Transplante renal de donante vivo: un análisis crítico de estrategias quirúrgicas basado en 40 años de experiencia
Renal transplantation with living donors. a critical analysis of surgical procedures based on 40 years of experience
R. Vela Navarrete1
, J.L. Rodríguez Miñón Cifuentes, J. Calahorra Fernández, C. González Enguita, J. Cabrera, J.V. García Cardoso, I. Castillon Vela, J.J. Plaza
Autor para correspondencia
rvela@fjd.es
Correspondencia autor: Dr. R. Vela Navarrete Departamento de Urología y Unidad de Trasplante renal Fundación Jiménez Díaz Avda. de los Reyes Católicos, 2 - 28040 Madrid Tel.: 915 504 800
Correspondencia autor: Dr. R. Vela Navarrete Departamento de Urología y Unidad de Trasplante renal Fundación Jiménez Díaz Avda. de los Reyes Católicos, 2 - 28040 Madrid Tel.: 915 504 800
Departamento de Urología y Unidad de Trasplante Renal. Servicio de Nefrología. Fundación Jiménez Díaz. Universidad Autónoma de Madrid
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"apellidos" => "Vela Navarrete" "email" => array:1 [ 0 => "rvela@fjd.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">1</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "J.L." "apellidos" => "Rodríguez Miñón Cifuentes" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Calahorra Fernández" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "González Enguita" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Cabrera" ] 5 => array:2 [ "nombre" => "J.V." "apellidos" => "García Cardoso" ] 6 => array:2 [ "nombre" => "I." "apellidos" => "Castillon Vela" ] 7 => array:2 [ "nombre" => "J.J." "apellidos" => "Plaza" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Departamento de Urología y Unidad de Trasplante Renal. Servicio de Nefrología. Fundación Jiménez Díaz. Universidad Autónoma de Madrid" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "1" "correspondencia" => "Correspondencia autor: Dr. R. Vela Navarrete Departamento de Urología y Unidad de Trasplante renal Fundación Jiménez Díaz Avda. de los Reyes Católicos, 2 - 28040 Madrid Tel.: 915 504 800" ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Renal transplantation with living donors. a critical analysis of surgical procedures based on 40 years of experience" ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2008-09-01" "fechaAceptado" => "2008-10-01" "PalabrasClave" => array:2 [ "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec88754" "palabras" => array:4 [ 0 => "Transplante renal" 1 => "Donante vivo" 2 => "Nefrectomía" 3 => "Estrategia quirúrgica" ] ] ] "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec88753" "palabras" => array:4 [ 0 => "Renal transplantation" 1 => "Living donors" 2 => "Nephrectomy" 3 => "Surgical strategies" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Introducción</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">La prioridad inexcusable de un programa de trasplante renal de donante vivo (TRDV) es la seguridad vital del donante, seguida de la preservación del órgano, obtenido en las mejores condiciones anatómicas y funcionales. La reducción de la morbilidad del donante, inmediata y a largo término, debe ser otro objetivo. Tanto en el TRDV como en el trasplante de cadáver el implante del órgano debe realizarse con las mayores garantías técnicas. Analizamos nuestra mortalidad, morbilidad, incidencias, técnica de la nefrectomía y otros datos relevantes observados en nuestro programa de TRDV iniciado en 1968, con la intención de comparar nuestros resultados con los publicados utilizando técnicas laparoscópicas de nefrectomía, y en consecuencia decidir si nuestro programa debe modificar, o no, sus estrategias quirúrgicas actuales.