Magnetic resonance imaging and computed tomography in long-term-functioning duct-occluded pancreas allotransplants.

Duct-occluded segmental-pancreas transplants develop progressive fibrotic atrophy, even though endocrine function seems to be unaffected. To determine end-stage size of the graft and to evaluate magnetic resonance imaging (MRI) and computed tomography (CT), these imaging techniques were applied in eight patients with well-functioning intraperitoneal prolamine-injected segmental-pancreas transplants for 79, 48, 35, 20, 19, 19, 18, and 10 mo. MRI was performed on a 1.5 Tesla system (Philips Gyroscan S15). T1- and T2-weighted images were acquired. CT (Siemens Somatom 2) was done before and after intravenous contrast agent. The graft was visualized in seven of eight patients with both techniques. Visualization with MRI (vs. CT) was considered excellent in 2 (vs. 1), good in 3 (vs. 6), and poor in 2 (vs. 0). The three grafts with function longer than 2 yr measured 3-4 cm in length; the remaining grafts measured 3-6 cm. Because of a marked decrease in size the transplants were no longer localized in Douglas' pouch but adjacent to or on top of the uterus or bladder, the position depending on the volume of these organs. The allografts exhibited an inhomogeneous structure with casual cystic degeneration visible with MRI due to a high signal intensity on T2-weighted images. This study suggests that shrinkage of the duct-occluded pancreatic segment due to exocrine atrophy may be terminated after approximately 2 yr. It is concluded that thereafter an overshooting fibrosis causing late endocrine graft failure may not be anticipated.

Kidney transplantation improves survival and is indicated in Fabry's disease.

BACKGROUND: Fabry's disease (FD) is an inborn error of glycosphingolipid catabolism with progressive systemic deposition of globotriaosylceramide thereby leading to renal and cardiac failure. Current therapy involves symptomatic medical management, dialysis, enzyme replacement therapy, kidney transplantation (KTx), and more recently gene therapy. Case fatalities occur in the fourth decade of life resulting from uremia unless dialysis or KTx is undertaken. STUDY DESIGN: This is a retrospective study aimed at determining the effect of KTx on the long-term outcome of patients with FD. RESULTS: Between 1964 and 1998, ten patients with FD received KTx at our institutions. Actuarial patient and graft survivals were 100% and 90% at 5 years; 76% and 66% at 10 years. One kidney graft was lost due to rejection. Patient survival data compared favorably at 5 years with survival of FD patients on hemodialysis alone (41%, P < .05). Five patients are alive at the time of this study, and five patients died with median survival time after KTx of 128 months (range: 74-160 months). CONCLUSIONS: This study demonstrates an excellent outcome in patients with FD in the first decade after KTx. In the absence of a severe contraindication, we advocate KTx to improve the overall prognosis of patients with renal failure due to FD. Based on the data, enzyme replacement therapy after KTx seems indicated, as FD progresses posttransplant, leading to case fatalities in the second decade after KTx.

Prospective evaluation of pretransplant blood transfusions in cadaver kidney recipients.

BACKGROUND: A beneficial effect of pretransplant transfusions on graft survival was demonstrated in the early 1970s. In the mid-1980s, however, retrospective studies showed that transfusions had lost their graft-protective effect in the cyclosporine era. During the last 10 years, deliberate transfusion pretreatment of transplant patients has been discontinued. METHODS: Within a collaborative project of 14 transplant centers, prospective recipients of cadaver kidney grafts were randomized to receive either three pretransplant transfusions or transplants without transfusions. RESULTS; The graft survival rate was significantly higher in the 205 transfusion recipients than in the 218 patients who did not receive transfusions (at 1 year: 90+/-2% vs. 82+/-3%, P=0.020; at 5 years: 79+/-3% vs. 70+/-4%, P=0.025). Cox regression analysis showed that this effect was independent of age, gender, underlying disease, prophylaxis with antilymphocyte antibodies, and preformed lymphocytotoxins. CONCLUSIONS; Transfusion pretreatment improves the outcome of cadaver kidney transplants even with the use of modern immunosuppressive regimens.

Surgery and environmental influence as risk-factors for the development of deep vein thrombosis in animal experiments.

