Research Spotlight

Testa, G. and L. Johannesson (2017). “The ethical challenges of uterus transplantation.” Curr Opin Organ Transplant: 2017 Aug [Epub ahead of print].

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PURPOSE OF REVIEW: As the techniques of uterus transplantation have evolved, culminating in a birth in 2014, the ethical debate has been enriched by several considerations. Uterus transplantation raises issues because of its unique features of being temporary, nonlifesaving, experimental, and expensive, with established alternatives. RECENT FINDINGS: Uterus transplantation entails risks for the recipient related to multiple surgeries and immunosuppression, yet studies have shown that women see infertility as a distressing element in their lives, justifying the risks. The alternative of surrogacy has its own ethical issues, and adoption does not provide for genetic progeny. Although patient decisions are susceptible to inconsistent reasoning, misconception of risks or wishful thinking, a carefully drafted and clearly explained informed consent can represent a valid ethical response in balancing risks and benefits. There is no evidence of increased risks for children born from uterus transplant. For living donors, the risks of hysterectomy are known and can be explained to facilitate proper informed consent. Allocation of deceased donor organs needs to be determined, as guidelines for other organs cannot readily be applied. Cost is an issue, as the procedure is expensive and not covered by insurance. SUMMARY: In this rapidly advancing field, a strong ethical foundation is needed to guide regulations and legislation.

Kim, P. T. W. and G. B. Klintmalm (2017). “The authors’ reply.” Transplantation 101(9): e311-e312.

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We appreciate the insightful comments by Prieto and colleagues 1 on our study that documented an association of biliary strictures and low hepatic artery flows in patients without arterial complications. We share their interest in hepatic flows in liver transplantation and applaud their great results in liver transplantation, especially their low biliary complication rates (12.8% and 8.3%). We recognize the difficulties with proving the relationship between a specific hepatic arterial flow (400 mL/min) and a specific outcome (eg, long-term biliary complications) after liver transplantation. It is true that there are multiple factors that are in play when trying to study the cause of biliary complications in liver transplantation. Because of this challenge, we recognize that it is important to have in-depth information and granularity of data when studying this topic. After documenting the relationship between ratio of hepatic arterial flow/body weight and overall biliary complications, we conducted this study to further understand the relationship.2,3 The details that are required to accurately study the topic include bile duct reconstruction technique (duct-to-duct vs hepaticojejunostomy), the contribution of arterial complications, distinction between leaks and strictures, and most importantly, comparison of the incidence of biliary complications in a Kaplan-Meier curve as a cumulative incidence instead of comparing absolute incidence. Just as the comparison of survival after transplantation is best reported as cumulative rates in a Kaplan-Meier curve, we feel that the incidence of biliary complication is most accurately reported as such. Only when our data were analyzed in depth with the necessary detail of the data, the relationship between low hepatic artery flow and cumulative biliary strictures in patients who had duct-to-duct anastomosis and without arterial complications was identified.

Roden-Foreman, K., J. Solis, A. Jones, M. Bennett, J. W. Roden-Foreman, E. E. Rainey, M. L. Foreman and A. M. Warren (2017). “Prospective evaluation of posttraumatic stress disorder and depression in orthopaedic injury patients with and without concomitant traumatic brain injury.” J Orthop Trauma 31(9): e275-e280.

