RESUMO
The efficacy of islet transplant is compromised by a significant loss of islet mass posttransplant due to an innate inflammatory reaction. We report the use of a combination of etanercept and anakinra (ANA+ETA) to block inflammatory islet damage in 100 patients undergoing total pancreatectomy with islet autotransplant. The patients were divided into 3 groups: no treatment (control [CTL]), etanercept alone (ETA), or a combination of etanercept and anakinra (ANA+ETA). Peritransplant serum samples were analyzed for protein markers of islet damage and for inflammatory cytokines. Graft function was assessed by fasting blood glucose, basal C-peptide, secretory unit of islet transplant objects (SUITO) index, and hemoglobin A1c . Administration of both antiinflammatory drugs was well tolerated without any major adverse events. Reductions in interleukin-6, interleukin-8, and monocyte chemoattractant protein 1 were observed in patients receiving ANA+ETA compared with the CTL group, while also showing a modest improvement in islet function as assessed by basal C-peptide, glucose, hemoglobin A1c , and SUITO index but without differences in insulin dose. These results suggest that double cytokine blockade (ANA+ETA) reduces peritransplant islet damage due to nonspecific inflammation and may represent a promising strategy to improve islet engraftment, leading to better transplant outcomes.
Assuntos
Diabetes Mellitus Tipo 1/terapia , Rejeição de Enxerto/prevenção & controle , Sobrevivência de Enxerto , Interleucina-1beta/antagonistas & inibidores , Transplante das Ilhotas Pancreáticas/métodos , Ilhotas Pancreáticas/citologia , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Adulto , Antirreumáticos/farmacologia , Autoenxertos , Quimioterapia Combinada , Etanercepte/farmacologia , Feminino , Seguimentos , Humanos , Imunossupressores/farmacologia , Secreção de Insulina , Proteína Antagonista do Receptor de Interleucina 1/farmacologia , Ilhotas Pancreáticas/efeitos dos fármacos , Ilhotas Pancreáticas/metabolismo , Masculino , Pancreatectomia , Prognóstico , Estudos RetrospectivosRESUMO
The success of human kidney allotransplantation was realized over six decades ago. First described 50 years ago, renal autotransplantation has been utilized sparingly as a salvage procedure for patients at risk of losing renal function, either from a benign or malignant condition. While classically associated with colorectal malignancies, Lynch syndrome also carries a small yet significant risk for the development of ureteral carcinoma. For these patients who develop chronic kidney disease, allotransplantation may not be an option due to the lifelong risk of several malignancies. We report the first known case of renal autotransplantation in a patient with metachronous ureteral cancer due to Lynch syndrome.
Assuntos
Neoplasias Colorretais Hereditárias sem Polipose/cirurgia , Transplante de Rim , Segunda Neoplasia Primária/cirurgia , Neoplasias Ureterais/cirurgia , Idoso , Feminino , Humanos , Segunda Neoplasia Primária/etiologia , Nefrectomia , Prognóstico , Transplante Autólogo , Neoplasias Ureterais/etiologiaRESUMO
BACKGROUND: Assessing the engrafted islet mass is important in evaluating the efficacy of islet transplantation. We previously demonstrated that the average secretory unit of islet transplant objects (SUITO) index within 1 month of allogeneic islet transplantation was an excellent predictor of insulin independence. However, the usefulness of the SUITO index for evaluating autologous islet transplantation has not been explored. The purpose of the present study was to assess the relationship between the SUITO index and clinical outcomes after total pancreatectomy followed by autologous islet transplantation. METHODS: We performed 27 total pancreatectomies followed by autologous islet transplantation from October 2006 to January 2011. Cases were divided into an insulin-independent group (IIG; n = 12) and an insulin-dependent group (lDG; n = 15). The SUITO index was calculated by the formula [fasting C-peptide (ng/mL)/fasting glucose (mg/dL) -63] × 1,500. The average SUITO index within the first month of transplantation except for days 0, 1, and 2, maximum SUITO index, and most recent SUITO index were calculated in each case, and values were compared between the IIG and the IDG. RESULTS: The average SUITO index within 1 month was significantly higher in the IIG than in the IDG (24.6 ± 3.4 vs 14.9 ± 2.0, respectively; P < .02). The maximum SUITO indices were 45.7 ± 7.7 in the IIG and 30.1 ± 8.1 in the IDG (not significant), and the recent SUITO indices were 36.9 ± 6.7 in the IIG and 22.8 ± 6.1 in the IDG (not significant). CONCLUSIONS: The average SUITO index within 1 month was an excellent predictor of insulin independence after total pancreatectomy followed by autologous islet transplantation.
