Patterns of acute rejection in portal-enteric versus systemic-bladder pancreas-kidney transplantation.

Portal-enteric (PE) transplantation of the pancreas allograft provides maintained physiologic drainage, and theoretically the portal delivery of transplantation antigens may have beneficial effects on the graft acceptance leading to improved graft survival. To determine whether the technique of pancreas placement affects the incidence of acute rejection we reviewed our experience in technically successful PE and systemic-bladder (SB) drained simultaneous pancreas and kidney (SPK) transplants performed between 1989 and 1994. Forty-seven recipients were included (SB = 30, PE = 17). All patients received cyclosporine based quadruple immunosuppression and survived at least 1 month. The two groups were comparable in HLA mismatches, cold ischemia time and level of immunosuppression at time of rejection. In the SB group the incidence of rejection was 1.04 kidney rejection/patient and 0.90 pancreas rejection/patient whereas the PE group experienced 0.53 kidney rejection/patient and 0.47 pancreas rejection/patient. The two groups were compared using incidence density statistics due to great variation in follow-up time. The SB group had a significant higher density of both kidney and pancreas rejections (p < or = 0.037 for kidney rejection and 0.058 for pancreas rejection). In addition, while 6 of 30 (20%) pancreas grafts and 4 of 30 (13%) kidney grafts were lost to irreversible rejection in the SB group, only 1 of 17 (6%) pancreas graft and 1 of 17 (6%) kidney graft were lost in the PE group. These data demonstrate, that the PE placement of pancreas allograft affects the rates of acute rejection and graft loss, and imply that there exist some important immunological advantages when the pancreas graft is drained into the portal circulation.

Diagnosis, management, and outcome of late duodenal complications in portal-enteric pancreas transplantation: case reports.

BACKGROUND: Enteric drainage (ED) of pancreas allografts is an alternative to the bladder drainage (BD) technique and eliminates unique metabolic complications seen in the BD pancreas transplant recipients. Little longterm data has been reported in ED pancreas transplants. STUDY DESIGN: Of 53 patients who underwent pancreas transplantations performed with ED drainage of the exocrine secretion to a Roux-en-Y limb, who had more than 6 months graft function, four patients were identified with late duodenal segment complications (more than 6 months after transplantation) and are presented as case reports. RESULTS: The duodenal segment complications occurred between 8 and 48 months after simultaneous pancreas-kidney transplantation. Three patients were diagnosed with leakage from the duodenal segment. All were managed operatively. The fourth patient developed a distal stricture of the transplant duodenum occluding the anastomosis between the duodenum and the Roux-en-Y limb and also had a pancreatic pseudocyst. Drainage via a cyst-jejunostomy resulted in graft salvage. The mean followup after operative management of the duodenal-related complications was 15 months (range, 3-24 months). The patient, pancreas and kidney graft survival are 100%. CONCLUSIONS: Late duodenal complications occurred in 8% of pancreas transplant recipients with ED. Operative intervention in all four patients resulted in excellent graft and patient outcome and is recommended for these complications.

[Thromboembolic complications after ambulatory herniotomy]. / Tromboemboliske komplikationer efter ambulant herniotomi.

Thromboembolism is a serious complication of surgery and prophylaxis is therefore recommended. This study examines a new aspect of the problem, the incidence of thromboembolism after day-case surgery. From 1982 to 1992, 2281 patients underwent day-case repair for inguinal hernia management. Hospital admission for thromboembolism within the first 30 days after surgery was identified by computer linkage to the National In-Patient register, which contains details of all hospital admissions in Denmark. One patient developed non-fatal pulmonary embolism. No other patients were admitted to hospital with venous thromboembolism within 30 days of herniorrhaphy. It is concluded that there is no need for routine prophylaxis for thromboembolism in day-case hernia surgery.

[Anastomotic leakage after low anterior resection for rectal cancer]. / Anastomoselaekage efter lav anterior resektion for cancer recti.

