2018 Scholarship Winners

Grand Prize Winner
Novel Concept of Inducing Chronic Allograft Nephropathy in an Animal Model
Manu Kaushik, MD
, Resident Physician, St. John Providence Hospital, Michigan State University, Southfield, MI

Renal transplantation has an established superiority in prolonging the longevity of patients with end stage renal disease. Though impressive advancements have improved the short-term survival of the graft, long-term survival is still a major concern. Chronic allograft nephropathy (CAN) remains to be the leading cause of late allograft loss. We wish to simulate CAN in an animal model, to test our hypothesis that a low flow state in the kidney transplant is the primary etiology behind the manifestation of CAN. If successful, this animal model will be the first of its kind and will allow testing of new treatments and prevention techniques against CAN.

The initial phase of the study involved 7 rabbits in the control group. All 7 subjects underwent right sided nephrectomies. The remaining kidney was given 1 year to adapt and compensate, following which the control group subjects were euthanized and the kidney was harvested. The necropsied kidney were sent for histopathology to determine the adaptive changes that would be expected in the remaining kidney, which would mimic the transplanted kidney. The pilot phase of the study involved 5 rabbits.  All subjects underwent a right nephrectomy under general anesthesia. Postoperative kidney function tests were followed to assess the progressive change in renal physiology. After 4 weeks of adaption period, the second operation was performed which involved clipping of the left renal artery of the left kidney, providing at least 50 % occlusion to the inflow, to mimic the change in diameter from the aorta to the iliac artery. This was done to replicate the decrease in blood flow in the transplanted kidney compared to the native organ. Post operative kidney function was followed in the immediate postoperative period and the kidney functions were trended on day 1,7,14,21 and 28.

Rabbit 1,2 and 4 had renal function within normal limits (creatinine 0.8-1.8 mg/dl) throughout, however rabbit 3 was found to have a significant elevation in creatinine (13.8 mg/dl) on postoperative day two  and had to be euthanized secondary to a post operative stroke. Rabbit 4 had a severe elevation in creatinine on postoperative one with creatinine levels of 14.1. The rabbit expired on postoperative day 2 itself. Histopathology of the pilot study specimens with hemotoxylin and eosin stains did not show any structural changes. By including electron microscopy in our main experiment, we expect to notice substantial pathological changes in the tubulo-interstium of the harvested specimens.

Chronic allograft rejection continues to be a culprit in loss of a kidney transplant. Successful development of an animal model, which simulates chronic rejection will be an essential step in understanding the pathophysiology of the disease process.

Honorable Mention
Reoperation After Lobectomy: A Retrospective Review
Tessa Cartwright, MD
, MPH, Cardiothoracic Surgery Fellow, University of Kentucky, Lexington, KY

The two most common approaches for surgical resection of a lung lobe are open versus video assisted thoracoscopic. The literature reveals multiple studies reporting 30-day survival rates when comparing  approaches; however, it has also been reported that the video-assisted approach is associated with shorter length of stay, lower overall costs, and reduced rates of overall complications.  There have been reports revealing no significant difference in operative times between approaches.  These conclusions have been replicated in many studies; however, there are no studies reviewing the patient population receiving open versus thoracoscopic lobectomies in recent literature.

We reviewed the demographics of patients undergoing either a lobectomy during the calendar years 2012-2015, we reported by the American College of Surgeons National Quality Improvement Program.   We compared clinical risk factors, intraoperative factors, 30-day complications, and related operations for patients undergoing open traditional thoracotomy or video-assisted pulmonary lobar resection.

Of the 19,294 patients undergoing lobar resection, 662 (3.4%) had a related reoperation within 30 days.  Five thousand seven hundred and thirty-seven (29.7%) of lobectomies performed were performed through an open approach whereas 13,557 (70.3%) were thoracoscopically performed.  Patients who underwent open procedures had higher rates of obesity (33.5% vs 31.7%, p< 0.001), smoking (35.8% vs 27.0%, p< 0.001), hypertension (57.6% vs 53.0%, p< 0.001), COPD (26.2% vs 20.7%, p< 0.001) and ASA Class III or greater (84.8% vs 74.5%, p< 0.001).  Unadjusted analysis showed that open procedures had higher rates of 30-day mortality (2.5% vs 1.1%, p< 0.001) along with longer median lengths of stay (6 days vs 3 days, p< 0.001). After adjusting for patient demographics and operative characteristics, open procedures were consistent associated with a statistically significant increase in 30-day mortalities (OR 1.88, p< 0.001), 30-day morbidities (OR 1.85, p< 0.001), and length of hospital stay (beta coefficient of 2.17, p< 0.001).

