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The present state of success in kidney transplantation, including its benefits to patients with end-stage renal failure, was achieved through relentless research, both in experimental animal models and human volunteers. Kidney transplantation has evolved during the past century thanks to various milestones in surgical techniques, immunology, immunosuppressive drugs, expansion of donor sources, organ preservation, transplant against immunological barriers (ABO blood group-incompatible and positive crossmatch transplants), and research on induction of tolerance, xenotransplants, and stem cell technology. Despite significant improvements in graft and patient survival, several issues still must be addressed to reduce the growing number of patients with kidney failure waiting to receive organs. This article provides an up-to-date review of the milestones in the history of kidney transplantation and highlights strategies to resolve current problems faced by patients and the transplant community.

Background Ischemia-reperfusion (IR) is one of the strongest nonimmune factors associated with the development of chronic allograft nephropathy (CAN). This effect is often exacerbated by immunosuppressive medications, most notably cyclosporine. Although traditionally the macrophage was thought to stimulate fibroblast activity in CAN, recent evidence supports a role for lymphocytes. FTY720 is a new immunosuppressant that promotes lymphocyte sequestration into lymph nodes and Peyer’s patches. This study investigated the effect of FTY720 on renal fibrosis in the rat following an IR insult (IRI). Methods A rat model of IRI was used in which male Sprague-Dawley rats (under isoflurane anaesthesia) underwent bilateral flank incision with removal of the right kidney and clamping of the left renal hilum for 45 minutes. Five groups of animals were studied (n = 4): nephrectomy only, IRI only, IRI + FTY720 (1 mg/kg/d), IRI + cyclosporine (15 mg/kg/d), and IRI + FTY 720 (1 mg/kg/d) and cyclosporine (15 mg/kg/d). Animals were humanely killed at 30 days. Results Serum creatinine (SCr) level was significantly reduced in the FTY720-treated animals. IRI alone produced a significant increase in SCr level compared with neprectomized animals (138 μmol/L vs 55 μmol/L; P < .05). This effect was potentiated by treatment with cyclosporine (173 μmol/L vs 55 μmol/L; P < .05). Treatment with FTY720 significantly reduced SCr level in rats following IRI alone (81 μmol/L vs 138 μmol/L; P < .01) and in rats following IRI + cyclosporine (98 μmol/L vs 173 μmol/L; P < .014). Parallel changes were seen in the levels of proteinuria. Fibrosis was assessed using Masson’s trichrome (MT) staining. IRI alone produced a significant increase in MT staining compared with nephrectomized animals (0.92 vs 0.03; P < .05). This effect was potentiated by treatment with cyclosporine (1.12 vs 0.92; P = .022). Treatment with FTY720 reduced the level of MT staining in rats following IRI alone (0.34 vs 0.92; P < .05) and in rats following IRI + cyclosporine (70.34 vs 1.12; P < .05). Levels of TGF-β1 were considerably reduced in FTY720-treated animals (compared with cyclosporine + IRI and IRI only), either alone (196 ± 31 pg/mL vs 1105 ± 59 pg/mL and 611 ± 38; P < .05) or in conjunction with cyclosporine (423 ± 26 pg/mL vs 1105 ± 59 pg/mL and 611 ± 38; P < .05). Conclusion Our study shows that treatment with FTY720 can reduce renal fibrosis as a result of IRI, both alone and in conjunction with cyclosporine. This provides promising evidence for using FTY720 in a calcineurin-free or reduced-dose immunosuppression protocol in an effort to reduce the incidence of CAN.

