Mechanical complications of long-term Tesio catheters.

Vascular access catheters such as Tesio-Caths are preferentially inserted in the internal jugular vein and serve as access for hemodialysis. Complications related to the removal of these types of lines are uncommon. We report four patients in whom the tip of the Tesio-Cath broke and was left stuck in the superior vena cava. Although there is no defined limit to the maximum length of stay of vascular access catheters for dialysis, the possibility of catheter entrapment should be considered. It remains to be determined whether removing Tesio-Caths every 16- 18 months is beneficial in avoiding this complication.

Interdigestive gastric motility patterns: the role of vagal and nonvagal extrinsic innervation.

Our study was designed to determine separately the roles of vagal and nonvagal extrinsic innervation in the initiation and coordination of patterns of gastric contractile activity and in the organization of the gastric slow wave. Four dogs first underwent transection of all extrinsic and intrinsic neural continuity to the stomach, except for careful preservation of vagal innervation to the stomach (stage 1). Manometry catheters and serosal electrodes were placed in the antrum, and electrodes were fixed to the small intestine. After recovery, motility was recorded during fasting and after feeding. A cyclic motor pattern occurred in the stomach with a period that was not different from that of the migrating motor complex in the small intestine (113 +/- 11 minutes vs 112 +/- 11 minutes; p greater than 0.05). Gastric and intestinal motility remained coordinated in time. Feeding inhibited this cyclic motor pattern in stomach and intestine. Antral tachygastria (slow wave frequency greater than 8 cycles/min) was infrequent (less than 1% of time). Each animal was restudied after completing extrinsic gastric denervation by a transthoracic vagotomy (stage 2). Vagotomy did not alter the presence, appearance, or period of cyclic gastric activity, nor did it disrupt temporal coordination with the duodenal migrating motor complex or increase the prevalence of tachygastria. In conclusion, neither vagal nor nonvagal extrinsic innervation to the stomach was required for initiation or coordination of the characteristic cyclic gastric motility pattern during fasting; although vagal innervation may modulate gastric myoelectric activity, its precise role is not evident in this study.

Net absorption of water, electrolytes, glucose, and folate from the in vivo, neurally isolated canine jejunum.

This study was designed to determine the effects of neural isolation of the jejunoileum (a model of intestinal transplantation) on jejunal absorptive function and associated changes that might occur over time. Net absorption of a simple, balanced crystalloid solution perfused in an 80 cm enterically isolated jejunal loop was assessed in two groups of conscious dogs with neurally intact jejunal loops or neurally isolated jejunal loops. Experiments were conducted 2, 4, and 8 weeks after surgery during fasting and after feeding to determine temporal changes. Net absorption of water and electrolytes (sodium, potassium, and chloride), glucose, and folate and loop transit times were not different (p greater than 0.05) between groups at any time point despite the presence of ongoing watery diarrhea and weight loss (15% +/- 8% body weight) in the dogs with neurally isolated jejunoileum. The effects of neural isolation (extrinsic denervation and disruption of enteric neural continuity and lymphatic drainage) do not appear to decrease net absorptive capacity for water, electrolytes, simple sugars, or folate when evaluated between 2 and 8 weeks after neural isolation. The watery diarrhea and weight loss do not appear to be related to a jejunal secretory diarrhea. These findings may have important implications in the transplanted small intestine.

Correlation between cystoscopic biopsy results and hypoamylasuria in bladder-drained pancreas transplants.

