Post-operative arterio-venous fistula blood flow influences primary and secondary patency following access surgery.

PURPOSE: Primary arteriovenous fistula arterio venous fistula (AVF) formation has proven to be the best and optimal vascular access for the majority of haemodialysis patients. At present there are limited data to suggest which haemodynamic parameters most correlate with the likelihood of early failure. The aim of this study is to identify the haemodynamic predictors of early failure, hence identify which fistulae may benefit from timely pre-emptive intervention. MATERIAL AND METHODS: Retrospective analysis of data was performed of 201 patients undergoing native AVF creation over a one year period. Demographic details, co-morbidity, preoperative vessel calibre were collected. Flow was measured by duplex ultrasound post operatively. RESULTS: Preoperative vein calibre (p = 0.01) and fistula flow (p < 0.001) positively affected primary patency. Age, gender, ethnicity, type of fistula, hypertension and preoperative arterial calibre did not influence outcome. Regression analysis showed that the strength of correlation between early postoperative fistula flow and patency decreased progressively with time. Six week flow predicts early, but not late, failure. ROC analysis identified 300 ml/min flow as the best predictor of patency. Fistulae with flow above 300 ml/min were more likely to remain patent over the next 12 months (p < 0.001, HR = 7.4). CONCLUSION: Postoperative fistula flow of less than 300 ml/min identifies AVFs at high risk of early failure. These may be candidates for early intervention with balloon assisted maturation. The findings of this retrospective cohort study strongly support the need for a more robust prospectively designed trial identifying haemodynamic factors that can predict mid and long-term AVF patency.

Radiological tumor density and lymph node size correlate with survival in resectable adenocarcinoma of the pancreatic head: A retrospective cohort study.

INTRODUCTION: Tumors within the pancreatic head show a variable density and enhancement on computerized tomography (CT). The relationship between the radiological appearance of pancreatic adenocarcinoma on CT and survival remains unclear. The aim of this study was to evaluate the relationship between the tumor density on CT and survival. We also evaluated the correlation between lymph node (LN) size and overall survival in patients undergoing pancreaticoduodenectomy for head of pancreas adenocarcinoma. MATERIALS AND METHODS: Case records of patients undergoing pancreaticoduodenectomy for the adenocarcinoma of pancreas head, between 2005 and 2009, were evaluated. CT was interpreted to document tumor density - Hounsfield unit (HU) and LN size of enlarged LNs. Histology was analyzed to review tumor differentiation and LN status. Survival was correlated with LN size and tumor density (HU). RESULTS: Increasing tumor density was significantly associated with an adverse outcome (P = 0.042, hazard ratio [HR] 1.034, 1.002-1.067 95% confidence interval [95% CI]). Patients with well-differentiated tumors had significantly lower tumor density as compared to moderately differentiated tumors (39.00 ± 26.00 vs. 71.31 ± 21.03 HU, P = 0.005). LN size more than 1 cm irrespective of LN status strongly correlated with the survival and was found to be an important prognostic factor (19.37 ± 2.71 months vs. 27.44 ± 2.74 months; P = 0.025; HR 2.70; 1.09-6.68 95% CI). CONCLUSION: Increasing pancreatic tumor density and the lymph nodal size of more than 1 cm are strong predictors of unfavorable overall survival for resectable adenocarcinoma of the pancreatic head. Further studies are required to identify the value of these proposed prognostic factors.

Do we need a different organ allocation system for kidney transplants using donors after circulatory death?

BACKGROUND: There is no national policy for allocation of kidneys from Donation after circulatory death (DCD) donors in the UK. Allocation is geographical and based on individual/regional centre policies. We have evaluated the short term outcomes of paired kidneys from DCD donors subject to this allocation policy. METHODS: Retrospective analysis of paired renal transplants from DCD's from 2002 to 2010 in London. Cold ischemia time (CIT), recipient risk factors, delayed graft function (DGF), 3 and 12 month creatinine) were compared. RESULTS: Complete data was available on 129 paired kidneys.115 pairs were transplanted in the same centre and 14 pairs transplanted in different centres. There was a significant increase in CIT in kidneys transplanted second when both kidneys were accepted by the same centre (15.5 ± 4.1 vs 20.5 ± 5.8 hrs p<0.0001 and at different centres (15.8 ± 5.3 vs. 25.2 ± 5.5 hrs p=0.0008). DGF rates were increased in the second implant following sequential transplantation (p=0.05). CONCLUSIONS: Paired study sequential transplantation of kidneys from DCD donors results in a significant increase in CIT for the second kidney, with an increased risk of DGF. Sequential transplantation from a DCD donor should be avoided either by the availability of resources to undertake simultaneous procedures or the allocation of kidneys to 2 separate centres.