Consistent with previously published data, our retrospective review of the American College of Surgeons National Quality Improvement Program for 2012-2015 revealed that open procedures are associated with higher rates of related reoperations and mortality.

Other Participants
Empyema from Misplacement of Percutaneous Nephrostomy Tube: A Diagnostic Challenge
Raed Abdulkareem, MD, General Surgery Resident, University of Illinois at Chicago, Chicago, IL

In this case report, we discuss the development of an empyema due to percutaneous nephrostomy tube placement.  In this instance, the nephrostomy tube was found to be traversing the pleural space and diaphragm resulting in bacterial tracking from a chronically infected kidney into the pleural space with resultant empyema. To our knowledge this is the first case report describing such a complication in the literature.

Nephrostomy tube placement is a common procedure employed to manage several different types of ureteral obstruction. The most common causes of obstruction are renal calculi, gynecological malignancy, or narrowing of the ureter due to chronic inflammation. Complications of nephrostomy tube placement are rare, and most commonly include bleeding, sepsis, organ injury, and death.

Multiple reports appear in the literature describing the aforementioned complications observed during nephrostomy tube placement, but based on a literature review, no other cases were found in which a nephrostomy tube traversing the thoracic cavity enroute to the kidney resulted in an empyema. Urinothorax and nephropleural fistula have been reported soon after placement or removal of percutaneous nephrostomy tubes; this complication usually resolved after simple thoracentesis or serial thoracenteses. A similar case from our review is presented by Kumar et al. who described a patient who underwent percutaneous nephrolithotomy (PCNL) for the removal of kidney stones. Several days after the procedure the patient became short of breath, and a pleural effusion was noted on a chest x-ray.  A video-assisted thoracoscopy was eventually performed that revealed an empyema.6. Thus, to our knowledge, the case presented here in our report is the first of its kind to be reported.

Although there are no other cases specifically describing nephrostomy tube placement into the chest, there are many other cases that outline other rare complications of a nephrostomy tube or PCNL. One such article describes two cases where PCNL led to severe venous bleeding. In one of the cases, the nephrostomy catheter was misplaced into the renal vein, and in the second case the catheter was placed into the inferior vena cava (IVC). In both cases, exploratory laparotomies were performed to stabilize the patients, and neither patient experienced any long-term consequences from the hemorrhage.

In conclusion, the main indication for the use of a nephrostomy tube is ureteral obstruction. Tube placement is a useful and simple procedure, but it does have certain complications of which the practitioner must be aware.

Retrospective, Single Site Study to Evaluate the Analgesic Effectiveness of Exparel (Liposomal Bupivacaine) Mixed with Bupivacaine hcl Versus ON-Q Pain Pump for Renal Transplant Recipient Incisions
Elizabeth Tacl, MD
, Resident, Sanford University of South Dakota Medical Center, Sioux Falls, SD

The primary objective is to determine if liposome bupivacaine with bupivacaine HCl can reduce the maximum pain levels observed post-surgery more than the standard analgesia methods, ON-Q pain pump, for donor nephrectomy and recipients as determined by an 10 point pain scale during inpatient recovery stay. Secondary objectives include to evaluate whether ON-Q pain pump versus Exparel require longer times until need for first narcotic dose, difference in post operative nausea or vomiting requiring intervention, time to first mobilization (time out of bed), total narcotic need, use of other pharmacologic pain adjunct needs (Flexeril, Tylenol, etc. ), and total length of hospital stay.

Methods: Charts of 40 patients were reviewed over a 14-month period. Patients either received ON-Q pain pump with standard post operative pain control or intraoperative periincisional Exparel. The following assessments will also be evaluated: 10 point pain scale, narcotic usage, data regarding use of antiemetic and other pharmacologic pain adjuvant medications, first mobilization and total length of stay.

Effective postoperative pain control is an essential component for the surgical patient. Data available indicates that an afferent neural blockade with local anesthetics is the most effective analgesic technique.

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