BACKGROUND: Urinary amylase (UA) remains the most common biochemical parameter to detect rejection in bladder-drained pancreas allografts. With the development of the cystoscopic transduodenal pancreas transplant biopsy technique, tissue samples of the pancreas graft are now frequently obtained. A definitive correlative analysis between UA activity and biopsy results has not been done in the three different pancreas transplant categories (simultaneous pancreas-kidney, pancreas transplant alone, and pancreas after kidney). METHODS: We studied 66 pancreaticoduodenal biopsy specimens obtained for hypoamylasuria. Rejection was defined as a greater than 25% decrease from stable posttransplantation baseline on two consecutive measurements at least 12 hours apart. To perform biopsies we used our newly developed 14- and 16-gauge core-cut needles (50 cm long). Biopsy specimens were considered positive if either pancreatic or duodenal rejection was found. To assess the quality of UA activity we studied 13 biopsy specimens from patients with stable UA levels; these 13 specimens were negative for rejection. RESULTS: Acute rejection was diagnosed in 36 biopsy specimens (55%). The mean decrease in UA levels was 67% +/- 8% (range, 28% to 99%) for the positive biopsy results, and 57% +/- 16% (range, 22% to 92%) for the negative biopsy results (p = 0.147). Within 1 month, UA levels returned to baseline in 19% of our patients with positive biopsy results versus 97% with negative results; postbiopsy 1-year graft survival was 64% versus 97% (p < or = 0.05). In assessing the test quality of our biopsy specimens (including 13 obtained for reasons other than hypoamylasuria), we found a sensitivity of 100% (stable UA levels mean no rejection) and a specificity of 30%. The predictive value of a positive test was 53%; of a negative test it was 100%. By performing biopsies we avoided antirejection treatment in 47% of the patients studied. We found no biopsy-related complications. CONCLUSIONS: Stable UA levels reliably rule out rejection; a decrease is a marker for acute rejection but is unspecific. Performing biopsy is currently the only way to reliably diagnose rejection in solitary pancreas recipients (pancreas transplant alone and pancreas after kidney) and in simultaneous pancreas-kidney recipients with isolated hypoamylasuria. The procedure is safe and should always be attempted to avoid unnecessary rejection treatment.

Duodenal complications in bladder-drained pancreas transplantation.

BACKGROUND: The most common type of pancreas transplantation is whole pancreaticoduodenal (with bladder drainage) from a cadaver donor. Complications can arise not only from the pancreas itself but also from the simultaneously transplanted duodenum. The purpose of this study was to analyze the incidence, diagnosis, and treatment of duodenal complications and their impact on patient and pancreas graft survival rates. METHODS: Our retrospective study is based on 425 pancreaticoduodenal transplantations performed between July 1, 1986, and June 30, 1994. Complications pertaining to the duodenal segment were labeled early if they occurred within the first postoperative month and late otherwise. Mean follow-up was 55 months (range, 13 to 108 months). RESULTS: We noted 85 (20%) duodenal complications: duodenal leaks (n = 42), hematuria (n = 26), recurrent urinary tract infections (n = 9), duodenal ulceration or necrosis (n = 6), and bladder stones (n = 2). Of these complications, 40 (48%) required surgical intervention. In all, duodenal complications resulted in 14 (16%) enteric conversions and eight (9%) pancreas graft losses (six because of duodenal leak and 2 because of hematuria). The mortality rate from duodenal complications was 0%. CONCLUSIONS: Duodenal complications were common, but they were not associated with a high rate of pancreas graft loss (only 9%). With early diagnosis and treatment, morbidity can be reduced and death avoided in pancreas transplant recipients.

Management of barium enema-induced colorectal perforation.

Unless recognized and treated promptly, colorectal perforation induced by barium enema examination is a life-threatening complication. Between 1977 and 1986, 13,000 barium enemas were performed at the Mayo Medical Center. Colorectal perforation occurred in five patients (overall incidence: 0.04%). The two colonic perforations were managed by immediate celiotomy with resection in one and primary repair in the other. The three rectal perforations were managed conservatively in two patients and by proximal diversion in one. All patients recovered. Perforations were believed to be related to the tip of the enema catheter or presumably to excessive hydrostatic pressure. In contrast to other reports, barium enema-induced colorectal perforation is not always fatal when recognized early and treated aggressively. Localized, contained extraperitoneal rectal perforation may be managed conservatively in selected patients.

Role of extrinsic and intrinsic nerves in hormonal induction of the migrating motor complex in the jejunum.

