Negative Pressure Wound Therapy is currently frequently used for dealing with either non-healing ... more Negative Pressure Wound Therapy is currently frequently used for dealing with either non-healing or open wounds following open abdominal surgical procedures. However, complications can arise including in particular infection, delayed and or slow wound healing, problems with device malfunction and in extreme cases failure to obtain complete healing of the abdominal wall. Due to the lack of accurate reporting of the rates of these particular complications, the true incidence remains unknown but could potentially be as high as 20% based on limited data from the last decade. The potential negative impact of NPWT on the bacterial bio burden in the abdominal wall is such that additional measures may be required to specifically address this, but evidence is lacking as to the best approach and in which patient sub groups. These particular complications can also pose additional challenges for surgeons, along with other members of the healthcare team, over and above the direct impact on patie...
Autologous saphenous vein grafts are occasionally used in renal transplant recipients, particular... more Autologous saphenous vein grafts are occasionally used in renal transplant recipients, particularly in living donors with short donor vessels or after donor vessel injury during allograft procurement. Autologous saphenous vein graft aneurysm formation is described as a late complication following the use of this conduit in renal transplant. We report a case of a 45-year-old woman who developed an autologous saphenous vein graft aneurysm 21 years after her living donor transplant, which was successfully managed with explantation of the graft, cold perfusion ex situ, and resection of the aneurysm, which was followed by reconstruction using deceased donor iliac vessels. The graft was then successfully reimplanted. Based on this experience and after a review of the literature related to autologous saphenous vein graft aneurysms in renal transplant, we recommend that surveillance for this particular complication should be considered no later than 10 years after implant of an autologous saphenous vein graft when used as an arterial conduit.
ABSTRACT Body: Introduction Hepatic venous outflow tract obstruction (HVOO) is uncommon after ped... more ABSTRACT Body: Introduction Hepatic venous outflow tract obstruction (HVOO) is uncommon after pediatric liver transplantation. We report 7 children with post liver transplant HVOO; their clinical features, investigations, management and outcomes. Methods Retrospective chart review of children with HVOO, transplanted at Australian National Liver Transplant Unit, Sydney, Australia (1985-2009). Demographics Of 228 transplants performed in 197 children, 7(3%) developed HVOO. 5 male, 4.5 years mean age). Indications: alpha-1-antitrypsin deficiency(3), biliary atresia(1); retransplant(3). Grafts all reduced size: 6 cut-downs (2 left lobe; 4 left lateral segment (LLS), II and III); in-situ split LLS 1). 2 were urgent transplants, one of which included an urgent re-transplant. The same surgical team has performed the vast majority of the total pediatric liver transplants from our centre. The hepatic vein-inferior vena cava anastomosis was performed by piggy-backing the donor hepatic vein(s) to the recipients hepatic venous confluence via the triangulation technique, with modifications as required. Results HVOO diagnosed 20 months (mean) post transplant (range 1 month to 8.2 years). Symptoms often subtle: abdominal pain(3), diarrhea(1); 2 children asymptomatic. Clinical signs: splenomegaly(6), ascites(5), edema(3), hepatomegaly(3), rapid marked weight gain(2). Jaundice unusual(1). Liver function tests were minimally deranged. The bilirubin was normal in 5 patients, with mild elevations in the other two (total/conjugated 110/25 and 31/17). Transaminases (AST, ALT) were normal(3), and ranged from 1-2 x normal(3), to > 4 x normal (1 patient). Serum albumin was usually low, mean 20 g/L. Other laboratory parameters included full blood counts, with abnormal values seen in 4 patients, usually reflecting hypersplenism (low platelets, white cell count). Coagulation was abnormal (despite near normal LFT), mean INR of 1.9. Diagnostic imaging with doppler ultrasound (US) was unreliable in identifying HVOO - reports of normal hepatic veins (HV) in 3, while patency of the HV (4) but with flow anomalies (dampened trace, loss of triphasic pattern, monophasic character). CT (2) and MRI (1) scans had "normal HV" when performed. Hepatic venogram the gold standard investigation for HVOO. All seven patients had a stricture at the HV/IVC anastomosis, and when measured there was significant pressure gradient across the anastomosis. Liver biopsy when performed (3) directly led to hepatic venograms and the diagnosis of HVOO. Management was balloon dilatation in all 7 patients: once only (1), 1-5 (3), >5 (3). HV stents were placed (3); two patients required x 3 stents. Outcomes: retransplant (4) for graft failure due to HVOO. Three of these had already undergone 2nd transplant, and all had required stenting. 1 has evolving cirrhosis (multifactorial including HVOO), another requires regular dilatations (x 9 over 4 year period). Conclusion HVOO post pediatric liver transplant results in significant morbidity and graft loss. The clinical presentation can be subtle. LFT are often minimally abnormal, and doppler US is unreliable. Diagnosis requires a high index of clinical suspicion, and is confirmed by hepatic venography. Treatment is with balloon dilatation; stenting in our experience has not been successful. All our patients with HVOO had received reduced size grafts; three who developed HVOO after their 2nd graft required a 3rd graft.