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OBJECTIVES: Psychological morbidities after injury [eg, posttraumatic stress disorder (PTSD) and depression] are increasingly recognized as a significant determinant of overall outcome. Traumatic brain injury (TBI) negatively impacts outcomes of patients with orthopaedic injury, but the association of concurrent TBI, orthopaedic injury, and symptoms of PTSD and depression has not been examined. This study’s objective was to examine symptoms of PTSD and depression in patients with orthopaedic trauma with and without TBI. DESIGN: Longitudinal prospective cohort study. SETTING: Urban Level I Trauma Center in the Southwest United States. PATIENTS/PARTICIPANTS: Orthopaedic trauma patients older than 18 years admitted for >/=24 hours. MAIN OUTCOME MEASUREMENTS: Questionnaires examining demographics, injury-related variables, PTSD, and depression were administered during hospitalization and 3, 6, and 12 months later. Orthopaedic injury and TBI were determined based on ICD-9 codes. Generalized linear models determined whether PTSD and depression at follow-up were associated with TBI. RESULTS: Of the total sample (N = 214), 44 (21%) sustained a TBI. Those with TBI had higher rates of PTSD symptoms, 12 months postinjury (P = 0.04). The TBI group also had higher rates of depressive symptoms, 6 months postinjury (P = 0.038). CONCLUSIONS: Having a TBI in addition to orthopaedic injury was associated with significantly higher rates of PTSD at 12 months and depression at 6 months postinjury. This suggests that sustaining a TBI in addition to orthopaedic injury places patients at a higher risk for negative psychological outcomes. The findings of this study may help clinicians to identify patients who are in need for psychological screening and could potentially benefit from intervention.

Salam, S., R. Kotloff, P. Garcha, S. Krishnan, D. Joshi, P. Grady and A. Duggal (2017). “Lung transplantation after 125 days on ecmo for severe refractory hypoxemia with no prior lung disease.” Asaio j 63(5): e66-e68.

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Venovenous extracorporeal membrane oxygenation (ECMO) has become a viable and increasingly utilized option for the treatment of refractory hypoxemia in severe acute respiratory distress syndrome (ARDS). However, options are limited for ARDS patients who fail to wean from ECMO. The high rates of infection, presence of extrapulmonary end organ damage, intensive care unit-acquired weakness, and high short-term mortality associated with ARDS are all significant hurdles that make lung transplantation a difficult prospect to consider. However, ECMO support has been used as a bridge to transplant in patients with other underlying chronic lung diseases. Our case illustrates the successful use of lung transplantation for a patient with no previous lung disease who developed refractory ARDS requiring protracted ECMO support. The use of ambulatory ECMO with early institution of physical therapy is an essential component in preparing such patients for successful transplantation.

Jaffe, D., D. Vier, J. Kane, M. Kozanek and C. Royer (2017). “Rate of neurologic injury following lateralizing calcaneal osteotomy performed through a medial approach.” Foot Ankle Int: 2017 Sept [Epub ahead of print].

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BACKGROUND: Calcaneal osteotomies are commonly used to correct varus hindfoot alignment in patients with symptomatic cavovarus deformity. Translational, closing wedge, and Malerba-type osteotomies have been implicated in the development of tarsal tunnel syndrome and neurologic injury to branches of the tibial nerve. The authors hypothesized that there would be minimal clinically important injury to the tibial nerve by performing a translational calcaneal osteotomy from a medial approach. METHODS: All patients undergoing a cavovarus reconstruction by a single surgeon were identified. Patients were included if they underwent a lateralizing calcaneal osteotomy via medial approach. Demographics, operative reports, and clinic notes were reviewed to identify concomitant procedures performed, incidence of postoperative tarsal tunnel syndrome, complications, and preoperative and postoperative nerve examinations. Postoperative radiographs were reviewed for location of the osteotomy relative to the posterior tubercle. RESULTS: Twenty-four patients underwent lateralizing calcaneal osteotomy via a medial approach. Of the osteotomies, 83.3% (20/24) were in the middle third of the calcaneus, with a mean of 11.6-mm translation. No patients developed postoperative tarsal tunnel syndrome or tibial nerve palsy. CONCLUSION: Lateralizing calcaneal osteotomy performed via a medial approach had a clinically negligible incidence of neurologic injury. Adequate translation was achieved to obtain correction of varus hindfoot deformity. The authors believe that there is less direct and less percussive injury to branches of the tibial nerve when performing the osteotomy from medial to lateral. This technique may represent an operative strategy to minimize risk to the tibial nerve and reduce neurologic deficit following cavovarus reconstruction.