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doi: 10.1001/archsurg.2009.173pmid: 19841354
Abstract JAMA Access to Kidney Transplantation Among Remote- and Rural-Dwelling Patients With Kidney Failure in the United States Marcello Tonelli, MD, SM; Scott Klarenbach, MD, MS; Caren Rose, MSc; Natasha Wiebe, MMath; John Gill, MD, MS Context: US residents with end-stage renal disease (ESRD) may live far away from the closest transplant center, which could compromise their access to kidney transplantation. Objective: To assess access to kidney transplantation as a function of distance from the closest transplant center or as a function of rural rather than urban residence. Design, Setting, and Participants: Observational study of 699 751 adult patients with kidney failure who had initiated renal replacement in the United States between 1995 and 2007 and were thus placed on a prospective mandatory registry list. Main Outcome Measures: Time to placement on the kidney transplant waiting list and time to kidney transplantation, both measured at the start of renal replacement. Results: During a median follow-up of 2.0 years (range, 0.0-12.5 years), 122 785 (17.5%) patients received a kidney transplant. Median distance to the closest transplant center was 15 miles. Participants were classified into distance categories by miles from a transplant center with 0 to 15 miles serving as the referent category. Compared with the referent category, the adjusted hazard ratios of deceased or living donor transplantation within each category follows: 16 to 50 miles, 1.03 (95% CI, 1.02-1.05); 51 to 100 miles, 1.11 (95% CI, 1.09-1.12); 101 to 136 miles, 1.14 (95% CI, 1.11-1.17); 137 to 231 miles, 1.16 (95% CI, 1.13-1.20); 232 to 310 miles, 1.20 (95% CI, 1.12-1.28); and more than 310 miles, 1.16 (95% CI, 1.09-1.23). When residence location was classified using rural-urban commuter areas, 79.6% of patients lived in urban; 10.3%, micropolitan; and 10.0%, rural areas. Compared with those living in metropolitan areas, the adjusted hazard ratios of deceased or living donor transplantation among patients residing in micropolitan communities was 1.13 (95% CI, 1.11-1.15) and 1.15 (95% CI, 1.13-1.18) for rural areas. Results were similar for both deceased donor and living donor transplantation and were consistent in multiple sensitivity analyses. Conclusion: Remote or rural residence was not associated with increased time to kidney transplantation among people treated for ESRD in the United States. JAMA. 2009;301(16):1681-1690. Since the formation of the Organ Procurement and Transplantation Network by the US Congress in 1984, the transplant community has worked to ensure equal access to the scarce national resource of solid organs for transplantation. However, policy cannot ensure equality, as many of the decisions required to gain access to transplantation are subjective. These steps include provider referral for evaluation by a transplant center, patient initiation and completion of evaluation requirements, acceptance for transplantation by a transplant center, organ offer by the transplant center, and organ acceptance by the patient. Variations in attitudes, resources, and policy interpretation by patients and providers alike have unfortunately resulted in disparities in access to transplantation across many domains, including sex, race, age, and socioeconomic status. Fortunately, as Tonelli and colleagues have nicely demonstrated, distance from transplant center and rural residence are not among these domains, at least not when kidneys are concerned. Thanks to mandated national registries from the United States Renal Data System and the Organ Procurement and Transplantation Network, every patient in the United States who develops end-stage renal disease is carefully tracked from initial onset of dialysis, to registration for the kidney waiting list, to transplantation, to organ failure, to retransplantation, and so forth, until death. This provides a powerful opportunity to study access to surgical treatment, since the population of possible surgical candidates and the subset who receive surgery are both fully enumerated. Inferences derived from this rich cohort are likely generalizable to many surgical specialties in which such studies would not be possible. Correspondence: Dr Segev, Division of Transplantation, Johns Hopkins University, 720 Rutland Ave, Ross 771B, Baltimore, MD 21205 ([email protected]). Financial Disclosure: None reported.