Checklist WIPER Physiological parameters • Check peripheries for stigmata of abdominal disease. Inspection • Skin : scars, stomas, sinuses/fistulas, distended veins, drains Ask patient to cough. Observe for pain, peritoneal irritation, hernias or musculoskeletal pain . • Abdominal wall : hernias (cough + head-up + heels off bed): inspect ventral abdominal wall, umbilicus, groins and scars • Abdominal cavity : distension, pulsations, masses, visible peristalsis • Flanks : scars, flank bulges Ask patient to lean forward. Inspect for hernias as patient strains . • Back : scars, sacral oedema, pressure ulceration • Ankles : peripheral oedema, calf swelling Palpation Kneel and look at patient's face to identify discomfort during palpation • Light palpation, four quadrants: identify peritonitis, distension, musculoskeletal pain (use four fingers of one hand). • Deep palpation, nine regions: identify masses, organomegaly, rebound tendernes , guarding (use two hands). • Liver, gallbladder and spleen → on inspiration • Kidneys → ballot with two hands • Aorta → lateral to medial palpation with two hands • Scars: incisional hernias → cough • Groins: inguinal and femoral hernias, inguinal lymph nodes → cough • Scrotum • Lower ribs and pelvis • Specific abdominal signs (see table on pages 49 – 50) Percussion • Percussion tenderness: peritoneal irritation • Ascites: dullness in flanks, shifting dullness, fluid thrill • Liver size, spleen size • Palpable bladder Auscultation • Bowel sounds • Abdominal aortic aneurysm bruit • Renal artery stenosis bruit • Liver/splenic bruits To complete the examination… • Digital rectal examination • External genitalia • Urine dipstick Examination notes The examination of the abdomen is a broad screening examination that may lead to a focused assessment of other systems. It remains the trademark examination of the general surgeon. A systematic anatomical approach is needed to provide an authoritative opinion. The examination of the abdomen can be structured around three anatomical layers: skin, abdominal wall and abdominal content.

Checklist WIPER • Patient supine. Expose both arms completely, as well as chest and abdomen. Physiological parameters General • Fluid status: shortness of breath, audible crackles, dry mucous membranes, facial oedema, peripheral oedema, cyanosis • Clinical features of immunosuppression or chronic steroid use Inspection Arm fistulas: • Radiocephalic fistula (wrist) • Brachiocephalic or brachiobasilic fistulas (antecubital fossa) • Prosthetic straight or loop grafts (PTFE) Fistula complications: • Non-functioning/thrombosed fistulas • Haematomas or ecchymosis from needling • Aneurysmal changes: tight or shiny skin • Hand ischaemia from fistula: steal syndrome or embolization Neck and chest (subclavian and internal jugular veins): • Raised JVP (fluid overload) • Dilated neck veins: central vein stenosis from long-term central dialysis lines • Temporary non-tunnelled haemodialysis intravenous catheters (VasCath) • Long-term tunnelled haemodialysis intravenous catheters (PermCath) Abdomen: • Peritoneal dialysis (PD) catheter • Scars: nephrectomy scars in flanks, midline scars for PD catheters, suprapubic catheter scars, iliac fossae scars for renal transplant (Rutherford Morison incision, ‘ hockey-stick ’ incision), laparoscopic scars for nephrectomy (donor) Leg: • Prosthetic PTFE loop graft. Palpation • Skin turgor: fluid status • Fistula (if present): thrill or pulse, palpable stenosis • Pulses (if fistula present): radial, ulnar, brachial, axillary, subclavian • Abdomen: • ascites • peritonitis (if PD catheter present) • ballotable masses (polycystic kidneys) •iliac fossa masses (transplanted kidney) Percussion • Percuss any iliac fossa mass to confirm it is dull (kidney) rather than cystic. Auscultate • Fistula: bruit (continuous ‘ machinery ’ bruit) • Chest: crackles, effusions (fluid overload) To complete the examination … • Examine groins (femoral lines) and lower limbs (fistulas and grafts). Examination notes What are the three most likely clinical scenarios? 1. End-stage renal failure patient on dialysis: a. peritoneal dialysis b. dialysis via fistula c. dialysis via intravenous line d. haemofiltration via intravenous line 2. Low-clearance patient approaching need for renal replacement with a fistula created in advance; still passes urine 3. Renal transplant patient: a. transplant working: not on dialysis but on immunosuppressive therapy b. transplant failed: recommenced dialysis; transplanted kidney may be in situ or removed What are the basic history points that need to be established in assessing for fistula formation? • Is the patient left- or right-handed?

End-stage renal failure is the degree of irreversible loss of renal function that is incompatible with life. Renal replacement therapy is needed and can be achieved by haemodialysis, peritoneal dialysis and kidney transplantation. This contribution will focus on the access techniques for haemodialysis and peritoneal dialysis.

