Total duodenectomy with enteric duct drainage: a rescue operation for duodenal complications occurring after pancreas transplantation.

Duodenal graft complications (DGC) occur frequently after pancreas transplantation but rarely cause graft loss. Graft pancreatectomy, however, may be required when DGC compromise recipient's safety. We herein report on two patients with otherwise untreatable DGC in whom the entire pancreas was salvaged by means of total duodenectomy with enteric drainage of both pancreatic ducts. The first patient developed recurrent episodes of enteric bleeding, requiring hospitalization and blood transfusions, starting 21 months after transplantation. The disease causing hemorrhage could not be defined, despite extensive investigations, but the donor duodenum was eventually identified as the site of bleeding. The second patient was referred to us with a duodenal stump leak, 5 months after transplantation. Two previous surgeries had failed to seal the leak, despite opening a diverting stoma above the duodenal graft. Thirty-nine and 16 months after total duodenectomy with dual duct drainage, respectively, both patients are insulin-independent and free from abdominal complaints. Magnetic resonance pancreatography shows normal ducts both basal and after intravenous injection of secretin. The two cases presented herein show that when DGC jeopardize pancreas function or recipient safety, total duodenectomy with enteric duct drainage may become an option.

Role of color Doppler sonography in post-transplant surveillance of vascular complications involving pancreatic allografts().

PURPOSE: To evaluate the role of color Doppler ultrasonography in the postoperative surveillance of the vascular complications involving pancreas allografts. METHODS: A retrospective analysis of a consecutive series of 223 pancreas transplantations was performed. All recipients received antithrombotic prophylaxis, which was tailored to the individual's estimated risk of thrombosis. All patients were monitored with daily color Doppler ultrasonography during the first post-transplant week and thereafter whenever clinically indicated. Vascular complications were defined as all thrombotic events requiring: increased anticoagulant therapy, angiography with fibrinolytic therapy, or repeat surgery. RESULTS: The overall patient survival rates at one, three, and five years after transplantation were 94.7%, 93.3%, and 91%, respectively. The overall graft survival rates at the same time points were 87.4%, 79.6%, and 75.6%, respectively. In 28 of the 223 cases (12.5%) graft thromboses were diagnosed with Doppler ultrasound within the first 10 days after transplantation. In 3 cases, graft pancreatectomies were performed because of a complete loss of blood flow in the parenchyma. An attempt to rescue the graft was made in 18 patients. Fourteen of these grafts were saved and are still functioning (77.7%); and 4 rescue attempts failed and the grafts were subsequently explanted (32.3%). CONCLUSION: Color Doppler ultrasound is a suitable tool for postoperative surveillance of pancreas transplant recipients. Its use can lead to early diagnosis and timely treatment of vascular complications.

Laparoscopic donor nephrectomy: short learning curve.

INTRODUCTION: The learning curve of laparoscopic donor nephrectomy (LDN) may represent a great technical challenge at centers with low volume of living donors. The number of LDNs required to overcome the learning curve is still unclear. Here we report the modality of approach to LDN at a low-volume living donor transplant center. MATERIALS AND METHODS: We reviewed the records of two groups of donors operated by two different surgeons between January 2002 and October 2005. We compared donor hospital stay, operative time, presence of multiple renal arteries, blood loss, operative details, and complications. RESULTS: The first six operations (group A) were performed by a well-trained laparoscopic surgeon (A.P.) with a consolidated experience in the LDN procedure, attended by our training surgeon (R.D.V.) who conducted the other six cases (group B). No conversion to an open procedure was necessary and there were no major minor complications. Mean operative time was 267.5 (+/-55.9) minutes in group A and 300 (+/-43.4) minutes in group B (P = .28). Mean warm ischemia time was 125 (+/-61.6) seconds in group A and 189.2 (+/-18.6) seconds in group B (P = .035). Mean hospital stay was 5.3 days in group A and 5.6 days in group B. CONCLUSIONS: LDN can be performed safely and efficiently in transplant centers with initial experience. A collaborative approach to this difficult procedure with a surgeon skilled in donor nephrectomy minimizes the risk to the donor and reduces the learning curve.

Simultaneous pancreas-kidney transplantation is improved by living kidney donation program.