The aim of this experimental study was to determine whether deep vein thrombosis (DVT) in animals occurs after osteosynthesis of the femur, and whether a postoperative drop in air pressure increases the frequency of DVT. Thus, osteosynthesis of the femur was performed in 10 New Zealand rabbits. Postoperatively a drop in air pressure of 300 hPA was induced. After 40 h in the pressure cabin ascending phlebography was performed (Group A). In a control-group of 10 other rabbits surgery was performed without postoperative drop in air pressure (Group B) while in a second control only the drop in air pressure was induced without surgery (Group C). The phlebographic studies showed DVT in 4 out of 10 rabbits in group A. In group B there was no demonstrable DVT while in group C one case of DVT was seen. The difference between group A and group B and C is statistically significant. In conclusion, a rapid drop in air pressure seems to have significant impact on the pathogenesis of DVT in rabbits after osteosynthesis of the femur.

Low molecular weight heparin (KABI 2165) as thromboprophylaxis in elective visceral surgery. A randomized, double-blind study versus unfractionated heparin.

In two randomized double-blind studies perioperative bleeding complications and thromboembolic events were assessed in 189 patients (pts) undergoing elective visceral surgery after subcutaneous administration of a low molecular weight (LMW) heparin fragment (KABI fragment 2165) or unfractionated (UF) heparin. The first study comparing 1 X 7'500 anti-factor Xa IU LMW heparin daily with 2 X 5'000 IU UF heparin was interrupted because of excessive bleeding complications (LMW heparin: 11/23 pts, UF heparin: 2/20 pts, p less than 0.01). In the second study (146 pts) the dose of LMW heparin was reduced to 1 X 2'500 anti-factor Xa IU. Bleeding complications (LMW heparin: 14.9%, UF heparin: 15.3%) and thromboembolic events (LMW heparin: 2.86%, UF heparin: 2.94%) were equal among the two groups. 2'500 anti-factor Xa IU/day of this LMW heparin fragment, corresponding to 15 mg/day, is the lowest dose of a LMW heparin used in a randomized clinical trial and was found to be a safe and efficient regimen in perioperative thrombosis prophylaxis. An advantage of LMW heparin over UF heparin is its once daily administration.

Lung herniation through a postthoracoscopy chest wall defect: demonstration with spiral CT.

The incidence of complications following thoracoscopy is approximately 10%, the most prevalent being prolonged air leak and chest pain. We report two cases of lung herniation through the chest wall defect created by thoracoscopy. Use of the Valsalva maneuver during CT scanning is recommended as a diagnostic imaging method in cases with suspected lung herniation.

Laparoscopic sonography. An alternative to routine intraoperative cholangiography?

OBJECTIVE: To determine whether laparoscopic sonography (LS) could be a valid alternative to intraoperative cholangiography (IOC) in the detection of bile duct stones and anatomical variations. DESIGN: Prospective, controlled study comparing LS and IOC using intraoperative findings and/or postoperative endoscopic retrograde cholangiopancreatography as the gold standard. SETTING: Department of Surgery at Zürich University Hospital, Switzerland. PATIENTS: One hundred consecutive patients undergoing laparoscopic cholecystectomy between January 1992 and January 1993. Twenty-three patients were operated on for acute cholecystitis, while the remainder experienced symptomatic bile duct stones. Ninety-six patients underwent preoperative sonography and 85 underwent intravenous cholangiography. Laparoscopic sonography was performed in all patients after dissection of the cystic duct. INTERVENTIONS: A 5.5-MHz sector scanner with a 360 degrees angle and an optimal depth of 1 to 4 cm was used. After LS, IOC was performed with a 4F ureteric catheter and a modern fluoroscope. Patients with bile duct stones were sent for endoscopic retrograde cholangiopancreatography postoperatively or the stones were removed laparoscopically. RESULTS: Unsuspected common duct stones in three patients and several small calculi in the cystic duct in one patient were detected intraoperatively. Sensitivities and specificities for the detection of bile duct calculi were 100% and 98% by LS and 75% and 99% by IOC, respectively. Anatomical variations of the extrahepatic bile ducts were detected by LS in 20 patients and by IOC in 21 patients. Laparoscopic sonography visualized variations of the hepatic arteries in 22 patients. The average time consumption for LS was 5.4 minutes (range, 2 to 12 minutes) and 16.4 minutes for IOC (range, 4 to 37 minutes). CONCLUSIONS: Laparoscopic sonography is a quick and reliable intraoperative diagnostic tool and could replace IOC in laparoscopic cholecystectomy. Additional trials in a larger patient population are needed for a final assessment.