The use of extended criteria donors is an effective way of reducing the shortage of deceased dono... more The use of extended criteria donors is an effective way of reducing the shortage of deceased donor organs. Evidence of significant liver trauma in a deceased donor usually rules out transplantation of the liver. The aim of this study was to evaluate the use and outcomes of donor livers with preprocurement trauma. Records of all 312 deceased donors with a history of trauma between January 1986 and September 2007 were reviewed. Donors with macroscopic liver injuries were identified, and data from recipient medical records were obtained. Data on declined donor offers were also evaluated. The median donor age was 20 (range, 10-57) years, and 9 of 15 (60%) were male. The liver injuries were predominantly lacerations (grades 1-5) and vascular injury. The right lobe was resected because of extensive damage in 3 cases. This resulted in 2 left lobes (back-table cut-down) and 1 left lateral segment allograft (in situ split). For the 15 recipients, the median age was 43 (3-69) years. Primary nonfunction was not seen. There was no difference in survival between whole and partial allografts. Three deaths occurred within 3 months post-transplantation. During the same period, 42 of 1405 donor offers (3%) were declined because of extensive liver trauma or major ongoing intra-abdominal hemorrhage. In conclusion, the use of donor livers with preexisting trauma leads to acceptable outcomes. Strategies to deal with trauma include resection of the right lobe if required. Use of deceased donor livers with injury is a safe way to expand the donor pool.
Background and Aim: Donor liver steatosis can impact on liver allograft outcomes. The aim of the... more Background and Aim: Donor liver steatosis can impact on liver allograft outcomes. The aim of the present study was to comprehensively report on the impact of type and grade of donor steatosis, as well as donor and recipient factors, including the reported Donor Risk Index (DRI), on liver allograft outcomes.Methods: A review of unit data for all adult liver transplant procedures from 2001 to 2007, as well as donor offers. Donor liver biopsies were regraded for steatosis by an experienced histopathologist.Results: Steatosis was detected in 184/255 (72%) of biopsies, of which 114 (62%) had microvesicular steatosis (MiS; 68 mild, 22 moderate, 24 severe) and 70 (38%) macrovesicular steatosis (MaS; 59 mild, 7 moderate, 4 severe). The majority (66/70, 94%) of biopsies with MaS also contained MiS. Allograft steatosis was associated with increasing donor body mass index (P = 0.000), plus donor male sex (P < 0.05). Primary non function (P = 0.002), early renal failure (P = 0.040), and r...