A series of 377 consecutive patients were operated upon with low anterior resection for rectal cancer in the nine Danish departments of surgical gastroenterology during 1992-1993. A retrospective analysis was carried out to calculate the frequency of anastomotic leakage and to evaluate factors of potential influence on the development of leakage according to the literature. Sixty-three patients (17%) developed leakage, which was followed by an increased mortality within the first three postoperative months. Only two variables significantly influenced the leakage rate: male gender was associated with a higher leakage rate (p = 0.02), whereas departments with a low number of rectal cancer surgeons had a low rate of anastomotic leakage (p = 0.02). In conclusion, the rather high frequency of anastomotic leakage calls for further clinical and pathogenetic research in this field. Until then, we recommend the routine use of a peroperative leakage test and selective use of prophylactic ostomy in cases of unsatisfactory anastomosis. Furthermore, it is recommended that low anterior resection for rectal cancer is limited to few surgeons in each department in order to ensure a uniform quality and hopefully also thereby reduce the rate of anastomotic leakage.

Prevention of hepatitis B recurrence with indefinite hepatitis B immune globulin (HBIG) prophylaxis after liver transplantation.

Liver transplantation for hepatitis B is followed by a high rate of recurrence some time after transplantation, resulting in poor outcome compared to liver recipients transplanted for other indications. Passive immunoprophylaxis with HBIG has been shown to decrease the rate of recurrence to 25-50%, but the intensity and length of treatment is still controversial. We studied 17 HBsAg positive patients who were transplanted for hepatitis B. Four did not receive immunoprophylaxis and they all reoccurred within 3 months. The remaining 13 have received indefinite, high dose HBIG (10,000 mu or 40,000 mu/dose depending on HBV DNA status pretransplant). Ten of 13 patients (77%) remain HBsAg negative after a mean follow-up of 16.7 months with six of these ten patients being HBV DNA positive pretransplant. Of the three who have experienced recurrence, two received extensive additional immunosuppression beyond that normally administered to transplant patients (chemotherapy, multiple antirejection treatment). The last patient received 110,000 u of HBIG during the first 3 months, which produced an anti-HBs titer level of 225 IU/L, but the following month he was HBsAg positive with an anti-HBs titer of 13 IU/L. We conclude that HBsAg positive patients can be safely transplanted using indefinite, high-dose HBIG prophylaxis, and that with adequate HBIG it is possible to prevent recurrence in HBV DNA positive patients as well.

Postoperative thromboembolism after day-case herniorrhaphy.

Thromboembolism is a serious complication of surgery and prophylaxis is therefore recommended. This study examines a new aspect of the problem, the incidence of thromboembolism after day-case surgery. From 1982 to 1992, 2281 patients underwent day-case repair for inguinal hernia management. Hospital admission for thromboembolism within the first 30 days after surgery was identified by computer linkage to the National In-Patient Register, which contains details of all hospital admissions in Denmark. One patient developed non-fatal pulmonary embolism. No other patients were admitted to hospital with venous thromboembolism within 30 days of herniorrhaphy. It is concluded that there is no need for routine prophylaxis for thromboembolism in day-case hernia surgery.

Rate and treatment of pelvic recurrence after abdominoperineal resection and low anterior resection for rectal cancer.

PURPOSE: This study was designed to analyze factors of importance for local recurrence after radical surgery for rectal cancer and to analyze course and outcome of treatment of pelvic recurrence. METHODS: One hundred seventy-five patients treated for rectal cancer with low anterior resection (LAR) or abdominoperineal resection (APR) were studied, retrospectively. Seventy-four patients had LAR and 101 had APR. RESULTS: The two groups were comparable with respect to Dukes classification, histologic differentiation, and male to female ratio. The rate of pelvic recurrence was 18 percent for LAR and 24 percent for APR (not significant). Recurrence rates were 27 percent after stapled anastomoses and 10 percent after handsewn anastomoses respectively (P = 0.09). Twenty five had pelvic recurrence diagnosed without signs of distant metastatic disease. They were treated with radiotherapy, palliative operations, or analgesics. The group receiving radiotherapy had a significantly longer survival (15.9 months) compared with other groups (2.4 months; P < 0.001). CONCLUSIONS: There is no difference in local recurrence rate after LAR and APR. Radiotherapy seems to increase survival in patients with an unresectable recurrence and should be offered irrespective of pain.