Assuntos
Insulina/metabolismo , Transplante das Ilhotas Pancreáticas/métodos , Transplante Autólogo/métodos , Adulto , Glicemia/metabolismo , Peptídeo C/metabolismo , Sobrevivência Celular , Diabetes Mellitus/prevenção & controle , Feminino , Humanos , Ilhotas Pancreáticas/citologia , Transplante das Ilhotas Pancreáticas/normas , Masculino , Pessoa de Meia-Idade , Pancreatectomia/métodos , Fatores Sexuais , Fatores de Tempo , Transplante Autólogo/normas , Resultado do TratamentoRESUMO
INTRODUCTION: When patients do not become insulin independent after islet cell transplantation (ICT), another aim is to eliminate severe hypoglycemia. Previously we reported that a secretory unit of islet transplant objects (SUITO) index score >10 was associated with a reduction of severe hypoglycemia. In this study, we assessed patients' satisfaction with their insulin therapy based on the SUITO index. METHODS: The study involved 11 islet recipients with type 1 diabetes who underwent ICT but still used insulin. From those patients, 41 Insulin Therapy Satisfaction Questionnaires (ITSQ) were collected. The SUITO index (fasting C-peptide [ng/mL] × 1500/blood glucose [mg/dL] - 63) was calculated at the same outpatient visits that the survey was administered. ITSQ scores were summarized using subscales and compared among 3 groups: the pre-ICT group, the low-SUITO group (SUITO index score <10 post-ICT), and the high-SUITO group (SUITO index score ≥10). Higher survey scores indicated better satisfaction. RESULTS: Significant trend relationships across the 3 groups were observed in the ITSQ total score (P = .02 with Jonckheere-Terpstra test) and subscale scores of glycemic control (P < .001), hypoglycemic control (P = .01), and inconvenience of regimen (P = .004). The pairwise comparisons between the 3 groups found significant differences: high SUITO versus both pre-ICT and low SUITO for the total ITSQ score (P = .03 and .005, respectively) and glycemic control score (P = .008 and .001, respectively), and high SUITO versus low SUITO for hypoglycemic control score (P = .04) and inconvenience of regimen score (P = .008). CONCLUSION: Islet recipients with a SUITO index ≥10 experienced higher satisfaction with insulin injection therapy compared with the pre-ICT group, even though they were insulin dependent. A SUITO index ≥10 is a reasonable benchmark for successful ICT.
Assuntos
Diabetes Mellitus Tipo 1/terapia , Insulina/uso terapêutico , Transplante das Ilhotas Pancreáticas/métodos , Ilhotas Pancreáticas/citologia , Adulto , Glicemia/metabolismo , Peptídeo C/metabolismo , Diabetes Mellitus Tipo 1/tratamento farmacológico , Feminino , Sobrevivência de Enxerto , Humanos , Hipoglicemia/terapia , Insulina/metabolismo , Transplante das Ilhotas Pancreáticas/normas , Masculino , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Satisfação do Paciente , Inquéritos e Questionários , Resultado do TratamentoRESUMO
Hepatitis C virus (HCV) causes progressive liver fibrosis in liver transplant recipients and is the principal cause of long-term allograft failure. The antifibrotic effects of sirolimus are seen in animal models but have not been described in liver transplant recipients. We reviewed 1274 liver recipients from 2002 to 2010 and identified a cohort of HCV recipients exposed to sirolimus as primary immunosuppression (SRL Cohort) and an HCV Control Group of recipients who had never received sirolimus. Yearly protocol biopsies were done recording fibrosis stage (METAVIR score) with biopsy compliance of >80% at both year one and two. In an intent-to-treat analysis, the SRL Cohort had significantly less advanced fibrosis (stage ≥2) compared to the HCV Control Group at year one (15.3% vs. 36.2%, p < 0.0001) and year two (30.1% vs. 50.5%, p = 0.001). Because sirolimus is sometimes discontinued for side effects, the SRL Cohort was subgroup stratified for sirolimus duration, showing progressively less fibrosis with longer sirolimus duration. Multivariate analysis demonstrated sirolimus as an independent predictor of minimal fibrosis at year one, and year two. This is the first study among liver transplant recipients with recurrent HCV to describe the positive impact of sirolimus in respect of reduced fibrosis extent and rate of progression.