Is laparoscopic appendectomy the new 'gold standard'?

OBJECTIVES: To determine the efficacy of laparoscopic appendectomy compared with open appendectomy in patients with acute appendicitis and to compare the morbidity between the two groups. DESIGN: Prospective sampling of 102 patients who underwent diagnostic laparoscopy and laparoscopic appendectomy for acute appendicitis and retrospective hospital chart review of 204 patients who underwent open appendectomy for acute appendicitis. RESULTS: The mean +/- SD duration of surgery was 83 +/- 29 minutes in the laparoscopic group and 64 +/- 30 minutes in the open appendectomy group (P < .001). Hospital stay was shorter in the laparoscopic group (P < .04). There was no difference in the complication rate between the patients who underwent laparoscopic appendectomy (13%) and the patients who underwent open appendectomy (11%). The occurrence of postoperative ileus was correlated with the duration of operation (P < .01) but not with laparoscopic appendectomy. CONCLUSIONS: The results confirm that laparoscopic appendectomy had a longer time of surgery, a shorter hospital stay, and no difference in complications. Further investigation will likely establish that laparoscopic appendectomy can be considered the "gold standard."

Hepatitis C RNA prevalence in a Western European organ donor pool and virus transmission by organ transplantation.

Liver disease is a common finding after organ transplantation and might in part be due to transmission of hepatitis C virus (HCV). The aim of this study was to determine the prevalence of positive results with different anti-HCV tests and HCV-RNA in a local donor pool and to clarify to what extent HCV was transmitted to organ recipients. Serum samples from 207 consecutive organ donors were analysed retrospectively with anti-HCV ELISA (2nd and 3rd generation), anti-HCV RIBA (2nd generation) and HCV polymerase chain reaction (PCR). Organ recipients at risk were identified and followed up serologically and clinically. Anti-HCV seroprevalance in organ donors was 4.3% for 2nd generation ELISA, 4.8% for 3rd generation ELISA and 1.9% for 2nd generation RIBA. HCV-PCR was positive in 1.4%. Nine organs from four RIBA-positive donors were transplanted into eight recipients of whom four became anti-HCV and PCR positive after transplantation. HCV-PCR became positive several days after transplantation whereas anti-HCV seroconversion took place after 8-9 months. Two recipients developed acute liver disease and another two showed features of mild chronic liver disease but no serious complications due to HCV infection were observed.

Prospective, randomized comparison of extrapleural versus epidural analgesia for postthoracotomy pain.

BACKGROUND: Thoracic epidural analgesia is considered the method of choice for postthoracotomy analgesia, but it is not suitable for every patient and is associated with some risks and side effects. We therefore evaluated the effects of an extrapleural intercostal analgesia as an alternative to thoracic epidural analgesia. METHODS: In a prospective, randomized study, pain control, recovery of ventilatory function, and pulmonary complications were analyzed in patients undergoing elective lobectomy or bilobectomy. Two groups of 15 patients each were compared: one received a continuous extrapleural intercostal nerve blockade (T3 through T6) with bupivacaine through an indwelling catheter, the other was administered a combination of local anesthetics (bupivacaine) and opioid analgesics (fentanyl) through a thoracic epidural catheter. RESULTS: Both techniques were safe and highly effective in terms of pain relief and recovery of postoperative pulmonary function. However, minor differences were observed that, together with practical benefits, would favor extrapleural intercostal analgesia. CONCLUSIONS: These results led us to suggest that extrapleural intercostal analgesia might be a valuable alternative to thoracic epidural analgesia for pain control after thoracotomy and should particularly be considered in patients who do not qualify for thoracic epidural analgesia.