The mechanism of induction of the migrating motor complex (MMC) by neural or humoral agents and their role in the control of fasting motility are not well understood. Our aim was to determine the role of extrinsic and intrinsic nerves in mediating the induction of the MMC by motilin. Three groups of dogs were studied. Group I consisted of neurally intact control dogs. In group II, intrinsic neural continuity between the duodenum and the jejunum was interrupted by transection and reanastomosis of the distal duodenum. Dogs in group III underwent disruption of all intrinsic and extrinsic neural input to the entire jejunoileum. Serosal electrodes were sewn to duodenum and jejunum in all dogs. After a 2-week recovery, fasting myoelectric activity was recorded on four or more occasions. Motilin (0.1 microgram/kg iv) was given 30 min after a spontaneous duodenal phase III. In group I (controls), motilin induced a premature MMC, which originated in the duodenum and migrated along the small intestine. In group II (intrinsic neural disruption), motilin induced a premature MMC, which began simultaneously in the proximal duodenum and proximal jejunum. In group III (intrinsic and extrinsic neural disruption), motilin induced a premature MMC in the duodenum but not in the jejunum; rather, a short, nonmigrating burst of spike potentials occurred simultaneously in all jejunal electrodes. These observations suggest that extrinsic innervation is necessary for motilin to induce phase III activity in the jejunum. Extrinsic neural pathways appear to mediate motilin-induced MMC activity in the jejunum.

Preserving function and long-term patency of dialysis access.

Of the 283, 932 patients with end stage renal disease (ESRD) receiving replacement therapy in the US in 1996, 62% were being treated with haemodialysis. Improved survival of haemodialysis patients coupled with the inability to provide enough renal transplants for the growing ESRD population has resulted in an increase in the average length of time patients spend on dialysis. Vascular accesses are, therefore, required to function for longer periods of time. Maintenance of a reliable access to the circulation has been described as the Achilles' heel of modern haemodialysis. Preserving access function and long-term patency are essential for efficient dialysis delivery.

Successful procurement of 50 pancreatic grafts using a simple and fast technique.

The procurement of a pancreatic graft must be as meticulous as possible and with minimum handling and blood loss so that the transplant procedure can be carried out with no complications. We describe the technique we are using in our institution which, contrary to others, requires that most of the dissection for donor pancreatectomy be done after crossclamping and intravascular flushing of the abdominal organs. We have performed 50 consecutive procurements of pancreatic grafts using this technique. All grafts were successfully transplanted with no evidence of post-transplant primary non-function or graft pancreatitis. We believe that this technique is faster and minimises handling of the pancreas and blood loss resulting in excellent post-transplant metabolic function of the pancreatic graft.

Use of the inferior epigastric artery as a jump graft for reconstruction of a lower pole artery for renal transplantation.

Before a kidney can be transplanted, the reconstruction of a damaged lower pole artery is vital to preserve the blood supply of the ureter.

Small bowel transplantation.

Many patients die each year lacking only a functional small bowel to survive. The minimum amount of small intestinal absorptive surface required to sustain life varies from patient to patient. Prolonged survival with oral alimentation alone has been reported in a few patients with an intact duodenum and as little as 15-45 cm of residual jejunum. However, without long-term total parenteral nutrition (TPN), prolonged patient survival is the exception rather than the rule. Chronic parenteral nutrition is associated with complications, including sepsis, venous thrombosis, metabolic disorders and liver dysfunction. From studies of patients currently on long-term TPN, it would appear that there are between two and three patients per million of population per year who develop irreversible small bowel failure. It is estimated that 20 new patients/year in the UK receiving home TPN would be potential candidates for small bowel transplantation.

Two cases of penile necrosis in diabetics with end-stage renal failure.

Distal penile necrosis associated with renal failure is a rare entity; only a few cases have been reported in the literature. Penile necrosis can frequently be a difficult management problem, the etiology of which is infectious, traumatic, or vascular. Physiological abnormalities are usually found in association with this condition, including diabetes, hyperparathyroidism, and peripheral vascular disease. Penile necrosis is a poor prognostic factor associated with high morbidity. We report two cases of this condition, presenting the clinical and pathophysiological background.

Transplantation of an annular pancreas with enteric drainage.

Annular pancreas (AP) is an uncommon congenital anomaly which often does not become symptomatic until late life. We report a case of successful transplantation of an AP in a type I IDDM woman. The whole pancreas with a duodenal cuff was procured from a 41-year-old previously healthy female. The AP was identified at the time of procurement and did not appear to have caused any significant duodenal obstruction. The graft was transplanted on the external iliac vessels and the exocrine secretions were drained enterically. In order to avoid any possible injury to the ductal system, a side-to-side duodenojejunal anastomosis was fashioned using the first and the second portion of the duodenum, leaving about 2 cm of free duodenal margin proximal to the pancreatic ring. The postoperative course was uneventful and at 1 month graft function is unremarkable. Although challenging from a technical point of view, transplantation of an AP is a safe procedure which allows good results. Given the limited number of organ donors and the difficulty in HLA-matching, every AP should be considered suitable for transplantation.