Assuntos
Hepatite C/prevenção & controle , Transplante de Fígado/efeitos adversos , Sirolimo/uso terapêutico , Adulto , Infecções por Citomegalovirus/etiologia , Progressão da Doença , Feminino , Rejeição de Enxerto/etiologia , Hepacivirus/efeitos dos fármacos , Hepatite C/etiologia , Humanos , Terapia de Imunossupressão/métodos , Cirrose Hepática/epidemiologia , Cirrose Hepática/etiologia , Cirrose Hepática/virologia , Transplante de Fígado/patologia , Masculino , Pessoa de Meia-Idade , Sirolimo/administração & dosagemRESUMO
BACKGROUND: The isolation of islets from the human pancreas critically depends on the efficiency of the digestive enzymes. Liberase HI had been used as a standard preparation until the issues concerning bovine spongiform encephalopathy. Thus, we must now use other collagenases for clinical islet transplantation, four of which we have evaluated herein. METHODS: The digestion of each of 17 pancreata from brain-dead donors was performed using the following collagenases: Liberase HI (HI; Roche, n = 9); Liberase MTF C/T (MTF; Roche, n = 4); Collagenase NB1 Premium Grade (NB1; Serva, n = 7); or Clzyme Collagenase HA (CI, VitaCyte, n = 4). Islet isolations were based on the Edmonton protocol for HI, whereas our modified islet isolation method was used for the three new enzymes (MTF, NB1, and CI). RESULTS: There were no significant differences in donor age, body mass index, pancreas size, and cold ischemic time among the four groups. The phase I time in the NB1 group was significantly shorter than in the CI group (P = .0014). The prepurification IEQ/g in the HI group was significantly lower than the others (P = .0003 vs MTF, .0007 vs NB1, and .0009 vs CI, respectively). The postpurification IEQ/g in the MTF group was significantly higher than in the HI group (P = .006). The viability in the NB1 group was significantly greater than the HI group (P = .003). CONCLUSION: Three new enzymes (MTF, NB1, and CI) may enable us to obtain higher islet yields than with HI.
Assuntos
Separação Celular/métodos , Colagenases/metabolismo , Ilhotas Pancreáticas/citologia , Adulto , Animais , Índice de Massa Corporal , Morte Encefálica , Bovinos , Encefalopatia Espongiforme Bovina/patologia , Humanos , Ilhotas Pancreáticas/patologia , Pessoa de Meia-Idade , Tamanho do Órgão , Pâncreas/anatomia & histologia , Pâncreas/patologia , Termolisina/metabolismo , Doadores de TecidosRESUMO
BACKGROUND: Monitoring functional islet mass after transplantation is critical to follow patients. Previously we demonstrated that the average secretory unit of islet transplant objects (SUITO) index within 1 month was an excellent predictor of insulin-free status or reduction in insulin dose. In this study, we analyzed the usefulness of daily SUITO index to assess clinical outcomes. METHODS: Five patients underwent islet transplantation, including 3 who received 2 transplantations and 2 who received a single graft. All 5 patients achieved insulin-free status with 3 remaining insulin free at the time of evaluation. We analyzed the daily relative insulin dose and SUITO index. The daily relative insulin dose was calculated as the total daily insulin dose/average pretransplant insulin dose. The SUITO index was calculated as [fasting C-peptide (ng/mL)]/[fasting blood glucose (mg/mL) - 63] x 1,500. The data analyzed based on time after islet transplantation were categorized as within or after 1 month. RESULTS: Within 1 month after islet transplantation, there was no correlation between the daily relative insulin dose and the daily SUITO index (P = .068; R = -0.33). After 1 month, the daily relative insulin dose and the daily SUITO index were strongly correlated (P < .0001; R = -0.70). When the cutoff value of the SUITO index was decided at 26 for insulin-free status, the positive predictive value was 84.1% and negative predictive value 89.4%. CONCLUSION: SUITO index was an excellent index to assess clinical outcomes beyond 1 month after islet transplantation.
