients were 1st time recipients HLA typing and crossmatch were performed off site B and T cell crossmatch were negative by the CDC method in all patients None of the recipients have significant titer of Anti-HLA antibodies. Majority of donors were females (53.8%) and majority of recipients were males (60%). Donor age ranged from18 to 66 with a mean of 30.2 years. Mostly donors were siblings (40%) or parents (12%) of the recipient. Donor Outcomes 47 were initially hand assisted Laparoscopic nephrectomies (one conversion) with conversion rate of 6.7 % (due to intraperitoneal adhesions ), the remaining twenty three were open donor nephrectomi with after an experience sharing at hospital Do rim in Brazil(a mini-incision (~10 cm) open donor nephrectomy technique has been utilized). There was 100% survival, two re -hospitalization for lymphocele. 1 donor complication – Heamopneumothorax,and Small bowel obstruction requiring exploration, Prolonged hospital stay (14 days) and another with major bleeding during open donor nephrectomy. Recipient Outcome There was only one hyper-acute rejection and four graft censored death one having superficial surgical site infection and one suffering from Atelectasis. Conclusion Despite challenges arising from a resource-limited setting, outcomes of Living Donor Kidney Transplantations (LDKT) performed at SPHMMC are comparable to international standards. Blending experiences from different countries and evolving into a more suitable contextual implimentation of LDKT makes the prospects for sustainable Living Donor Transplantation in Ethiopia are promising. Ethiopian Mistry of Health.

Experiences of the Live Organ Donor: Lessons Learned Pave the Future Dianne LaPointe Rudow Introduction The experience of a live organ donor is multi–faceted and is as unique as each person who agrees to take a risk to save another. Factors include: type of organ donated (kidney vs. liver), relationship to the recipient (related—biological or non–biological vs. non–related), decision–making and motivation for donation, support systems available within and outside of the transplant program, and outcomes of the donation for both recipient and donor. The variety of experiences is apparent in the narratives within this special issue. I want to thank the authors of each story for sharing their experiences of the live donation process. As difficult as it must have been to write, it was difficult for someone like me, a transplant professional who is a strong advocate for quality donor care, to hear. But with each success and failure of transplantation, we can learn in the hopes of improving things for the next. Despite the fact that the field of transplantation is over 50 years old and the first kidney donors were live donors, viewing the field of live donation as a subspecialty of transplantation is a new concept (LaPointe Rudow, 2011). Live donation is, in fact, as specialized as lung transplant, liver transplant, transplant infectious disease, and kidney transplant. All of those subspecialties have clinicians and researchers with expertise in the area. Live donation experts exist and teams of live donor professionals staff most transplant programs today. Additionally regulatory bodies, professional societies, and advocacy groups strive to improve the care of the live organ donor (Medicare Conditions of Participation, 2007; Organ Procurement and Transplant Network, 2011; National Kidney Foundation 2011). Many years have been spent perfecting the surgical procedure and refining the proper testing to ensure that donation is safe for the donor. Live donation is, however, more than a surgery; in recent years, transplant professionals acknowledge that the psychosocial impact of donation on donors, whether positive or negative, can be significant but it is not yet completely understood. Much debate has occurred as to the components of the psychosocial evaluation, length and type of follow up, and the role of the independent live donor advocate (Amsterdam Forum, 2005; Ommen et al. 2011; Pruett et. al. 2006; Schroder et. al. 2008; Simpson & Pomfret 2012). The ethical concepts of paternalism and autonomy are in tension as we attempt to justify live donation. Perhaps nowhere else is ethical deliberation more vigorous than in the debate regarding whether informed consent for live donation is attainable, driven largely by the plight of the patient and the consequent vulnerability of the donor in an effort to help the patient. These quandaries are illustrated in the compelling narratives of this special issue. [End Page 45] Narrative Themes Based on an analysis of the narratives, I will present a series of dominant themes that emerged from the stories; these will be exemplified by illustrative quotations from the live donor’s narratives. Live Donation has Psychological Effects on the Donor There are many psychological effects of live donation both pre–and post–donation. The narratives describe feelings such as “I felt like a hero,” “feelings of anxiety, anger and ambivalence,” “it’s the best thing I ever did,” “I would do it all over again,” “a sense of loss,” and feelings of “suicidal thoughts.” The dichotomy of feelings expressed demonstrates the uniqueness of the live donor experience. One donor has nothing but good things to report regarding his or her experience while another feels lasting ill emotional affects requiring ongoing counseling even though the recipient has done well. Pre–donation psychological issues Traditionally, the psychosocial evaluation explores the pre–donation emotional and family stressors to ensure that there are no issues or underlying psychiatric disorders that will make donation high risk for psychological complications. All donors writing the narratives were found to be suitable donors. That being said, there is no standardized approach to the psychological evaluation. Organ Procurement and Transplant Network (OPTN)/United Network for Organ Sharing (UNOS) (Organ Procurement and Transplant Network, 2011) have policies and guidelines and the Centers for Medicare Conditions of Participation (COP) (Medicare Conditions of...

Laparoscopic Living Donor Nephrectomy: A Look at Current Trends and Practice Patterns at Major Transplant Centers Across the United States

Introduction: Insurance status on admission has been associated with mortality after trauma. Hypothesis: We hypothesized that outcome and care delivery is unaffected by insurance stauts in our trauma center Methods: We retrospectively reviewed patients admitted to our center over 10 years. Baseline demographics, insurance status, injuries, toxicology, type of insurance (public vs. private) co-morbidities, and admission physiology were abstracted from the trauma registry. Logistic regression was used to determine the independent effect of insurance status on in-hospital mortality. Results: 62,073 patients were analyzed. Mortality was 4.4%. 27.8% were uninsured. Unadjusted mortality for uninsured vs. insured patients was 5.9% vs. 3.8% (p<0.0001). Adjusting for demographics, injury severity, number of co-morbidities, mechanism of injury, toxicology, and admission physiology, mortality was not associated with insurance status (OR=0.87, CI=0.74-1.02). In adjusted analysis there was also no difference in hospital charges between patients with and without insurance. When looking at types of insurance, crude mortality rates were 2.7% for private insurance, 9.4% for Medicare, and 5.2% for Medicaid (p<0.0001). In adjusted analysis, there was no difference in mortality when comparing those with public insurance vs. no insurance (OR=0.90, 0.71-1.15 for Medicare; OR=1.04, 0.76-1.42 for Medicaid), but private insurance was associated with lower mortality (OR=0.84, 0.71-0.99). When comparing those patients with insurance to those without, there was no difference in total hospital charges in adjusted analysis. Conclusions: Mortality following injury is not independently associated with lack of insurance, but rather affected by pre-injury factors and injury severity. Private insurance was associated with better outcome, although public insurance was equivalent to no insurance. In our trauma center hospital resource allocation does not seem to be affected by insurance status.