Use of vascular closure staples in vascular access for dialysis, kidney and pancreas transplantation.

We report our experience with the use of the vascular closure staples (VCS) in vascular access for dialysis, as well as in kidney and pancreas transplantation. We used the VCS for 50 endogenous arterio-venous fistulas (AVFs). There were no complications. The use of the VCS contributed in creating an excellent anastomosis and minimising operative time. All AVFs are in use for dialysis (follow up two months to one year). The excellent results from our experience with the use of VCS for vascular access encouraged us to use them in kidney and pancreas transplantation. We performed six cadaveric kidney transplants (the first operation was the first application of the VCS in kidney transplantation in Europe) and two cadaveric pancreas-kidney transplants (the first operation being the first application of the VCS in pancreas transplantation in the world). There were no complications. The use of VCS created an excellent anastomosis and minimised warm ischaemia time. All kidney transplant recipients have normal creatinines (follow up 1-5 months) and the recipients of pancreatic transplants are insulin independent (follow up 1-3 months).

Successful partial transplant pancreatectomy with end-to-side duct-to-ureter anastomosis: salvage of a pancreatic allograft.

Segmental pancreatic transplantation has been abandoned because of the high incidence of technical complications. We report the first case in the literature of the salvage of a partially ischemic pancreatic allograft. The procedure consisted of resecting the head of the pancreas and draining the residual segment to the ureter with a duct-to-ureter end-to-side anastomosis. The postoperative course was uneventful, and 15 months after surgery graft function is satisfactory with a urinary amylase level of 5000 U/h. The duct-to-ureter drainage technique should be part of every transplant surgeon's repertoire, because in emergency situations like the one described, it can be used to save a pancreatic allograft.

Sonographic appearance of oxidised cellulose (Surgicel): pitfall in the diagnosis of renal vein thrombosis in a transplant kidney.

We report the misleading sonographic appearance of Surgicel in the diagnosis of renal vein thrombosis in a case of kidney transplant and a review of the literature. Removal of the Surgicel before closure is advisable to avoid misdiagnosis.

Methotrexate-induced hepatic necrosis requiring liver transplantation in a patient with rheumatoid arthritis.

MTX-induced hepatic injury and liver enzyme elevations have been demonstrated after treatment of leukemia, gestational disease and during treatment of psoriasis and rheumatoid arthritis. A 40-year-old man with a long standing history of rheumatoid arthritis was treated with MTX over a 6 month period and developed an overwhelming hepatic necrosis. He was successfully transplanted.

Reversal of steal syndrome following creation of arteriovenous fistula by banding with a Gore-Tex cuff: a new technique.

Steal syndrome, especially in elderly patients with peripheral vascular disease, is a serious complication following creation of an arteriovenous fistula (AVF) that, if neglected, can lead to amputation. The classic maneuver to deal with the steal syndrome is the ligation of the AVF and performance of another procedure to gain dialysis access. We describe a simple technique of effectively reversing the steal syndrome by banding the vein of the AVF with a ringed Gore-Tex cuff that salvages the AVF and allows its immediate use for dialysis.

Refashioning of an aneurysmatic arterio-venous fistula by using the multifire GIA 60 surgical stapler.

We describe a technique for refashioning an aneurysmatic arterio-venous fistula by using the multifire GIA 60 surgical stapler. After obtaining proximal and distal control of the aneurysmatic vein each aneurysmal segment of the anterior wall of the vein is excised by applying the GIA 60 stapler. The layer of the staple-line is re-enforced with one layer of 6/0 prolene continuous suture. After completion of the procedure, the size of the vein is reduced by approximately 50%. The AVFs were successfully re-used for dialysis within four weeks postoperatively.

Pre-emptive renal transplantation.

We report our experience with pre-emptive renal transplantation and review the literature. While eliminating the cost, complications and inconvenience of dialysis, transplantation prior to dialysis therapy can be performed safely and effectively as it does not pose any additional immunological hazards to allograft outcome. It is safe regardless of the immunosuppressive agents employed and is successful without early rejection even in the nonuremic state.