Background Renal warm ischemic injury and immunosuppression with cyclosporin A (CsA) may contribute to chronic allograft nephropathy after cadaveric transplantation. This study establishes whether CsA can sensitize the kidney to injury and fibrosis induced by renal warm ischemia (RWI). Methods The left kidney of Sprague-Dawley rats was subjected to 30 min of warm ischemia and/or intraperitoneal CsA (15 mg/kg/d) for 30 days (n=6 per group). Renal injury and fibrosis were assessed histologically together with immunohistochemistry for collagen III, transforming growth factor (TGF)-beta1, ED1 (macrophage marker), and alpha-smooth muscle actin. Renal mRNAs for collagen III, TGF-beta 1, matrix metalloproteinase (MMP)-2, and tissue inhibitor of metalloproteinase-1 together with MMP enzyme activity were also determined. Results RWI or CsA alone produced only minor effects on renal injury and fibrosis. However, in CsA-treated rats, RWI produced a marked increase in tubulointerstitial fibrosis, as shown by the potentiation of collagen III and TGF-beta1 determined by immunochemistry and mRNA analysis. The up-regulation of tissue inhibitor of metalloproteinase-1 mRNA was associated with a decrease in MMP enzyme activity. In CsA-treated rats, RWI was also associated with an increase in inflammatory infiltrates, elevated immunostain for ED1 (indicating extensive macrophage influx), and elevated immunostain for alpha-smooth muscle actin (indicating myofibroblast activation). Conclusions In the rat, CsA can sensitize the kidney to fibrosis induced by renal warm ischemia. In renal transplantation, when cadaveric donor kidneys have been subjected to a period of warm ischemia, CsA may be an inappropriate choice for immunosuppressive therapy.

Thomas Starzl in Denver, USA, performed the first liver transplant in 1963. Though the initial results were poor, a number of groups developed programmes of liver transplantation in several countries during the 1960s and 1970s. However, at this stage, the procedure was considered to be experimental, since the science of organ transplantation was relatively primitive, and immunosuppression was based on the use of steroids and azathioprine. Transplantation was logistically and technically a demanding procedure that produced mediocre results and remained the preserve of a small number of pioneers. The advent of cyclosporin-based immunosuppression in 1978 heralded a new era. Organ rejection could be suppressed more reliably and the dose of steroids reduced, with substantial benefits in many areas, particularly wound healing and infectious complications. In the mid-1980s, liver transplantation moved from the status of an experimental therapy to an established treatment for end-stage liver disease. Liver transplantation expanded rapidly, with programmes opening in many countries. During the 1990s, though the enthusiasm for liver transplantation was great, liver transplant activity plateaued due to donor shortages. Meanwhile, the results continue to improve with new immunosuppressive agents, improved preservation and innovative surgical techniques. Liver transplantation is widely performed around the world. In the UK, 600–700 liver transplants are carried out annually. This is a highly specialized service carried out in seven nationally designated centres. The results of liver transplantation are comparable to those of kidney and heart transplantation and with a lower long-term attrition. Immunological problems, disease recurrence and donor availability remain the major challenges.

Background. Tissue transglutaminase (TG2), a cross-linking enzyme, modulates deposition of extracellular matrix protein in renal fibrosis. This study aimed to examine TG2 and its cross-link productε(γ-glutamyl)-lysine in the Fisher-Lewis rat renal transplantation (RTx) model of chronic allograft nephropathy (CAN).Materials and Methods. Left renal grafts from male Fisher and Lewis were transplanted into Lewis rats, generating allografts and isografts, respectively. Blood pressure, renal function, and proteinuria were monitored for up to 52 weeks. At termination, CAN was assessed in the renal tissue by light and electron microscopy, TG2 andε(γ-glutamyl)-lysine by immunofluorescence, and the urinaryε(γ-glutamyl)-lysine by high performance liquid chromatography.Results. Compared to the isograft, the allografts were hypertensive, proteinuric, and uraemic and developed CAN. Extracellular TG2 (glomerulus:64.55±17.61versus2.11±0.17,P<0.001; interstitium:13.72±1.62versus3.19±0.44,P<0.001),ε(γ-glutamyl)-lysine (glomerulus:21.74±2.71versus1.98±0.37,P<0.01; interstitium:37.96±17.06versus0.42±0.11,P<0.05), TG2 enzyme activity (1.09±0.13versus0.41±0.03 nmol/h/mg protein,P<0.05), TG2 mRNA (20-fold rise), and urinaryε(γ-glutamyl)-lysine (534.2±198.4 nmol/24 h versus57.2±4.1 nmol/24 h,P<0.05) levels were significantly elevated in the allografts and showed a positive linear correlation with tubulointerstitial fibrosis.Conclusion. CAN was associated with upregulation of renal TG2 pathway, which has a potential for pharmacological intervention. The elevated urinaryε(γ-glutamyl)-lysine, measured for the first time in RTx, is a potential biomarker of CAN.