Liver transplantation with atrioatrial anastomosis for Budd-Chiari syndrome.

We report the case of a young woman with Budd-Chiari syndrome in whom mesentericoval shunt was first performed, followed by transcaval liver resection and hepatoatrial anatomosis 3 years later. Liver transplantation became necessary 5 years later because of deterioarating liver function with portal hypertension and bleeding. Successful transplantation was performed with atrioatrial anastomosis with help of cardiopulmonary bypass, simplifying considerably the technical procedure and reducing dramatically blood loss.

Phase II study of intra-arterial fluorouracil and mitomycin-C for liver metastases of colorectal cancer.

Effectiveness, toxicity and complications of 5-fluorouracil (FU) and mitomycin-C (MMC) treatment were analyzed in 30 patients with metastatic colorectal cancer confined to the liver. The treatment schedule was FU 2.0-2.5 g/day for 5 days followed by MMC 10 mg/m2 every 2 h on day 6 to a maximum total dose of 60 mg. Treatment courses were repeated every 6 weeks and were given on an outpatient basis via external pump and arterial port systems. In 30 fully evaluable patients, one complete response, 17 partial responses (overall response rate 60%), and stabilization of disease in 8 patients (26%) were obtained for a median duration of 13 months. Median overall survival was 18.2 months (25.5 months for responding patients, 15 months for nonresponders). Grade 1-2 toxicity (WHO classification) consisted of leukopenia (23%), mucositis (20%), nausea/vomiting (16%), and abdominal pain (10%). Two patients (7%) developed severe mucositis. No life-threatening side effects were observed; in particular, there was no sclerosing cholangitis or chemical hepatitis. Catheter-related problems (occlusion, displacement, rupture, infection) occurred in 10 patients (33%) at a median follow-up time of 12 months. We conclude that intra-arterial FU and MMC constitute an effective, safe, and nontoxic treatment in metastatic colorectal cancer confined to the liver. Catheter-related problems are the most important factors limiting treatment.

Local and systemic toxicity of intra-hepatic-arterial 5-FU and high-dose or low-dose leucovorin for liver metastases of colorectal cancer.

In an ongoing prospective study 11 patients with unresectable liver metastases from colorectal carcinoma have been treated with hepatic-arterial infusion of 5-FU (1 g m-2) for 24 h on days 1 to 5 combined with a rapid infusion of high-dose leucovorin (100 mg m-2) (HD-regimen) or low-dose leucovorin (20 mg m-2) (LD-regimen) on days 1, 3 and 5. There was only mild local toxicity grade 1 and grade 2 in both regimen. Twenty-four cycles with high-dose leucovorin and 42 cycles with low-dose leucovorin showed a mild to moderate systemic toxicity, including haematological changes, stomatitis and diarrhoea. We did not see any grade 4 toxicity and no treatment-related fatalities occurred in this series. Eighty per cent reduction of leucovorin dosage leads to a significant decrease in grade 2 and grade 3 haematological and gastrointestinal toxicity.

Long-term complete remission of melanoma liver metastases after intermittent intra-arterial cisplatin chemotherapy and surgery.

This paper presents the case of a female patient with liver metastases of a malignant melanoma showing complete remission after 10 courses of regional, intra-arterial chemotherapy with cisplatin. The drug was administered as continuous infusion for 5 days. The daily dosage amounted to 30 mg/m2. The interval between courses was 6 weeks. Nausea and vomiting were seen after each course, while pathological serum creatinine levels only appeared after the eighth course. The only lesion in the liver still visible on CT scan after chemotherapy was removed by left hemihepatectomy. Meticulous histological examination revealed a big focus of necrotic tissue without any tumour cells. At the time of publication the patient is alive and disease-free over 9 years later.

Long-term results of hepaticojejunostomy for benign lesions of the bile ducts.