</p> <span class="elsevierStyleSectionTitle">Material y métodos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Nuestro programa de trasplante renal se inició en 1964, con riñón de cadáver, y en 1968 con riñón del donante vivo. Desde junio de 1968 hasta junio del 2008 hemos realizado 243 TRDV; un reducido número de trasplantes por año. La técnica de nefrectomía empleada desde 1968-1972 fue el abordaje supracostal propuesto por Turner-Warrick y desde 1972 una miniincisión subcostal, anterior extraperitoneal. La lumbotomía convencional con resección de la última costilla nunca ha sido practicada. El riñón derecho fue utilizado en el 78% y el implante en la fosa ilíaca derecha en el 85% La cirugía del donante y el receptor se realizan simultáneamente en dos quirófanos adyacentes, por dos equipos distintos, siendo un solo cirujano responsable de ambos procedimientos; la nefrectomía y el implante. Las complicaciones peroperatorias y postoperatorias, potencialmente relacionadas con la nefrectomía, o de otra naturaleza, han sido evaluadas por los equipos urológicos y nefrológicos.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">No se han detectado en nuestra serie ningún caso de muerte del donante, pérdida del órgano o complicaciones mayores tales como neumotórax, hemorragias necesitando transfusión, infecciones graves, reintervenciones. Complicaciones menores tales como paresia intestinal, fiebre, infección de la herida operatoria, fueron más frecuentes con el abordaje supracostal que con el miniincisional. Igualmente, este abordaje ha reducido el dolor postoperatorio, consumo de analgésicos y tiempo de recuperación. En el seguimiento a largo plazo la incidencia de hernias incisionales, o paresia de la pared abdominal, no han sido detectadas. La responsabilidad personal de un cirujano en ambos procedimientos soslaya reclamaciones sobre la calidad anatómica y funcional del órgano, facilita la elección de vasos para la anastomosis y reduce el tiempo operatorio y de ocupación de quirófano.</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El análisis de nuestros resultados cuestiona la conveniencia de sustituir nuestra estrategia quirúrgica actual por los potenciales beneficios e inconvenientes de la nefrectomía laparoscópica, especialmente en un programa de TRDV de reducido número anual. Nuestra técnica de nefrectomía ha ofrecido, a lo largo de una experiencia de 40 años, máximas garantías vitales para el donante y de calidad anatómica y funcional para el órgano, con morbilidad postoperatoria similar a la conseguida con la incisión final laparoscópica.</p>" ] "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Absolute priority in an LDKT programme are donnor safety and kidney optimal anatomical and functional preservation. Reduced donnor morbidities,both at short and long term,are important objectives. Excellent technical grafting is a must as are the strategies employed for facilitatig it. We revised the incidences of our whole LDKT programme (40 years 243 donors) to confirm if these exigences have been acomplished or a change to new surgical procedures is recommended.</p> <span class="elsevierStyleSectionTitle">Material and methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Between 1968-2008 243 nephrectomies and grafting has been performed,a reduced number per year (A cadaver programme has been running simultaneously since 1964). For the nephrectomies a Turner-Warrick apprach was inititialy used and since 1973 a miniincisional, anterior, extraperitoneal approach of approximately 10 cm in length. The right kidney was removed in 75% of the cases and the right iliac area for the implant in 85% In adjacent opperating rooms, one team performs the nephrectomy while the other prepares and dissects free the grafting vessels. Most of the time the same senior surgeon performed both operatios: the nephrectomy and the implant. Peroperative and postoperative complications were evaluated by urologists and nephrologists in charge.