This report is concerned with the place of the basic medical sciences, and particularly of anatomy, in the training of surgeons in the UK and Ireland. It reviews the present arrangements and their perceived shortcomings and outlines the proposals for a new 2-year program of Basic Surgical Training drawn up by the four Royal Colleges of Surgery in the UK and Ireland. The new proposals severely restrict the time available to surgical trainees for study of anatomy, exposure to which has already been drastically curtailed in the undergraduate medical course. Although it is intended by the Royal Colleges that specialized anatomy appropriate to the various surgical specialties will be examined during Higher Surgical Training, the author contends that anatomy as it applies to all aspects of surgery must be learned and examined thoroughly during Basic Surgical Training. Examination by MCQs' alone is not enough: there is a need for practical assessment in the final assessment at the end of Basic Surgical Training, and this should involve anatomists as well as surgeons. Surgical skills are built upon anatomical knowledge, the study and examination of which must not be reduced to a level where it is detrimental to the care of patients.

A task group of the JCPDS—International Center for Diffraction Data (ICDD) was established with the charge of investigating the use of silver behenate, CH3(CH2)20COO·Ag, as a possible low-angle calibration standard for powder diffraction applications. Utilizing several data collection and analysis techniques, long-period spacing (d001) values with a range of 58.219–58.480 Å were obtained. Using the same collected data and one data analysis refinement calculation method resulted in dm values with a range of 58.303–58.425 Å. Data collected using a silicon internal standard and the same singular data analysis calculation method provided d001 values with a range of 58.363–58.381 Å.

A bioassay for cyst nematode hatching activity is described which is applicable to purification research on hatching factors. Using an easily-constructed incubation unit, based on a 96-well microtitre plate, cysts were suspended, via "thimbles" of wire mesh, in test samples. The use of size-graded cyst samples reduced inter-replicate variability with respect to total egg content and hatching rate. The optimised bioassay procedure used 340 μl test volumes and replicate sizes of five cysts, and the cumulative number of juveniles hatching per cyst after 5 days was closely positively correlated with final hatch (after 31 days). This procedure significantly reduces the labour, time and space requirements of hatching bioassay.

As a result of interest in the characterization of materials with large d-spacings and layer periodicities, it has become necessary to develop a low-angle diffraction material which has welldefined diffraction peaks down to very small 2θ angles. The use of silver behenate, CH3(CH2)20COO-Ag, was introduced by one of the authors (TB) at the 1991 International Centre for Diffraction Data (ICDD) Annual Meeting and was shown to have a set of well-defined (001) diffraction peaks down to 1.5° 2θ when using CuKα radiation. The silver behenate diffraction peaks were observed to be slightly asymmetric with relatively long tails at the low angle side of the peaks. The average crystallite size along the c-axis was estimated using the Scherrer equation and was found to be 900 Å. A task group of the JCPDS-ICJDD Data Collection and Analysis Subcommittee was established with the charge of investigating the use of silver behenate as a possible low-angle calibration material for diffraction applications. Utilizing several data collection and data analysis techniques, d001 long-period spacings in the range of 58.219-58.480 Å were obtained. Using the same collected data and one data analysis refinement calculation method resulted in long-period spacing with a range of 58.303-58.425 Å. Data collected using a silicon internal standard and the same singular data analysis calculation method provided d001 values with a range of 58.363-58.381 Å. The formation of a full-range 2θ diffraction sample was also investigated. Silver behenate and inorganic powders were mixed with an epoxy binder to form a permanent sample which provides diffraction peaks over the entire 2θ range of a powder diffractometer.

Pathological conditions involving the lesser sac of the peritoneal cavity in patients on peritoneal dialysis (PD) can pose significant diagnostic and therapeutic challenges. Lack of appreciation of these challenges may delay diagnosis and compromise outcome. A case series by Li and colleagues in this issue of Peritoneal Dialysis International highlights the diagnostic challenges presented by lesser sac infection in PD patients, and in this accompanying commentary we discuss the development and anatomy of the lesser sac, as well as the pathological conditions and investigations relevant to the management of patients on PD.