Assuntos
Diabetes Mellitus Tipo 1/cirurgia , Insulina/metabolismo , Transplante das Ilhotas Pancreáticas/métodos , Ilhotas Pancreáticas/metabolismo , Glicemia/metabolismo , Peptídeo C/sangue , Diabetes Mellitus Tipo 1/tratamento farmacológico , Monitoramento Ambiental/métodos , Seguimentos , Gluconatos , Humanos , Derivados de Hidroxietil Amido , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Secreção de Insulina , Soluções para Preservação de Órgãos , Fosfatos , Resultado do Tratamento , TrealoseRESUMO
BACKGROUND: Simple monitoring of engrafted islet function is important for follow-up of recipients after islet transplantation. We previously developed a simple assessment tool for islet graft function; the secretory unit of islet transplant objects (SUITO) index. The aim of this study was to clarify the relationship between the SUITO index and the outcomes of intravenous glucose tolerance tests (IVGTT). METHODS: Fifteen series of blood samples from 6 islet recipients were collected before 3, 5, 10, 20, and 30 minutes after injection of 0.5 g/kg 50% dextrose. The SUITO index was calculated using plasma C-peptide and glucose level at fasting baseline. Samples were divided into the following 3 groups; low-SUITO (SUITO index <10; n = 3); middle-SUITO (SUITO index > or =10 to <26; n = 4); and high-SUITO (SUITO index > or =26; n = 8). RESULTS: A threshold SUITO index of 26 showed good sensitivity (85.7%) and specificity (75.0%) to predict a blood glucose level of >10 mmol/L at 30 minutes. Blood glucose levels in the low-SUITO group were significantly higher than among the other 2 groups at baseline and 10, 20 and 30 minutes (P < .05). Glucose-level areas under the receiver-operating characteristic curve during IVGTT in the low-SUITO group were also significantly larger than among the other 2 groups (P < .05). CONCLUSION: The SUITO index, using only a fasting blood sample, predicted IVGTT outcomes.
Assuntos
Glicemia/metabolismo , Diabetes Mellitus Tipo 1/cirurgia , Teste de Tolerância a Glucose , Transplante das Ilhotas Pancreáticas/fisiologia , Peptídeo C/sangue , Diabetes Mellitus Tipo 1/sangue , Monitoramento Ambiental/métodos , Jejum , Humanos , Curva ROC , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Although islet transplantation using young donors is more effective than older donors, islet isolation from young donor is notoriously difficult. This may relate to islet ontogeny and collagen composition in the young pancreas. Therefore, we examined whether a high concentration of collagenase could improve the separation of islets from exocrine tissues resulting in an high islet yield. METHODS: We used six human pancreata from brain-dead donors of less than 30 years old. Islet isolation was performed based on the Edmonton protocol with modifications. All pancreata were digested with Collagenase NB1 Premium Grade (Serva). The pancreas was expanded by injecting either 200 mL of cold collagenase solution (2.5 mg/mL, standard group, n = 3) or 100 mL of solution (5 mg/mL, new group, n = 3) in a controlled manner under low pressure for 5 minutes. Then the pressure was raised for another 5 minutes. The following procedure and evaluation were performed based on the Edmonton protocol. RESULTS: Phase II time in the new group was significantly shorter than the standard group. The ratio of embedded islets in the new group was significantly lower than the standard group. The postpurification islet equivalents per pancreas weight (IEQ/g) and the recovery rate in the new group were higher than the standard group, but not significantly. There was no significant difference in the postpurification purity, viability, and final tissue volume. CONCLUSION: Our simple modification with an initially concentrated collagenase preparation using a syringe significantly improved the ratio of embedded islets, resulting in a higher yield from young donors.