BACKGROUND: Hepaticojejunostomy has been the method of choice for the treatment of benign lesions of the extrahepatic bile ducts for years. In the era of minimally invasive and interventional techniques, a review of its long-term results is necessary to set the standard with which these new techniques have to be compared. METHODS: A retrospective analysis was carried out for 51 patients (16 females, 35 males) aged 24 to 83 years (average 48 +/- 13) who had undergone hepaticojejunostomy for benign lesions at our institution between 1980 and 1989. Twelve patients had had up to 4 prior operations of their bile ducts. The main indications for operation were chronic pancreatitis (n = 33) and iatrogenic bile duct lesions (n = 15). If possible, a low end-to-side hepaticojejunostomy was performed. The Hepp-Couinaud approach was saved for high strictures and recurrences. All patients were reassessed by questionnaire at an average of 7.6 years (range 2 to 13) after the operation. RESULTS: Four Hepp-Couinaud and 47 low hepaticojejunostomies were performed. Postoperative complications were seen in 17 patients (33%), 4 of whom had a reoperation. One patient died, for a mortality rate of 2%. The hospital stay averaged 24 +/- 17 days (range 8 to 90). Late complications developed in 13 patients (25%) 2 months to 6 years after the operation. Stenosis and cholangitis necessitated reoperation in 3 cases, cholangitis without stenosis was treated in 4, and other complications were seen in 5 cases. One patient died with a liver abscess, and 12 died of causes unrelated to the operation. When questioned, 31 of 35 patients were in good or very good condition. CONCLUSIONS: Hepaticojejunostomy is a safe and reliable method for the treatment of benign lesions of the bile ducts even in young patients in need of a long-term biliary bypass.

Magnetic resonance-guided laparoscopic interstitial laser therapy of the liver.

BACKGROUND: There is a necessity for an imaging method during laparoscopy to get a three-dimensional access to the target. In this study we evaluated laparoscopic interstitial laser therapy of the liver under magnetic resonance imaging guidance. METHODS: Five domestic pigs underwent laparoscopy in an open-configuration magnetic resonance system. Under simultaneous real-time magnetic resonance imaging interstitial laser therapy was applied to the liver. Magnetic resonance images, macroscopic aspects of the lesions, and light microscopic findings were compared. RESULTS: The interventions could be safely performed. There was no image artifact caused by instruments or by the carbon dioxide. Dynamic gadolinium-enhanced imaging proved to significantly predict the macroscopic volume of the laser lesions. CONCLUSIONS: Magnetic resonance-guided laparoscopic interstitial laser therapy of the liver combines the advantages of minimal invasive surgery and magnetic resonance imaging. Further development should focus on laparoscopic instruments and temperature sensitive sequences.

Laparoscopic Roux-en-Y choledochojejunostomy.

OBJECTIVE: Although surgical biliary bypass for nonresectable periampullary tumors is superior to endoscopic stent placement, the latter has become popular because of the "minimally invasive" approach. Laparoscopic biliary bypass would appear to offer the advantages of both. However, this technique remains technically difficult using existing instrumentation. This study investigates the efficacy of a new endoscopic device designed for rapidly completing a small-diameter intestinal anastomosis under laparoscopic guidance. METHODS: Eighteen female pigs (mean weight 35 kg, range 31 to 44) were randomly divided into three groups: animals undergoing handsewn (group H) or instrumental transient endoluminally stented anastomosis (TESA; groups P and D) laparoscopic Roux-en-Y choledochojejunostomy. For TESA two different reabsorbable stents were used, polyglycolic acid (PGA; group P) and polyurethane ester (Degrapol; group D). Blood chemistry, weight gain, and abdominal X-rays were taken weekly to document any possible migration or reabsorption of the radio-opaque stents. After 3 months, necropsy was performed. Patency of the biliary bypass and choledochojejunostomy were examined using fluoroscopy and measured by introducing graduated dilators into the anastomosis. RESULTS: Fluoroscopy revealed immediate passage of contrast through the anastomosis in all animals. Weight gain, bilirubin, and alkaline phosphatase were within normal range in all groups. Diameter of the bile duct (group H 10.7 +/- 2.9 mm/group P 9.5 +/- 3.6 mm/group D 11.0 +/- 4.6 mm) and choledochojejunostomy (group H 4.5 +/- 1.1 mm/group P 4.7 +/- 1.8 mm/group D 3.6 +/- 1.9 mm) did not differ. The time required to complete the biliary bypass was significantly decreased when TESA was applied (group H 152 +/- 13 min/group P 86 +/- 14 min, P <0.001/group D 110 +/- 20 min, P <0.002). CONCLUSIONS: Applying TESA, laparoscopic choledochojejunostomy can be performed rapidly and safely, revealing good bypass function over a period of 3 months. With regard to treatment for nonresectable periampullary tumors, TESA may offer a new therapeutic approach combining the benefits of minimally invasive endoscopic stent placement with the functional results and lower readmission of conventional Roux-en-Y choledochojejunostomy.