This study reports a retrospective analysis of the details of the anatomy of the renal arteries of 403 kidney donors and the arterial complications related to 513 subsequent kidney transplants in our transplant unit. Multiple renal arteries occurred bilaterally in 10.2% of donors and unilaterally in 20.8%, a total incidence of 31%. There was a higher incidence of vascular-related complications following transplantation of kidneys with multiple renal arteries. Attention is drawn to the need for careful technique in identification of multiple renal vessels, especially aberrant vessels, at the time of donor nephrectomy and also to the different techniques available for anastomosis of multiple renal arteries in kidney transplant recipients. © 1992 Wiley-Liss, Inc.

Wound infection in the setting of immunosuppressed state such as renal transplantation (RT) causes significant morbidity from sepsis, prolongs hospital stay and is expensive. Vacuum-assisted closure (VAC) therapy is a new technique of management of wound based on the principle of application of controlled negative pressure. The aim of this study was to assess the efficacy of VAC therapy in the management of wound infection following RT.This is a prospective study of a cohort of 180 consecutive RTs performed over a period of 4 years, where the data were retrieved from a prospectively maintained computerised database and case-notes.9 of 180 (5%) patients developed wound infection following RT which led to cavitations and dehiscence with copious discharge, and refused to heal with conventional treatment. All 9 cases were treated with VAC therapy. The VAC system was removed after a median of 9 (range 3-30) days when discharge from the wound ceased. Four patients were discharged home with portable VAC device and managed on an outpatient basis, where the system was removed after a median 5.5 (range 3-7) days. The median hospital stay after initiation of VAC therapy was significantly shorter (5, range 2-12 days) than on conventional treatment prior to VAC therapy (11, range, 5-20 days) (p=0.003). Complete healing was achieved in all cases.The use of VAC therapy is an effective and safe adjunct to conventional and established treatment modalities for the management of wound infection and dehiscence following RT. Key words: Renal transplantation, wound infection, vacuum-assisted closure therapy.

Background Renal ischemia-reperfusion injury (IRI) is an unavoidable event in renal transplantation; the effects of IRI can be seen in both the acute and long-term function of the transplanted organ. For this reason, research into the pathophysiology of ischemia-reperfusion is at the forefront of transplantation research. Animal models, particularly in the rat, provide a useful research tool in studying the intricacies of IRI and in evaluating new treatments. We describe a model of right nephrectomy and left renal clamping for 45 minutes and demonstrate the effects of temperature variation during the ischemic period. Methods Male Sprague-Dawley rats (under isoflurane anesthesia) underwent bilateral flank incision with removal of the right kidney and clamping of the left renal hilum for 45 minutes. The animals were divided into 3 groups (n = 6): group 1 had the procedure performed on a heating mat with no temperature control facilities, group 2 used no heating mat, and group 3 used a rectal temperature-controlled homeothermic blanket system (Harvard Medical, United Kingdom). Temperature was taken every 5 minutes throughout the procedure and blood samples were taken on a daily postoperative basis via tail vein venepuncture. Results The average temperature at the end of the procedure in group 1 was 39.67°C and the creatinine level at day 3 was 574 ± 17.84, in group 2 the temperature was 32.6°C and the creatinine level was 115 ± 4.06, and in group 3 the temperature was maintained between 36.5°C–37°C and the serum creatinine level was 329 ± 19.18. The temperature of the animal during the ischemia phase of IRI significantly affects the severity of injury. Relative hyperthermia resulted in more severe renal injury and unrecoverable acute renal failure, no source of heat led to a relative hypothermia, and reduction of renal injury. Use of the homeothermic heating blanket led to an increase in creatinine level by day 3, indicating a significant ischemic stimulus; however, by day 10 the creatinine level had returned to normal. Conclusion This illustrates the importance of temperature as a variable in animal models of IRI and thus should be clearly stated in all experimental methods to ensure an appropriate ischemic stimulus and for adequate comparisons between various therapeutic interventions.