BACKGROUND: Shortage of suitable donors and current graft allocation priorities reduce the number of cadaveric kidneys available to diabetic recipients. The concurrent excess of solitary cadaveric pancreata and the excellent results of living kidney transplantation make simultaneous cadaveric pancreas-living kidney transplantation (SPLKTx) an attractive alternative to simultaneous pancreas-kidney transplantation (SPKTx). METHODS: Between June 2001 and June 2003, 80 recipients were enrolled in the SPKTx waiting list. Each recipient's family was counseled about living kidney donation (LKD). Twenty-nine (36.2%) candidates were evaluated for LKD and 8 (27.6%) were disqualified. The remaining 21 candidates were scheduled for LKD and 18 actually donated. RESULTS: Thanks to LKD 18 additional recipients were transplanted, thus expanding the donor pool from 33 to 51 (P =.004). The median waiting time for SPLKTx was 14 days as compared with 95 days for SPKTx (P =.006). Without LKD the median waiting time for SPKTx would have been 198 days (P =.02). Similarly, 1 year after the enrollment on the waiting list 60% of recipients had been transplanted, while without LKD only 42% would had been grafted (P =.01). Two-year recipient survival rate was 100% for SPLKTx compared with 96.9% for SPKTx. Equivalent figures for kidney and pancreas were 80.0% and 84.0% for SPLKTx compared with 96.9% and 96.9% for SPKTx. CONCLUSIONS: LKD expanded the kidney donor pool, reduced the waiting time of recipients listed for a totally cadaveric procedure, and increased their chance to get a timely graft. One-year outcome of SPLKTx equaled that of SPKTx.

Thrombosis in the portal venous system after elective laparoscopic splenectomy.

BACKGROUND: The occurrence of thrombosis in the portal system is an underappreciated complication of splenectomy. Presenting symptoms are usually mild and nonspecific. The short hospital stay associated with the laparoscopic approach could delay the early diagnosis of this condition unless routine imaging controls are planned after discharge. METHODS: The records of 40 patients who underwent laparoscopic splenectomy at our institution were reviewed for clinical signs of thrombosis in the portal system and associated factors. All patients were also enrolled in a color Doppler ultrasound surveillance program. RESULTS: Nine patients (22.5%) developed thrombosis of the splenic vein, progressing to the portal vein in five cases (12.5%). Six patients (15%) were symptomatic. Thrombosis occurred even as late as 4 months after splenectomy. Spleen weight was the only significant factor predictive of postoperative thrombosis. The combination of splenomegaly and an elevated preoperative platelet count was associated with a 75% incidence of this complication. CONCLUSION: The high risk of thrombosis after the laparoscopic resection of large spleens should prompt strict postoperative imaging surveillance, combined with a more aggressive anticoagulation prophylaxis.

Laparoscopic living donor nephrectomy in Italy: a national profile.

BACKGROUND: There are no data concerning the national experience with laparoscopic live donor nephrectomy (LLDN) in Italy. A survey was therefore conducted in May 2003 to establish current practice patterns and to describe the outcome of this procedure. METHODS: A self-administered questionnaire was mailed to the 37 Italian kidney transplant centers. Items covered each center's attitude toward LLDN, number of cases performed, and the outcome of donors and recipients. RESULTS: The return rate was 100%. The surveyed centers performed 4818 kidney transplants between January 2000 and May 2003, including 401 (8.3%) from living donors of whom 113 (28.2%) used grafts retrieved by laparoscopy. Despite an absolute increase in the number of living donors, the occurrence of a similar trend in cadaveric donation did not significantly change the overall living donor rate. Sixty-eight percent of LLDNs were done at only two centers. There was no mortality or graft loss and only a minor morbidity related to LLDN. Italian transplant surgeons showed a positive attitude toward LLDN; only a few of those not performing it had no plans to begin an LLDN program. CONCLUSIONS: Three years after the first national case, LLDN had not yet change the living donor rate, although an increasing number of donor nephrectomies were now performed by laparoscopy. Overall the results with the new technique are encouraging, although the pattern of diffusion of LLDN between different areas is heterogeneous and will demand continuous efforts on training programs in laparoscopic techniques for transplant surgeons.

Simultaneous cadaver pancreas-living donor kidney transplantation.