</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">No donors dead,organs lost or major complications in the donors have been documented Minor complications such as intestinal paresia, wound infection,persistent incisional pain were common. Miniincisional abdominal approach reduced postoperative pain and hospital stay (4 days). At long term no incisional hernia or abdominal paresia have been documented. Simultaneous work reduces ischemia time (30-45 s warm: 30- 45 min cold) and opperatig room occupation(patient preparation plus anesthesia plus operation)estimated in 90-120 min for the nephrectomy and 120-160 for the grafting. The responsibility of the senior surgeon in both procedures facilitates vessel selection for the grafting.</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">No reasons have been found to reconvert our current nephrectomy procedure to laparoscpic or modify current surgical strategy. Superior safety of open surgery for donors and organs is confirmed. Pain and recovery time are reduced in laparoscopic surgery but not as much when compared with miniincisional approach. Open surgery permits optimal anatomical and functional organ extration facilitatig the quality of the implant. As numbers matter in laparoscopic surgery open nephrectomy isrecommended for reduced LDKT programmes.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "Referencias" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:33 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1." 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| 2019 Agosto | 0 | 1 | 1 |
| 2019 Julio | 0 | 13 | 13 |
| 2019 Junio | 0 | 6 | 6 |
| 2019 Mayo | 0 | 53 | 53 |
| 2019 Abril | 0 | 11 | 11 |
| 2019 Marzo | 0 | 8 | 8 |
| 2019 Febrero | 0 | 7 | 7 |
| 2019 Enero | 0 | 1 | 1 |
| 2018 Diciembre | 0 | 6 | 6 |
| 2018 Noviembre | 0 | 4 | 4 |
| 2018 Octubre | 0 | 19 | 19 |
| 2018 Febrero | 0 | 1 | 1 |
| 2018 Enero | 0 | 1 | 1 |
| 2017 Diciembre | 1 | 5 | 6 |
| 2017 Noviembre | 3 | 2 | 5 |
| 2017 Octubre | 3 | 1 | 4 |
| 2017 Septiembre | 5 | 2 | 7 |
| 2017 Agosto | 6 | 0 | 6 |
| 2017 Julio | 12 | 2 | 14 |
| 2017 Junio | 6 | 11 | 17 |
| 2017 Mayo | 12 | 5 | 17 |
| 2017 Abril | 13 | 0 | 13 |
| 2017 Marzo | 7 | 33 | 40 |
| 2017 Febrero | 3 | 4 | 7 |
| 2017 Enero | 4 | 0 | 4 |
| 2016 Diciembre | 12 | 3 | 15 |
| 2016 Noviembre | 16 | 0 | 16 |
| 2016 Octubre | 32 | 4 | 36 |
| 2016 Septiembre | 12 | 3 | 15 |
| 2016 Agosto | 18 | 2 | 20 |
| 2016 Julio | 9 | 1 | 10 |
| 2016 Junio | 17 | 6 | 23 |
| 2016 Mayo | 15 | 9 | 24 |
| 2016 Abril | 19 | 5 | 24 |
| 2016 Marzo | 15 | 11 | 26 |
| 2016 Febrero | 13 | 5 | 18 |
| 2016 Enero | 15 | 12 | 27 |
| 2015 Diciembre | 10 | 6 | 16 |
| 2015 Noviembre | 24 | 2 | 26 |
| 2015 Octubre | 18 | 4 | 22 |
| 2015 Septiembre | 7 | 2 | 9 |
| 2015 Agosto | 15 | 3 | 18 |
| 2015 Julio | 13 | 2 | 15 |
| 2015 Junio | 5 | 1 | 6 |
| 2015 Mayo | 9 | 0 | 9 |
| 2015 Abril | 8 | 6 | 14 |
| 2015 Marzo | 9 | 1 | 10 |
| 2015 Febrero | 12 | 3 | 15 |
| 2015 Enero | 9 | 1 | 10 |
| 2014 Diciembre | 17 | 8 | 25 |
| 2014 Noviembre | 12 | 2 | 14 |
| 2014 Octubre | 25 | 3 | 28 |
| 2014 Septiembre | 28 | 3 | 31 |
| 2014 Agosto | 22 | 8 | 30 |
| 2014 Julio | 18 | 3 | 21 |
| 2014 Junio | 21 | 3 | 24 |
| 2014 Mayo | 11 | 2 | 13 |
| 2014 Abril | 11 | 6 | 17 |
| 2014 Marzo | 9 | 1 | 10 |
| 2014 Febrero | 7 | 1 | 8 |
| 2014 Enero | 9 | 1 | 10 |
| 2013 Diciembre | 9 | 1 | 10 |
| 2013 Noviembre | 10 | 5 | 15 |
| 2013 Octubre | 7 | 4 | 11 |
| 2013 Septiembre | 7 | 10 | 17 |
| 2013 Agosto | 7 | 2 | 9 |
| 2013 Julio | 6 | 1 | 7 |
| 2008 Noviembre | 287 | 0 | 287 |
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