Transplantation of renal allografts (RA) from older donors has become more common, despite confli... more Transplantation of renal allografts (RA) from older donors has become more common, despite conflicting data on outcome between reports from large series versus individual centres. Factors other than donor age per se may contribute to RA outcome. The outcome of RA procured from 114 older donors over 55 yr of age in NSW, between 1990 and 1997, was analysed. Corresponding donor factors, including demographics, medical history, inotrope use, major hypotension and findings at procurement, were also analysed. Of the potential RA, 8% were discarded and the remainder transplanted. Factors significantly associated with renal discard were pre-transplantation donation biopsy abnormality (p &lt; 0.001) and a history of cardiovascular (CV) disease in the donor (p &lt; 0.02). Donor aortorenal atherosclerosis (AS; p &lt; 0.09) and a donor age of 65 yr or older (p &lt; 0.08) were common in the discard group. The never function rate was 7.6% and was associated with a history of a discarded partner kidney (p &lt; 0.05). The delayed graft function rate was 33% and was associated with a history of donor CV disease. At a median follow up of 5 yr, the death censored allograft failure rate was 24%. Allograft failure was associated with a history of donor hypertension (p &lt; 0.05). Donor AS (p &lt; 0.7) tended to have been more common in the allograft failure group. A number of cadaveric organ donor factors documented at procurement may be associated with inferior outcome of RA. These include biopsy abnormality, history of donor CV disease and history of donor hypertension. A donor age of 65 yr or older or significant visible aortorenal AS may also be factors. This retrospective review of kidneys procured from 114 older cadaveric organ donors identifies factors apart from donor age, which may have a negative impact on both allograft utilisation and outcome. Theses factors include renal biopsy abnormality, history of donor CV disease, discard of a partner kidney and donor hypertension. Visible AS in the donor aorta documented at renal procurement may also be a factor.
To test the effectiveness of a simpler surgical technique for cadaveric liver procurement for liv... more To test the effectiveness of a simpler surgical technique for cadaveric liver procurement for liver transplantation, a prospective randomized study was carried out between August 1994 and December 1995, to compare aortic perfusion only (APO) for flush-preservation of the liver with the conventional combined aortic and portal perfusion (APP) technique. Forty multiple organ donors were enrolled with 20 in each arm of the trial. Donor parameters (age, bodyweight, liver function tests), surgeons performing the operations, the involvement of other procurement teams and the total ischaemic times were similar in the two groups. The liver recipients had a wide range of native liver pathology but were of similar age, sex and bodyweight in the two groups. The mean procurement operation times for the APO and APP groups were 126.7+/-38.6 and 137.8+/-55.9 min, respectively (P=ns). The perfusion took longer to complete in the APO group (10.2+/-1.7 vs 7.2+/-1.4 min (APP), P &lt; 0.001). The liver temperature fell to its lowest level (12.5+/-3.4 degrees C (APO) vs 11+/-3 degrees C (APP), P=ns) in a similar time (11.9+/-3.8 min (APO) vs 9.3+/-3.4 mins (APP), P=ns). There was no graft primary non-function or graft arterial injury in either group. There was no significant difference between the APO and APP initial graft outcomes. The 3-month patient survival rate was identical in the two groups (95%); 81% of renal grafts from the APO donors functioned well from the time of transplantation as did 76% of those from APP donors. It is concluded that the APO procurement technique produces equivalent results to those achieved with the APP method. The simplicity of the APO technique makes it the preferred technique.
The vertebrate ocular lens undergoes a spatially defined pattern of differentiation which may be ... more The vertebrate ocular lens undergoes a spatially defined pattern of differentiation which may be regulated by the ocular distribution of proteins from the fibroblast growth factor (FGF) family. The ability of altered FGF-1 (acidic FGF) distribution to disrupt the normal pattern of lens differentiation was evaluated by the production of transgenic mice which express FGF-1 under the control of the lens-specific αA-crystallin promoter. Since FGF-1 lacks a classical signal peptide consensus sequence, transgenic mice were also produced with a chimeric construct containing the signal peptide sequence of the FGF-4 gene fused in frame to the coding sequences of the FGF-1 cDNA in order to obtain extracellular expression of the transgene. The presence of transgenic mRNA and protein was confirmed by in situ hybridization, Western analysis and immunohistochemistry. The ocular histology of newborn and young adult transgenic mice expressing FGF-1 without a signal peptide appeared normal. In contr...
