In what is believed to be a first-ever procedure, surgeons at Johns Hopkins have successfully removed a healthy donor kidney through a small incision in the back of the donor's vagina.
"The kidney was successfully removed and transplanted into the donor's niece, and both patients are doing fine," says Robert Montgomery, M.D., Ph.D., chief of the transplant division at Johns Hopkins University School of Medicine who led the team that performed the historic operation.

The transvaginal donor kidney extraction, performed Jan. 29 on a 48-year-old woman from Lexington Park, Md., eliminated the need for a 5-to-6-inch abdominal incision and left only three pea-size scars on her abdomen, one of which is hidden in her navel.

Transvaginal kidney removals have been done previously to remove cancerous or nonfunctioning kidneys that endanger a patient's health, but not for healthy kidney donation. Because transplant donor nephrectomies are the most common kidney removal surgery - 6,000 a year just in the United States - this approach could have a tremendous impact on people's willingness to donate by offering more surgical options," says Montgomery.

"Since the first laparoscopic donor nephrectomy was performed at Johns Hopkins in 1995, surgeons have been troubled by the need to make a relatively large incision in the patient's abdomen after completing the nephrectomy to extract the donor kidney. "That incision is thought to significantly add to the patient's pain, hospitalization and convalescence," says Montgomery. "Removing the kidney through a natural opening should hasten the patient's recovery and provide a better cosmetic result."

Both laparoscopies and transvaginal operations are enabled by wandlike cameras and tools inserted through small incisions. In the transvaginal nephrectomy, two wandlike tools pass through small incisions in the abdomen and a third flexible tool housing a camera is placed in the navel.

Video images displayed on monitors guide surgeons' movements. Once the kidney is cut from its attachments to the abdominal wall and arteries and veins are stapled shut, surgeons place the kidney in a plastic bag inserted through an incision in the vaginal wall and pull it out through the vaginal opening with a string attached to the bag.

Montgomery says the surgery took about three and a half hours, roughly the same as a traditional laparoscopic procedure.

The Jan. 29 operation is one of a family of new surgical procedures called natural orifice translumenal endoscopic surgeries (NOTES) that use a natural body opening to remove organs and tissue, according to Anthony Kalloo, M.D., the director of the Division of Gastroenterology at Johns Hopkins University School of Medicine and the pioneer of NOTES. The most common openings used are the mouth, anus and vagina.

Since 2004, successful NOTES in humans have removed diseased gallbladders and appendixes through the mouth, and gallbladders, kidneys and appendixes through the vagina.

Recently, Kalloo says, some medical experts have called for more studies to compare the safety and effectiveness of NOTES against traditional laparoscopies, which also leave very small scars, have been in use for many years, and are proven to be safer and less painful for patients than older "open" abdominal procedures. He supports more studies.

But, he adds, "natural orifice translumenal endoscopic surgery is the final frontier to explore in making surgery scarless, less painful and for obese patients, much safer." An organ donor, in particular, is most deserving of a scar-free, minimally invasive and pain-free procedure."

Additional surgeons from Johns Hopkins University School of Medicine who participated in the procedure were Mohamad E. Allaf, M.D., assistant professor in the departments of Urology and Biomedical Engineering and director of minimally invasive and robotic surgery; Andy Singer, M.D., Ph.D., assistant professor in the Division of Transplant Surgery; and Wen Shen, M.D., M.P.H., assistant professor in the Department of Gynecology and Obstetrics.

When does severe childhood obesity become a child protection issue? This is just one of the ethical, medical and legal questions confronting doctors as they deal with increasing rates of childhood obesity, according to a series of articles in the latest Medical Journal of Australia.

Dr Shirley Alexander from Westmead Children's Hospital and her colleagues say severe childhood obesity is a common problem that can result in acute and chronic life-threatening complications. Their article examines the case of a severely obese child whose parents were unwilling or unable to adhere to management programs aimed at helping her lose weight.

"We argue that in a sufficiently extreme case, notification of child protection services may be an appropriate professional response," the report says.

According to the report, parental neglect can be a causative factor in ongoing obesity and related medical problems including sleep apnoea.

The case described in the article, an amalgamation of real issues from a number of actual cases, described a four-year-old girl who was 110cm tall and weighed in at a hefty 40kg. The child watched TV for six hours a day and had temper tantrums when denied food. A family-focused multidisciplinary approach failed to stop or reverse the child's weight gain. Child protection authorities were finally notified when the child's health continued to deteriorate. She was introduced to a program of physical activity and reduced dietary intake that soon had her losing weight.

The report concludes that a doctor is duty bound to report severe cases of inadequately managed paediatric obesity to the authorities.

A related article by Joanne Stubbs and Helen Achat says that collecting accurate data is essential in the fight against obesity. The article says monitoring and reporting on childhood obesity provide information on which to base, and subsequently evaluate, our efforts and are dependent on 'opt out' consent to minimise problems of inadequate participation.

"Ongoing population-based anthropometric measurement is fundamental to such efforts (early intervention in weight problems). We argue this is only possible with 'opt out' consent."

'Opt out' consent facilitates the recruitment of a representative sample of the population for valid and meaningful anthropometric information and, at the same time, leaves the individual with the right to decline participation. The article calls on ethics committees to support endeavours to confront the challenges of childhood obesity by allowing opt-out consent for anthropometric measurement studies.

The final article in the series written by nutritionalist Dr Tim Gill and a diverse group of experts in paediatrics, public health, nutrition and endocrinology from the University of Sydney, refutes recent commentary downplaying the prevalence of childhood obesity saying it remains a widespread health concern that warrants population-wide prevention programs.

The statements or opinions that are expressed in the MJA reflect the views of the authors and do not represent the official policy of the AMA unless that is so stated

UK's secretary of state for health, Alan Johnson, said on BBC One's Andrew Marr show on Sunday that on Tuesday he is going to unveil a new government plan to raise the national profile of dementia to improve early diagnosis and quality of treatment and this would include a raft of new initiatives including the provision of "memory clinics" in every town and more support for carers.

The intention is to end the stigma that surrounds dementia: "it's a bit like cancer was 20 years ago," said Johnson. "It wasn't the subject of polite conversation". But unlike cancer, people still joke about dementia and Alzheimer's.

And it takes on average about three years for someone with the condition to receive a diagnosis. Johnson told Andrew Marr he wants people to seek diagnosis much earlier. There are drugs that can improve memory and other ways like changes to diet and lifestyle that can make a measurable difference if diagnosis is early enough.

There are about 700,000 people living with dementia in the UK, many of them without any support from the NHS or social services. Johnson said he wants the national strategy to transform their treatment and quality of life.

According to a report in the Telegraph, Phil Hope, the care services minister, said in December that over the coming decades, the number of people with dementia "is going to double, even treble".

Although Johnson conceded that the NHS needed "re-balancing" to overcome ageism against patients, he said he hoped the days when doctors and health professionals said a condition wasn't worth treating because the patient was too old are long gone.

Johnson is unveiling his plan for a national dementia strategy in the House of Commons on Tuesday. He told Andrew Marr there is money to see the plan through, and it will include more support for people looking after family members with dementia at home.

Johnson said that often it is the carers, the spouses and family members that experience the trauma of dementia, and they need help and support too, and "they need it very early" he said.