Redefining the R1 resection for pancreatic ductal adenocarcinoma: tumour lymph nodal burden and lymph node ratio are the only prognostic factors associated with survival.

INTRODUCTION: The presence of positive nodal disease (LND) and the number of lymph nodes involved (LNB) are known to be significant prognostic markers for resected adenocarcinoma of the pancreas. In addition, the ratio of the number of involved nodes to the number of nodes resected known as the lymph node ratio (LNR) is emerging as an important prognostic marker. The role of the resection margin (RM) as presently defined (R1 ≤ 1 mm) is unclear as results differ based on the dataset. The aim of this study was to assess the impact of nodal disease and a redefined RM on outcome. MATERIAL AND METHODS: Retrospective analysis of pancreatic head resections for adenocarcinomas from 2003-2009. The RM was re-analysed based on tumour clearance and categorized into: histopathological evidence of a tumour; ≤ 0.5 mm, ≤ 1 mm, ≤ 1.5 mm, or ≤ 2.0 mm of the actual surgical resection margin. The impact of histopathological variables on cancer-specific survival (CSS) and disease-free survival (DFS) was analysed. RESULTS: LND, LNB and LNR were independent prognostic markers for CSS (P = 0.048, 0.003, 0.016) but, did not influence DFS. A LNR < 0.143 was associated with a higher CSS [38.16 ± 4.69 versus 20.59 ± 2.20 months, P = 0.0042, hazard ratio (HR) 3.74 (95% confidence interval (CI) 1.52-9.23)]. An R1 RM was not associated with CSS or DFS on multivariate analysis, irrespective of the distance. LNB and LNR maintained independent significance irrespective of the size of the RM. CONCLUSION: LNB and LNR are the only prognostic factors for CSS in patients with pancreatic head adenocarcinoma, but do not predict recurrence. Microscopic RMs does not seem to influence the outcome even when redefined. Further prospective studies are indicated to substantiate these findings.

Biochemical indicators of in-hospital complications following pancreatic surgery.

Early recognition of complications following pancreatic surgery could reduce morbidity and mortality. White cell counts (WCCs), platelets (PLTs), C-reactive protein (CRP) and albumin (ALB) are commonly used as guides in clinical decision making. However, the evidence to support their role as early indicators of complications is unclear. A retrospective cohort analysis of consecutive pancreatic surgical procedures between 2004 and 2008 was performed. Operative procedures, inflammatory markers--WCCs, PLTs, CRP, and ALB--preoperatively and on postoperative days (PODs) 1, 3, 5, 7, 9, 12, and 15, and clinical outcomes were recorded. WCC > 11 x 10(9)/L on POD5 was significantly associated with complications [odds ratio (OR), 2.60; P = 0.0067]. ALB < 28 g/L on POD7 was significantly associated with a postoperative complication (OR, 2.94; P = 0.0031). WCC > 12.2 x 10(9)/L and ALB < or = 28 g/L on POD7 were more likely to be associated with a complication (OR, 4.86; P = 0.0002). Postoperative WCC and ALB levels may be useful as aids to the early diagnosis of complications following pancreatic surgery.

Pleomorphic adenoma of the breast should be excised with a cuff of normal tissue.

Pleomorphic adenoma is a benign tumor found rarely in the breast but commonly in the salivary gland. Unlike the salivary gland variant management guidelines are poorly defined in the breast. We describe the first case of pleomorphic adenoma of the breast that has recurred for the second time following previous surgical excisions, and review the available literature. Due to the risk of recurrence and malignant transformation, we recommend complete excision of the lesion with a cuff of normal tissue, as is the practice in the salivary gland. Clinicians should be aware of the condition, as preoperative diagnosis will facilitate adequate surgery. Patients should be informed about the risk of recurrence. We recommend follow-up for at least a period of 5 years with yearly clinical examinations.