Objective: To ascertain the gender distribution across public health boards in Australia. Design ... more Objective: To ascertain the gender distribution across public health boards in Australia. Design & Setting: Analysis of data and information obtained from a cross sectional audit of online publicly listed health boards within Australia from October to December 2019. Results: The majority of public health boards have close to equal representation of women as board members however women are underrepresented in Chair roles. Victoria has significantly more women on health boards, whereas New South Wales has significantly less women on health boards and in Chair positions. Conclusions: Further efforts are required to drive gender equity in senior leadership roles in public health boards across Australia
Negative Pressure Wound Therapy is currently frequently used for dealing with either non-healing ... more Negative Pressure Wound Therapy is currently frequently used for dealing with either non-healing or open wounds following open abdominal surgical procedures. However, complications can arise including in particular infection, delayed and or slow wound healing, problems with device malfunction and in extreme cases failure to obtain complete healing of the abdominal wall. Due to the lack of accurate reporting of the rates of these particular complications, the true incidence remains unknown but could potentially be as high as 20% based on limited data from the last decade. The potential negative impact of NPWT on the bacterial bio burden in the abdominal wall is such that additional measures may be required to specifically address this, but evidence is lacking as to the best approach and in which patient sub groups. These particular complications can also pose additional challenges for surgeons, along with other members of the healthcare team, over and above the direct impact on patie...
Autologous saphenous vein grafts are occasionally used in renal transplant recipients, particular... more Autologous saphenous vein grafts are occasionally used in renal transplant recipients, particularly in living donors with short donor vessels or after donor vessel injury during allograft procurement. Autologous saphenous vein graft aneurysm formation is described as a late complication following the use of this conduit in renal transplant. We report a case of a 45-year-old woman who developed an autologous saphenous vein graft aneurysm 21 years after her living donor transplant, which was successfully managed with explantation of the graft, cold perfusion ex situ, and resection of the aneurysm, which was followed by reconstruction using deceased donor iliac vessels. The graft was then successfully reimplanted. Based on this experience and after a review of the literature related to autologous saphenous vein graft aneurysms in renal transplant, we recommend that surveillance for this particular complication should be considered no later than 10 years after implant of an autologous saphenous vein graft when used as an arterial conduit.
ABSTRACT Body: Introduction Hepatic venous outflow tract obstruction (HVOO) is uncommon after ped... more ABSTRACT Body: Introduction Hepatic venous outflow tract obstruction (HVOO) is uncommon after pediatric liver transplantation. We report 7 children with post liver transplant HVOO; their clinical features, investigations, management and outcomes. Methods Retrospective chart review of children with HVOO, transplanted at Australian National Liver Transplant Unit, Sydney, Australia (1985-2009). Demographics Of 228 transplants performed in 197 children, 7(3%) developed HVOO. 5 male, 4.5 years mean age). Indications: alpha-1-antitrypsin deficiency(3), biliary atresia(1); retransplant(3). Grafts all reduced size: 6 cut-downs (2 left lobe; 4 left lateral segment (LLS), II and III); in-situ split LLS 1). 2 were urgent transplants, one of which included an urgent re-transplant. The same surgical team has performed the vast majority of the total pediatric liver transplants from our centre. The hepatic vein-inferior vena cava anastomosis was performed by piggy-backing the donor hepatic vein(s) to the recipients hepatic venous confluence via the triangulation technique, with modifications as required. Results HVOO diagnosed 20 months (mean) post transplant (range 1 month to 8.2 years). Symptoms often subtle: abdominal pain(3), diarrhea(1); 2 children asymptomatic. Clinical signs: splenomegaly(6), ascites(5), edema(3), hepatomegaly(3), rapid marked weight gain(2). Jaundice unusual(1). Liver function tests were minimally deranged. The bilirubin was normal in 5 patients, with mild elevations in the other two (total/conjugated 110/25 and 31/17). Transaminases (AST, ALT) were normal(3), and ranged from 1-2 x normal(3), to &gt; 4 x normal (1 patient). Serum albumin was usually low, mean 20 g/L. Other laboratory parameters included full blood counts, with abnormal values seen in 4 patients, usually reflecting hypersplenism (low platelets, white cell count). Coagulation was abnormal (despite near normal LFT), mean INR of 1.9. Diagnostic imaging with doppler ultrasound (US) was unreliable in identifying HVOO - reports of normal hepatic veins (HV) in 3, while patency of the HV (4) but with flow anomalies (dampened trace, loss of triphasic pattern, monophasic character). CT (2) and MRI (1) scans had &quot;normal HV&quot; when performed. Hepatic venogram the gold standard investigation for HVOO. All seven patients had a stricture at the HV/IVC anastomosis, and when measured there was significant pressure gradient across the anastomosis. Liver biopsy when performed (3) directly led to hepatic venograms and the diagnosis of HVOO. Management was balloon dilatation in all 7 patients: once only (1), 1-5 (3), &gt;5 (3). HV stents were placed (3); two patients required x 3 stents. Outcomes: retransplant (4) for graft failure due to HVOO. Three of these had already undergone 2nd transplant, and all had required stenting. 1 has evolving cirrhosis (multifactorial including HVOO), another requires regular dilatations (x 9 over 4 year period). Conclusion HVOO post pediatric liver transplant results in significant morbidity and graft loss. The clinical presentation can be subtle. LFT are often minimally abnormal, and doppler US is unreliable. Diagnosis requires a high index of clinical suspicion, and is confirmed by hepatic venography. Treatment is with balloon dilatation; stenting in our experience has not been successful. All our patients with HVOO had received reduced size grafts; three who developed HVOO after their 2nd graft required a 3rd graft.