BACKGROUND: The expansion of the donor pool achieved with living kidney donation (LKD) is particularly beneficial for diabetic patients, who have a worse prognosis during dialysis when compared to other kidney recipients. Simultaneous cadaver pancreas-living kidney transplantation (SPLKTx) merges the advantages of LKD with those of cadaver donation, and may be an attractive alternative to simultaneous pancreas kidney transplantation (SPKTx). METHODS: The outcomes of 18 SPLKTx were compared with those of 33 SPKTx. RESULTS: LKD expanded the donor pool from 33 to 51 (P =.004). Median wait time was shorter for SPLKTx (14 days) than for SPKTx (95 days) (P =.006). The risk for surgical complications was not increased by SPLKTx, as witnessed by relaparotomy rates (SPLKTx: 2/18, 11.1%; SPKTx: 2/33, 6.1%; P >.05). Hospital stay averaged 26.1 +/- 11.2 days for SPLKTx and 27.1 +/- 16.3 for SPKTx (P >.05) with equivalent 30-day readmission rates (SPLKTx: 5.5%; SPKTx: 6.1%); (P >.05). One acute kidney rejection occurred in SPLKTx (5.5%) as compared with four in SPKTx (12.1%); (P >.05). Equivalent rates for the pancreas were 5.5% (1/18) for SPLKTx and 3.0% (1/33) for SPKTx (P >.05). Two-year recipient survival rates were 100% for SPLKTx as compared with 96.9% for SPKTx. Equivalent figures for kidney and pancreas were 80.0% and 84.0% for SPLKTx and 96.9% and 96.9% for SPKTx. CONCLUSIONS: SPLKTx is a valuable alternative to SPKTx. Further development of SPLKTX relies on increased rates of living kidney donation.

Grasping and dissecting instrument for hand-assisted laparoscopic surgery: development and early clinical experience.

BACKGROUND: The operative potential of hand-assisted laparoscopic surgery (HALS) could be enhanced by the introduction of a new generation of assisting instruments. These tools will have to meet specific requirements of shape, function, and safety of use. METHODS: Problems related to the working environment of HALS and deriving projectual restrictions of HALS instruments were analyzed in order to develop and manufacture a working prototype with grasping and dissecting properties to assist during HALS procedures. The resulting instrument was mechanically and clinically tested in 22 HALS procedures. RESULTS: The additional benefit of the new device was particularly appreciated during dissection and isolation of vascular pedicles (nephrectomies and splenectomies). It was shown to be safe and effective in providing the additional assistance it was designed for. CONCLUSION: The described grasping and dissecting instrument for HALS is of great value in assisting the surgeon during fine dissection, as required in selected procedures. New generation of HALS instruments should comply with the functional and safety issues analyzed in this report.

Hand-assisted laparoscopic low anterior resection: initial experience with a new procedure.

BACKGROUND: Laparoscopic low anterior resection for rectal cancer has never gained wide acceptance among general surgeons, mainly due to the technical difficulties encountered during pelvic dissection. It has therefore been stated that these patients should undergo open rather than laparoscopic surgery. Hand-assisted laparoscopic surgery (HALS) is a new technique that has the potential to overcome many of the existing limitations of pure laparoscopy. In the treatment of rectal cancer, HALS could reproduce an operative setting similar to that of the open approach. METHODS: To assess the technical feasibility of hand-assisted laparoscopic low anterior resection for rectal cancer and evaluate potential benefits and drawbacks of this new procedure, a pilot study was conducted at a university hospital on 16 consecutive patients during a 12-month period. Only patients with extraperitoneal rectal cancer were included in this series. Patients' clinical data, operative time, conversion rate, complications, and early outcome measures were prospectively examined. RESULTS: There were 9 men and 7 women. The average +/- SD operation time was 238 +/- 38 min. Conversion to open surgery was never required. Ten of 16 patients were off pain medication on the third postoperative day. Eight were able to walk the day after surgery. Three minor postoperative complications were recorded. Mean postoperative stay for patients without complications was 5.6 +/- 1.4 days. CONCLUSION: From a technical standpoint, the reported hand-assisted procedure makes pelvic dissection during laparoscopic low anterior resection almost equivalent to the laparotomic operation. The incision for hand access that is needed with this technique does not seem to compromise the quick recovery of patients undergoing purely laparoscopic procedures.

Surgical endarterectomy for suprarenal iliac artery stenosis in renal allograft recipient.

Aortoiliac surgery performed in renal transplant recipients carries the risk of inducing a prolonged period of ischemia that can threaten organ survival. Recently, endovascular techniques have been increasingly applied but the rate of complications and recurrences remains significant. We report the case of a kidney heterotopic allotransplant recipient who presented with a history of new-onset arterial hypertension, right lower limb claudication, and allograft dysfunction related to a long, eccentric, and ulcerated plaque causing hemodynamic stenosis of suprarenal iliac artery that was successfully managed with surgical endarterectomy. Despite new advances in less invasive procedures such as transluminal angioplasty and stent implantation, surgical endarterectomy of suprarenal iliac artery may be safely performed in selected heterotopic kidney transplant recipients. It allows for complete removal of the plaque, with better long-term results, and does not preclude subsequent endovascular or surgical procedures; therefore it should be considered a therapeutic option in this clinical setting.

Laparoscopic and hand-assisted laparoscopic live donor nephrectomy.