doi: 10.1001/archsurg.2009.34pmid: 19852096
Yamamoto and colleagues are to be congratulated on the third and, thus far, the largest single-institution series examining the addition of a buttress to reinforce a stapled distal pancreatic transection. I, along with my colleagues, have also presented a case series on this subject,1 and, like my own, the article by Yamamoto et al has a number of significant shortcomings that prevent a definitive conclusion regarding the effectiveness of buttressing. In this series, the authors interpret their data to suggest that the use of Seamguard to reinforce a stapler likely reduces the incidence of pancreatic occlusion failure. The major weakness of their conclusion stems from the fact that this is a retrospective review of nonstandardized techniques used at the surgeon's discretion. The possibility that these results represent nothing more than accidental selection of a favorable patient group should be strongly considered. An example of how surgeon bias can unwittingly return a statistically significant result in a retrospective review is present in this same article. The authors demonstrate that use of octreotide causes a significant increase in the rate of pancreas occlusion failure (odds ratio, 4.2). As the authors hint at in the “Comment” section, it is more likely that surgeons used octreotide if they believed the risk for leakage was elevated. The authors rightfully conclude that a multi- institutional study would likely best define the true effect of buttressing a staple line. In our experience, not all pancreases can be stapled, including, for example, the very thick pancreas, the fibrotic pancreas, and the pancreas with a triangular shape. We believe nothing short of a randomized, controlled trial will adequately address the significant potential for selection bias. To avoid bias, surgeons could determine the randomization schema after they decide that a pancreas is suitable for stapling. To measure the effect of the buttressing material, a uniform stapler and stapler size should be predetermined. The appropriate comparison group would not be all other closure types but a naked staple line vs a buttressed staple line. Correspondence: Dr Hawkins, Department of Surgery, Washington University School of Medicine, 66 S Euclid Ave, Campus Box 8109, St Louis, MO 63110 ([email protected]). Financial Disclosure: None reported. References 1. Thaker RIMatthews BDLinehan DCStrasberg SMEagon JCHawkins WG Absorbable mesh reinforcement of a stapled pancreatic transection line reduces the leak rate with distal pancreatectomy. J Gastrointest Surg 2007;11 (1) 59- 65PubMedGoogle ScholarCrossref
doi: 10.1001/archsurg.2009.35pmid: 19852097
As a complication of both open and endovascular repair of AAAs, colonic ischemia, or ischemic colitis, may require nonvascular abdominal surgeons to assist in diagnosis and management. This report documents a large experience with elective EVAR for infrarenal AAA with a commendably low incidence of colonic ischemia of 1.4%. This low incidence is all the more admirable in that it includes late-appearing colonic ischemia beyond the immediate postoperative interval. Among the frequently cited mechanisms for colonic ischemia after intervention for AAA, this series illustrates that emboli from intraluminal manipulations can cause severe, even fatal, ischemia and that coil embolization of 1 hypogastric artery is associated with a small increase in the incidence of ischemia. Intraoperative occlusion of the IMA, commonly part of open aneurysm repair and universal with EVAR, did not by itself cause ischemia in this series. However, patients with chronic abdominal aneurysms of a size requiring intervention, as a group, have severe systemic atherosclerosis. The noted frequency of ischemia in “watershed areas” of colonic arterial supply raises the possibility that long-term or acute occlusion of the IMA or coil occlusion of 1 hypogastric artery may contribute to gut ischemia by reducing the opportunity for collateral flow if there is occlusive atherosclerosis in other visceral arterial trunks. If that vulnerable pathological anatomy is present, low cardiac output or sepsis may precipitate symptomatic gut ischemia as described in this report. The widespread distribution of atherosclerosis and the consequent possibilities of end-organ ischemia need always to be kept in mind when managing acute abdominal complications in patients with AAAs, especially if they have undergone open or endovascular repair. Correspondence: Dr Bredenberg, Department of Surgery, Maine Medical Center, 22 Bramhall St, Portland, ME 04107 ([email protected]). Financial Disclosure: None reported.