An increasing number of abdominal aortic aneurysms (AAA) occur in renal failure patients because of strong association between atherosclerosis and chronic kidney disease. Endovascular aneurysm repair (EVAR) has proven to be an effective modality to treat AAA, particularly in patients with renal disease, because of its several advantages over the standard open procedure, including lower morbidity, shorter operative time, and shorter hospital stay. A Medline search showed a single publication on renal transplantation (RT) following EVAR of AAA. In this context, we report our case of successful RT in a patient who had undergone EVAR 2 years prior for a 5.7-cm AAA. No stent-related complications, such as graft occlusion, dislodgement, dissection, or endoleak, were observed in the perioperative period. The transplanted kidney had primary function leading to a stable serum creatinine of 115 micromol/L at 6 months. Although the long-term outcome of RT after endovascular repair of AAA remains unknown, currently available evidence shows favorable outcomes of EVAR in the normal population, in patients with renal diseases, and in RT recipients; hence, RT should not be denied to renal failure patients who have undergone EVAR in the past.

Eleven rats were given twice-daily intraperitoneal injections of 20 mL of dialysis fluid containing 4.5% glucose for 6 weeks. The peritoneal ultrafiltration capacity of this group was compared with that of a control group of 10 rats that had received no injections by measuring the volume and glucose concentration of the dialysate remaining in the peritoneal cavity 2 hours after injection. Animals that had received injections of dialysis fluid showed significant loss of peritoneal ultrafiltration: volume of dialysate remaining in the control group was 31 (13–35) mL, and in the experimental group was 25 (11–45) mL, with p

Intraabdominal fibrous adhesions are a major cause of intestinal obstruction.1 By far the most common cause of intraabdominal adhesions is previous surgical intervention. Most surgeons regard intraabdominal adhesions as a problem, because reoperation on the abdomen is made difficult by prolonged dissection of fibrous adhesions with the risk of visceral damage. Because adhesions may have such serious consequences, it is not surprising that a very large number of techniques have been devised with the aim of preventing their development. Many of these however have been shown to be unreliable. 1,2 Many of the techniques used have been of an empirical nature, and little improvement can be expected unless the underlying pathogenesis is understood because a clear understanding of pathogenesis is a prerequisite to rational prophylaxis and therapy.

Anatomy teaching in the UK is in crisis. This contribution presents the problems and proposes solutions at undergraduate and postgraduate level. At undergraduate level, there is a need for a core curriculum that provides an anatomical basis for patient examination, interpretation of imaging and safe conduct of basic interventional procedures, as well as student-selected components. At postgraduate level, the colleges and schools of surgery must provide exposure to anatomy via appropriate courses and by the resurrection of demonstrator posts.

Femoral nerve palsy has been reported after percutaneous ilioinguinal field infiltration with general anaesthesia for inguinal herniorrhaphy. The mechanism whereby this could occur was studied in cadaver dissections. It was found that the plane between the transversus abdominis muscle and the transversalis fascia was continuous laterally with the tissue plane deep to the iliacus fascia, which is the plane containing the femoral nerve. Injection of methylene blue 1 ml into this plane resulted in pooling of dye around the femoral nerve. Femoral nerve palsy may result from infiltration of a sufficient volume of local anaesthetic into the plane between the transversus abdominis muscle and the transversalis fascia with tracking of the injectate deep to the iliacus fascia to affect the femoral nerve. This finding has important implications for the performance of a percutaneous ilioinguinal field block particularly in day surgery provision.

This chapter reviews the cellular events in peritoneal repair and discusses them in relation to the formation of postoperative intraperitoneal adhesions. Peritoneal defects heal rapidly and large defects heal as rapidly as small ones. Healing occurs for the most part without adhesion formation. Centripetal growth from the margin of peritoneal wounds contributes little to the healing process, the new mesothelium being derived from the metaplasia of subperitoneal perivascular connective tissue cells that resemble primitive mesenchymal cells. There is little evidence to support earlier concepts that macrophages were transformed into mesothelial cells.

Summary A case of adenocarcinoma of the sigmoid colon, presenting as a testicular mass, is described. At sigmoid colectomy widespread metastases were found and only palliative care could be offered thereafter. The incidence and age of such a presentation and manner of spread of the occult primary are discussed.