A comparison of the pathophysiologic effects of carbon dioxide, nitrous oxide, and helium pneumoperitoneum on intracranial pressure.

BACKGROUND: Previous studies have suggested that diagnostic laparoscopy may be contraindicated in multiple trauma patients with closed head injuries because of the detrimental effects of carbon dioxide (CO2) pneumoperitoneum on intracranial pressure (ICP). In this study we compared the effects of two alternative inflation gases, helium (He) and nitrous oxide (N2O), against the standard agent used in most hospitals, CO2. ICP was monitored in experimental animals both with and without a space occupying intracranial lesion designed to simulate a closed head injury. METHODS: Twenty-four domestic pigs (mean, 30 kg) were divided into four groups (6 CO2, 6 He, 6 N2O, and 6 control animals without insufflation). All animals were monitored for ICP, intraabdominal pressure, mean arterial pressure, end-tidal CO2 (ETCO2), and arterial blood gases. These parameters were measured for 30 minutes prior to introducing a pneumoperitoneum and then for 80 minutes thereafter. The measurements were repeated after artificially elevating the ICP with a balloon placed in the epidural space. RESULTS: The mean ICP increased significantly in all groups during peritoneal insufflation compared with the control group (P < 0.005). The CO2-insufflated animals also showed a significant increase in PaCO2 (P < 0.05) and ETCO2 (P < 0.05), as well as a decrease in pH (P < 0.05). After inflating the epidural balloon the ICP remained significantly higher in animals inflated with CO2 as compared with the He and N2O groups (P < 0.05). CONCLUSIONS: Peritoneal insufflation with He and N2O resulted in a significantly less increase in ICP as compared with CO2. That difference was most likely due to a metabolically mediated increase in cerebral perfusion (PaCO2) in the CO2 group. Further studies need to be conducted to determine the safety and efficacy of using He and N2O as inflation agents prior to attempting diagnostic or therapeutic laparoscopy in patients with potential closed head injuries.

Recurrent and de novo membranous glomerulonephritis in renal cadaver allotransplants.

Significant glomerular changes occur in a substantial number of renal cadaver allotransplants. Transplant glomerulopathy and recurrent glomerulonephritis account for most of the lesions whereas the development of de novo glomerulonephritis is a rare event. Only a few cases of membranous glomerulonephritis in the graft have been documented. The four patients presented all developed heavy proteinuria of 11.5 to 14 g/day 5 months to 1 year after transplantation. Three cases of de novo membranous glomerulonephritis were transplanted because of renal failure due to chronic pyelonephritis, chronic glomerulonephritis and medullary sponge kidney. One patient has recurrent membranous glomerulonephritis. Transplant biopsy revealed only minimal glomerular changes by light microscopy in all cases. Immunofluorescence and electron microscopy demonstrated typical membranous glomerulonephritis.

Prolonged survival after renal transplantation in primary hyperoxaluria of childhood.

Cadaver renal transplantation was performed in a 14-year-old girl with primary hyperoxaluria. Acute tubular necrosis was present initially, and a moderate rejection crisis occurred at 6 weeks. Renal biopsy performed at 4 months showed considerable deposition of calcium oxalate. Urinary excretion of oxalate varied between 315-371 mg/24 hr per 1.73 m2 (normal less than 50 mg). Despite these unfavourable factors, renal function has remained stable for the last 2 1/2 years; the serum creatinine is 1.5 mg/100 ml at 3 years. This is the longest surviving graft reported so far in documented primary hyperoxaluria. Graft failures in previous reports could in part be explained by additional complicating factors. It is concluded that renal transplantation is not necessarily contraindicated in primary hyperoxaluria.