The use of extended criteria donors is an effective way of reducing the shortage of deceased dono... more The use of extended criteria donors is an effective way of reducing the shortage of deceased donor organs. Evidence of significant liver trauma in a deceased donor usually rules out transplantation of the liver. The aim of this study was to evaluate the use and outcomes of donor livers with preprocurement trauma. Records of all 312 deceased donors with a history of trauma between January 1986 and September 2007 were reviewed. Donors with macroscopic liver injuries were identified, and data from recipient medical records were obtained. Data on declined donor offers were also evaluated. The median donor age was 20 (range, 10-57) years, and 9 of 15 (60%) were male. The liver injuries were predominantly lacerations (grades 1-5) and vascular injury. The right lobe was resected because of extensive damage in 3 cases. This resulted in 2 left lobes (back-table cut-down) and 1 left lateral segment allograft (in situ split). For the 15 recipients, the median age was 43 (3-69) years. Primary nonfunction was not seen. There was no difference in survival between whole and partial allografts. Three deaths occurred within 3 months post-transplantation. During the same period, 42 of 1405 donor offers (3%) were declined because of extensive liver trauma or major ongoing intra-abdominal hemorrhage. In conclusion, the use of donor livers with preexisting trauma leads to acceptable outcomes. Strategies to deal with trauma include resection of the right lobe if required. Use of deceased donor livers with injury is a safe way to expand the donor pool.
Background and Aim: Donor liver steatosis can impact on liver allograft outcomes. The aim of the... more Background and Aim: Donor liver steatosis can impact on liver allograft outcomes. The aim of the present study was to comprehensively report on the impact of type and grade of donor steatosis, as well as donor and recipient factors, including the reported Donor Risk Index (DRI), on liver allograft outcomes.Methods: A review of unit data for all adult liver transplant procedures from 2001 to 2007, as well as donor offers. Donor liver biopsies were regraded for steatosis by an experienced histopathologist.Results: Steatosis was detected in 184/255 (72%) of biopsies, of which 114 (62%) had microvesicular steatosis (MiS; 68 mild, 22 moderate, 24 severe) and 70 (38%) macrovesicular steatosis (MaS; 59 mild, 7 moderate, 4 severe). The majority (66/70, 94%) of biopsies with MaS also contained MiS. Allograft steatosis was associated with increasing donor body mass index (P = 0.000), plus donor male sex (P < 0.05). Primary non function (P = 0.002), early renal failure (P = 0.040), and r...