This report is concerned with the place of the basic medical sciences, and particularly of anatomy, in the training of surgeons in the UK and Ireland. It reviews the present arrangements and their perceived shortcomings and outlines the proposals for a new 2-year program of Basic Surgical Training drawn up by the four Royal Colleges of Surgery in the UK and Ireland. The new proposals severely restrict the time available to surgical trainees for study of anatomy, exposure to which has already been drastically curtailed in the undergraduate medical course. Although it is intended by the Royal Colleges that specialized anatomy appropriate to the various surgical specialties will be examined during Higher Surgical Training, the author contends that anatomy as it applies to all aspects of surgery must be learned and examined thoroughly during Basic Surgical Training. Examination by MCQs' alone is not enough: there is a need for practical assessment in the final assessment at the end of Basic Surgical Training, and this should involve anatomists as well as surgeons. Surgical skills are built upon anatomical knowledge, the study and examination of which must not be reduced to a level where it is detrimental to the care of patients.

We have examined the ultrastructural localization of immunoreactive platelet-derived growth factor (PDGF) in Wistar rats injected with cyclosporin A (CyA, 12.5 mg/kg/day) for 4 weeks. CyA injections resulted in a significant increase in serum creatinine (47 +/- 3 vs. 35 +/- 2 mumol/l, p0.05) and a reduction in creatinine clearance (0.29 +/- 0.07 vs. 0.53 +/- 0.04 ml/min/100 g b.w., p0.01). CyA-treated rats displayed marked hypertrophy and hypergranularity of the juxtaglomerular cells. Morphometric studies showed a significant increase in the number (2.8 +/- 0.3 vs. 1.8 +/- 0.3, p0.05) and a 60% increase in the volume of secretion granules within these cells. PDGF was detected exclusively within the secretion granules of the juxtaglomerular cells of the afferent arterioles of CyA-treated animals. We conclude that CyA therapy or its induced haemodynamic alterations result in increased accumulation of PDGF-BB within the secretion granules of the juxtaglomerular cells.

As a result of interest in the characterization of materials with large d-spacings and layer periodicities, it has become necessary to develop a low-angle diffraction material which has well-defined diffraction peaks down to very small 2{theta} angles. The use of silver behenate, CH{sub 3}(CH{sub 2}){sub 20}COO-Ag, was introduced by one of the authors (TB) at the 1991 International Center for Diffraction Data (ICDD) Annual Meeting and was shown to have a set of well-defined (00l) diffraction peaks down to 1.5{degrees} 2{theta} when using CuK{alpha} radiation. The silver behenate diffraction peaks were observed to be slightly asymmetric with relatively long tails at the low angle side of the peaks. The average crystallite size along the c-axis was estimated using the Scherrer equation and was found to be 900 {Angstrom}. A task group of the JCPDS-ICDD Data Collection and Analysis Subcommittee was established with the charge of investigating the use of silver behenate as a possible low-angle calibration material for diffraction applications. Utilizing several data collection and data analysis techniques, d{sub 001} long-period spacings in the range of 58.219-58.480 {Angstrom} were obtained. Using the same collected data and one data analysis, refinement calculation method resulted in long-period spacings with a range ofmore » 58.303-58.425 {Angstrom}. Data collected using a silicon internal standard and the same singular data analysis calculation method provided d{sub 001} values with a range of 58.363-58.381 {Angstrom}. The formation of a full-range 2{theta} diffraction sample was also investigated. Silver behenate and inorganic powders were mixed with an epoxy binder to form a permanent sample which provides diffraction peaks over the entire 2{theta} range of a powder diffractometer. 8 refs., 3 figs., 1 tab.« less

Summary A case of adenomatous polyp occurring at a ureterocaecal anastomosis, 25 years after urinary diversion following a total cystectomy for carcinoma of the bladder, is reported. Bilateral nephrectomy for chronic pyelonephritis was carried out 25 years after the initial surgery and, following this, a sinus formed at the incision at the right loin. A sinogram showed contrast filling the right ureter and caecum, and outlined a lobulated filling defect at the ureterocaecal anastomosis. Subsequent histology revealed a dysplastic tubulovillous adenoma. The clinical presentation and management of tumours at the ureterointestinal junction are discussed.