Cescon, Matteo; Cucchetti, Alessandro; Grazi, Gian Luca; Ferrero, Alessandro; Viganò, Luca; Ercolani, Giorgio; Ravaioli, Matteo; Zanello, Matteo; Andreone, Pietro; Capussotti, Lorenzo; Pinna, Antonio Daniele
doi: 10.1001/archsurg.2009.98pmid: 19852098
The surgical management of HCC in the cirrhotic patient remains a tremendous challenge, despite an array of treatment options including hepatic resection, ablative techniques, and liver transplantation. Although not without controversy, most regard resection as the treatment option of choice for solitary, relatively small, resectable lesions in those cirrhotic patients with preserved liver function. Unfortunately, HCC recurrence is common and often affects overall survival. Thus, it is important to determine those factors that predict HCC recurrence for 2 reasons: first, to identify that population most likely to benefit from traditional resection and, second, to direct those at greatest risk for recurrence toward alternate modalities. In this article, the authors present their experience with resection for HCC in 204 patients. Although retrospective in nature, the patients included are fairly homogeneous: all were cirrhotic, with compensated hepatic function and relatively early HCC. By focusing on disease-free survival, the authors avoid the confounding effect that hepatic disease progression has on overall survival. Through a simple but thorough analysis, the authors demonstrate that a diagnosis of HBV infection negatively affects disease-free survival. As referenced, this result has been previously reported.1,2 Two observations are difficult to explain. First, HBcAb positivity, even without evidence of active viral replication, was an independent predictor of HCC recurrence. Second, HCV infection was not associated with HCC recurrence. The authors offer an explanation for the former observation but not the latter. Nonetheless, the independent association of HBV infection with HCC recurrence has important implications for the role of antiviral therapy after resection and for the consideration of adjuvant or alternative therapy (ie, liver transplantation) for patients at greatest risk of HCC recurrence. Correspondence: Dr Levi, Department of Surgery, University of Miami Miller School of Medicine, Highland Professional Building, 1801 NW Ninth Ave, Ste 327, Miami, FL 33136 ([email protected]). Financial Disclosure: None reported. References 1. Sun HCZhang WQin LX et al. Positive serum hepatitis e antigen is associated with higher risk of early recurrence and poorer survival in patients after curative resection of hepatitis B-related hepatocellular carcinoma. J Hepatol 2007;47 (5) 684- 690PubMedGoogle ScholarCrossref 2. Kubo SHirohashi KYamazaki O et al. Effect of the presence of hepatitis B e antigen on prognosis after liver resection for hepatocellular carcinoma in patients with chronic hepatitis B. World J Surg 2002;26 (5) 555- 560PubMedGoogle ScholarCrossref
doi: 10.1001/archsurg.2009.135pmid: 19852099
In their article, “Predictors of Long-term Mortality After Bariatric Surgery Performed in Veterans Affairs Medical Centers,” Arterburn et al make several salient conclusions. The first and most important point is that the postoperative mortality rate between 30 days and 1 year is higher than the 30-day postoperative mortality rate. The second point is that patients with a BMI greater than 50 and a diagnostic cost group score of greater than 2 were at increased risk for mortality at any point up to the year in which they were studied and that 25% of these patients died within the first 3.5 years of follow-up. In their unadjusted data, the authors found that male sex, older age, and higher American Society of Anesthesiologists classification also correlated with a higher risk of death in the first year after gastric bypass. These data are important because they correlate with data of other series that concern risk of death during the first year after gastric bypass.1-3 The mortality rate in this series, which is slightly higher than the national average, reflects many of the factors that contribute to increased mortality (ie, male, older, increased comorbidities). Despite seeing increased mortality up to 1 year, others have demonstrated a clear survival benefit of bariatric surgery during 5 to 10 years, with survival advantage (operated on vs not operated on) beginning at 6 months after surgery.4-6 Therefore, despite the fact that the mortality rate increases during the postoperative period up to 1 year, it is small and does not negate the several advantages for patients who undergo bariatric surgery. However, there seems to be a group of patients (male, older, high morbidity scores) in whom bariatric surgery may not offer a survival advantage. Correspondence: Dr Deveney, Department of Surgery, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239 ([email protected]). Financial Disclosure: None reported. References 1. Marsk RFreedman JTynelius PRasmussen FNäslund E Antiobesity surgery in Sweden from 1980 to 2005: a population-based study with a focus on mortality. Ann Surg 2008;248 (5) 777- 781PubMedGoogle ScholarCrossref 2. DeMaria EJMurr MByrne TK et al. Validation of the obesity surgery mortality risk score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity. Ann Surg 2007;246 (4) 578- 584PubMedGoogle ScholarCrossref 3. Sjöström LNarbro KSjöström CD et al. Swedish Obese Subjects Study, Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357 (8) 741- 752PubMedGoogle ScholarCrossref 4. Perry CDHutter MMSmith DBNewhouse JP McNeil BJ Survival and changes in comorbidities after bariatric surgery. Ann Surg 2008;247 (1) 21- 27PubMedGoogle ScholarCrossref 5. Peeters AO’Brien PELaurie C et al. Substantial intentional weight loss and mortality in the severely obese. Ann Surg 2007;246 (6) 1028- 1033PubMedGoogle ScholarCrossref 6. Adams TDGress RESmith SC et al. Long-term mortality after gastric bypass surgery. N Engl J Med 2007;357 (8) 753- 761PubMedGoogle ScholarCrossref
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