Renal grafts from living donors represent an important source of organs, particularly for young patients with chronic renal failure. Laparoscopic donor nephrectomy is a relatively new technique, which has the potential to increase the pool of available kidney grafts by removing some disincentives to live donation. The technique used for left kidney donation at our center, the first to introduce laparoscopic live donor nephrectomy in Italy, is described in this report. To further reduce warm ischemia time, the kidney is preloaded inside the extraction bag and 2 staplers are used to transect the renal artery and vein. The spread of the new technique in our country and in the rest of Europe is likely to raise the issue of training in laparoscopic surgery for transplant surgeons.

A quantitative test to estimate neutralizing antibodies to the hepatitis C virus: cytofluorimetric assessment of envelope glycoprotein 2 binding to target cells.

Hepatitis C virus (HCV) is a major cause of chronic hepatitis. The virus does not replicate efficiently in cell cultures, and it is therefore difficult to assess infection-neutralizing antibodies and to evaluate protective immunity in vitro. To study the binding of the HCV envelope to cell-surface receptors, we developed an assay to assess specific binding of recombinant envelope proteins to human cells and neutralization thereof. HCV recombinant envelope proteins expressed in various systems were incubated with human cells, and binding was assessed by flow cytometry using anti-envelope antibodies. Envelope glycoprotein 2 (E2) expressed in mammalian cells, but not in yeast or insect cells, binds human cells with high affinity (Kd approximately 10(-8) M). We then assessed antibodies able to neutralize E2 binding in the sera of both vaccinated and carrier chimpanzees, as well as in the sera of humans infected with various HCV genotypes. Vaccination with recombinant envelope proteins expressed in mammalian cells elicited high titers of neutralizing antibodies that correlated with protection from HCV challenge. HCV infection does not elicit neutralizing antibodies in most chimpanzees and humans, although low titers of neutralizing antibodies were detectable in a minority of infections. The ability to neutralize binding of E2 derived from the HCV-1 genotype was equally distributed among sera from patients infected with HCV genotypes 1, 2, and 3, demonstrating that binding of E2 is partly independent of E2 hypervariable regions. However, a mouse monoclonal antibody raised against the E2 hypervariable region 1 can partially neutralize binding of E2, indicating that at least two neutralizing epitopes, one of which is hypervariable, should exist on the E2 protein. The neutralization-of-binding assay described will be useful to study protective immunity to HCV infection and for vaccine development.

Physical and biochemical changes of thermal mud after maturation.

Thermal mud is a therapeutic agent whose antirheumatic effectiveness is optimized by a process of maturation. The maturation of thermal mud was followed at 48 degrees C under controlled conditions by measuring physical and biochemical changes due to the growth of colonizing thermophilic microorganisms. Thermogravimetric measurements allowed us to identify the building up of an organic component including phospholipids and in particular a previously recognized sulfoglycolipid, which was further purified. The compound may be responsible for the antirheumatic effect of the mud and is produced by the colonizing species which develop in a period of maturation subsequent to that of production of photosynthetic pigments.

S-acetyl- and S-phenylacetyl-glutathione as glutathione precursors in rat plasma and tissue preparations.

S-acetyl- and S-phenylacetyl-glutathione derivatives were synthesized by using a new procedure. The derivatives were incubated with rat plasma and red blood cells, and also with cytosol from rat liver, kidney and heart, or tissue slices from rat heart, kidney and liver. A limited hydrolysis of the compounds occurs in plasma, whereas hydrolysis occurs to a larger extent in tissue cytosols. Both purified and crude gamma-glutamyl-transpeptidase from different sources recognized the S-acetyl- and S-phenylacetyl derivatives as substrates. Intracellular glutathione increases after incubating the derivatives with red blood cells. A potential role of S-acetyl- and S-phenylacetyl-glutathione in replenishing cells with exogenous glutathione is envisaged.

Synthesis and purification of biologically active rat brain-derived neurotrophic factor from Escherichia coli.

The cDNA for rat brain-derived neurotrophic factor was cloned as the prepro and mature sequences into two independent expression vectors under control of the T7 promoter. When these vectors were transfected into Escherichia coli the prepro and mature forms of brain-derived neurotrophic factor accounted for about 20% and 25% of total E. coli proteins, and displayed molecular sizes of 26 kDa and 15 kDa, respectively. Mature brain-derived neurotrophic factor was extracted from E. coli inclusion bodies, refolded in the presence of CuCl2 and purified. The resulting protein had an ED50 of 3 ng/ml in supporting survival of cultured embryonic dorsal root ganglion neurons.