Transplantation of renal allografts (RA) from older donors has become more common, despite confli... more Transplantation of renal allografts (RA) from older donors has become more common, despite conflicting data on outcome between reports from large series versus individual centres. Factors other than donor age per se may contribute to RA outcome. The outcome of RA procured from 114 older donors over 55 yr of age in NSW, between 1990 and 1997, was analysed. Corresponding donor factors, including demographics, medical history, inotrope use, major hypotension and findings at procurement, were also analysed. Of the potential RA, 8% were discarded and the remainder transplanted. Factors significantly associated with renal discard were pre-transplantation donation biopsy abnormality (p &lt; 0.001) and a history of cardiovascular (CV) disease in the donor (p &lt; 0.02). Donor aortorenal atherosclerosis (AS; p &lt; 0.09) and a donor age of 65 yr or older (p &lt; 0.08) were common in the discard group. The never function rate was 7.6% and was associated with a history of a discarded partner kidney (p &lt; 0.05). The delayed graft function rate was 33% and was associated with a history of donor CV disease. At a median follow up of 5 yr, the death censored allograft failure rate was 24%. Allograft failure was associated with a history of donor hypertension (p &lt; 0.05). Donor AS (p &lt; 0.7) tended to have been more common in the allograft failure group. A number of cadaveric organ donor factors documented at procurement may be associated with inferior outcome of RA. These include biopsy abnormality, history of donor CV disease and history of donor hypertension. A donor age of 65 yr or older or significant visible aortorenal AS may also be factors. This retrospective review of kidneys procured from 114 older cadaveric organ donors identifies factors apart from donor age, which may have a negative impact on both allograft utilisation and outcome. Theses factors include renal biopsy abnormality, history of donor CV disease, discard of a partner kidney and donor hypertension. Visible AS in the donor aorta documented at renal procurement may also be a factor.
To test the effectiveness of a simpler surgical technique for cadaveric liver procurement for liv... more To test the effectiveness of a simpler surgical technique for cadaveric liver procurement for liver transplantation, a prospective randomized study was carried out between August 1994 and December 1995, to compare aortic perfusion only (APO) for flush-preservation of the liver with the conventional combined aortic and portal perfusion (APP) technique. Forty multiple organ donors were enrolled with 20 in each arm of the trial. Donor parameters (age, bodyweight, liver function tests), surgeons performing the operations, the involvement of other procurement teams and the total ischaemic times were similar in the two groups. The liver recipients had a wide range of native liver pathology but were of similar age, sex and bodyweight in the two groups. The mean procurement operation times for the APO and APP groups were 126.7+/-38.6 and 137.8+/-55.9 min, respectively (P=ns). The perfusion took longer to complete in the APO group (10.2+/-1.7 vs 7.2+/-1.4 min (APP), P &lt; 0.001). The liver temperature fell to its lowest level (12.5+/-3.4 degrees C (APO) vs 11+/-3 degrees C (APP), P=ns) in a similar time (11.9+/-3.8 min (APO) vs 9.3+/-3.4 mins (APP), P=ns). There was no graft primary non-function or graft arterial injury in either group. There was no significant difference between the APO and APP initial graft outcomes. The 3-month patient survival rate was identical in the two groups (95%); 81% of renal grafts from the APO donors functioned well from the time of transplantation as did 76% of those from APP donors. It is concluded that the APO procurement technique produces equivalent results to those achieved with the APP method. The simplicity of the APO technique makes it the preferred technique.
The vertebrate ocular lens undergoes a spatially defined pattern of differentiation which may be ... more The vertebrate ocular lens undergoes a spatially defined pattern of differentiation which may be regulated by the ocular distribution of proteins from the fibroblast growth factor (FGF) family. The ability of altered FGF-1 (acidic FGF) distribution to disrupt the normal pattern of lens differentiation was evaluated by the production of transgenic mice which express FGF-1 under the control of the lens-specific αA-crystallin promoter. Since FGF-1 lacks a classical signal peptide consensus sequence, transgenic mice were also produced with a chimeric construct containing the signal peptide sequence of the FGF-4 gene fused in frame to the coding sequences of the FGF-1 cDNA in order to obtain extracellular expression of the transgene. The presence of transgenic mRNA and protein was confirmed by in situ hybridization, Western analysis and immunohistochemistry. The ocular histology of newborn and young adult transgenic mice expressing FGF-1 without a signal peptide appeared normal. In contr...
Objective: To ascertain the gender distribution across public health boards in Australia. Design ... more Objective: To ascertain the gender distribution across public health boards in Australia. Design & Setting: Analysis of data and information obtained from a cross sectional audit of online publicly listed health boards within Australia from October to December 2019. Results: The majority of public health boards have close to equal representation of women as board members however women are underrepresented in Chair roles. Victoria has significantly more women on health boards, whereas New South Wales has significantly less women on health boards and in Chair positions. Conclusions: Further efforts are required to drive gender equity in senior leadership roles in public health boards across Australia
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Papers by Deborah Verran