A study was performed to test the hypothesis that renal allograft recipients are at high risk of developing anal human papillomavirus (HPV) infection and anal intraepithelial neoplasia (AIN). A total of 133 renal allograft recipients and 145 control patients underwent anoscopy and biopsy. A polymerase chain reaction was used to detect HPV16 DNA in biopsy samples. A histological diagnosis of anal HPV infection or AIN was made in 32 allograft recipients (HPV infection, five; AIN I, 20; AIN II, three; AIN III, three; AIN III and anal cancer, one). One subject with AIN was detected in the control group. HPV16 DNA was detected in 47 and 12.4 per cent of anal biopsies in the allograft and control groups respectively. Renal allograft recipients are at high risk of developing anal HPV infection and neoplasia (P

Today, more than ever, the postgraduate surgical trainee requires instruction in anatomy, for no longer does the undergraduate get a thorough grounding in anatomy. In the past, the postgraduate trainee had formal tuition and examination in anatomy at 2nd M.B. and, therefore, only recall and reinforcement of knowledge were necessary to learn the anatomy required for the old Primary Examination of the four Royal Colleges of Surgeons. In recent years, the amount of time for teaching anatomy in the undergraduate course has been drastically reduced and, in many medical schools, anatomy is taught on prosected specimens rather than allowing the student to dissect the human body. In some cases, knowledge is acquired by self-directed learning and by virtual reality programs on the computer. The old 2nd M.B. examination has virtually disappeared and teaching of anatomy has changed from a discipline-based method, to systems-based or problem-based teaching with self-directed learning. Consequently, the basic anatomical knowledge of the postgraduate trainee is now totally inadequate and much new learning is required for the professional examinations in surgery.

The principal causes of failure of a pancreas transplant are rejection and vascular thrombosis. There is an unusually high attrition rate for pancreas transplants, but study models have been difficult to develop. In a rat model that allows study of acute rejection to the exclusion of nonspecific effects of transplant surgery on the pancreas, in vitro synthesis of prostacyclin (PGI2) and thromboxane A2 (TXA2) by transplanted pancreas and the blood vessels transplanted with it was measured using an RIA for their stable hydrolysis products 6-keto-prostaglandin F1 alpha and thromboxane B2 (TXB2). TXB2 synthesis was significantly greater in allotransplanted pancreas than isotransplanted pancreas from the 5th day after transplantation. Rejection was complete in the allografted group 7-9 days after transplantation. 6-Keto-prostaglandin F1 alpha synthesis was similar in the pancreas for both allografts and isografts. Similar changes were seen in aorta, celiac artery, superior mesenteric artery, and portal vein transplanted with the pancreas. In the transplanted aorta, TXB2 was significantly greater in the allograft group from the third posttransplant day. A group of CsA-treated allografts sampled after 9 days had transplanted pancreatic parenchymal and vascular prostanoid synthesis in the isograft range. The changes in PGI2 and TXA2 synthesis that accompany cellular rejection may mediate vascular failure in rejecting pancreas transplants, and changes in PGI2 and TXA2 synthesis in blood vessels transplanted with the pancreas could promote early vascular thrombosis.

To assess the surgical workload on a renal unit, with particular reference to non-transplant-related surgery and to assess the workload in relation to surgical staffing levels.Prospective audit of all surgical procedures carried out on patients in acute or chronic renal failure, and on transplanted patients, within a one year period.A purpose-built renal unit serving a population of 1.7 million.The number of surgical procedures, both transplant and non-transplant-related, according to type and severity, with particular reference to the levels of surgical staffing.Transplant-related surgery accounted for only 6.5 per cent of the total surgical workload (general, vascular and renal) of the 'transplant surgeons'. Taking into account only the renal-related workload, transplant-related surgery accounted for just 16.5 per cent of the workload, the remainder being related to vascular access and peritoneal access for dialysis, and general surgical procedures on patients in renal failure and transplanted patients. The surgical workload undertaken by a relatively small number of staff was high, representing 531 Intermediate Equivalents per Service Equivalent Value per annum.When assessing workload and adequacy of surgical staffing on a Renal Unit, care should be taken to account for all surgical activity on renal patients and not just that related to transplantation since only 16.5 per cent of the surgical workload is transplant-related.

Histology of pancreas transplant rejection is complicated by non-specific appearances related to undrained exocrine secretions. Using a rat model of pancreas transplantation with exocrine drainage into the urinary tract, morphology of acute rejection has been studied with minimal interference from non-specific change. Unmodified acute rejection was complete after 7-9 days. Intralobular lymphocytic infiltration, which differentiated allografts from isografts, was present 5 days after transplantation and lymphocytic infiltration of islets and blood vessel walls developed between 5th and 7th days. Cyclosporin A immunosuppression of allografts resulted in marked attenuation of the cellular infiltrate. The nature of the infiltrate and its suppression with cyclosporin A indicated an allograft reaction.