Assuntos
Ilhotas Pancreáticas/patologia , Adulto , Envelhecimento/fisiologia , Índice de Massa Corporal , Morte Encefálica , Separação Celular/métodos , Colagenases/metabolismo , Humanos , Ilhotas Pancreáticas/anatomia & histologia , Ilhotas Pancreáticas/citologia , Tamanho do Órgão , Pâncreas/anatomia & histologia , Pâncreas/enzimologia , Doadores de Tecidos , Adulto JovemRESUMO
INTRODUCTION: We previously established a mouse pancreatic stem cell line without genetic manipulation. In this study, we sought to identify and isolate human pancreatic stem/progenitor cells. We also tested whether growth factors and protein transduction of pancreatic and duodenal homeobox factor-1 (PDX-1) and BETA2/NeuroD into human pancreatic stem/progenitor cells induced insulin or pancreas-related gene expressions. MATERIALS AND METHOD: Human pancreata from brain-dead donors were used for islet isolation with the standard Ricordi technique modified by the Edmonton protocol. The cells from a duct-rich population were cultured in several media, based on those designed for mouse pancreatic or for human embryonic stem cells. To induce cell differentiation, cells were cultured for 2 weeks with exendin-4, nicotinamide, keratinocyte growth factor, PDX-1 protein, or BETA2/NeuroD protein. RESULTS: The cells in serum-free media showed morphologies similar to a mouse pancreatic stem cell line, while the cells in the medium for human embryonic stem cells formed fibroblast-like morphologies. The nucleus/cytoplasm ratios of the cells in each culture medium decreased during the culture. The cells stopped dividing after 30 days, suggesting that they had entered senescence. The cells treated with induction medium differentiated into insulin-producing cells, expressing pancreas-related genes. CONCLUSION: Duplications of cells from a duct-rich population were limited. Induction therapy with several growth factors and transduction proteins might provide a potential new strategy for induction of transplantable insulin-producing cells.
Assuntos
Células Secretoras de Insulina/citologia , Insulina/metabolismo , Células-Tronco/citologia , Morte Encefálica , Técnicas de Cultura de Células/métodos , Diferenciação Celular/efeitos dos fármacos , Núcleo Celular/ultraestrutura , Citoplasma/ultraestrutura , Ditizona , Exenatida , Fator 7 de Crescimento de Fibroblastos/farmacologia , Peptídeo 1 Semelhante ao Glucagon/farmacologia , Humanos , Insulina/genética , Secreção de Insulina , Células Secretoras de Insulina/efeitos dos fármacos , Células Secretoras de Insulina/fisiologia , Peptídeos/farmacologia , RNA Mensageiro/genética , Células-Tronco/efeitos dos fármacos , Células-Tronco/fisiologia , Doadores de Tecidos , Peçonhas/farmacologiaRESUMO
INTRODUCTION: For clinical islet transplantation, many centers have recently introduced of human islet cultures prior to transplantation. They provide flexibility to evaluate isolated islets and pretreat patients. However, isolated islets deteriorate rapidly in culture. In the present study, we compared fresh human and porcine islets with cultured islets for c-Jun NH(2)-terminal kinase (JNK) activity. MATERIALS AND METHODS: Islet isolations from human and porcine pancreata were performed using the standard Ricordi technique with a modified Edmonton protocol. Isolated islets cultured for 24 hours at 37 degrees C with 5% CO(2) in culture medium were evaluated for counts and JNK activity. RESULTS: After 24 hours of culture, the percentages of surviving islets were 86.9% for human and 47.3% for porcine sources. JNK activity in isolated islets declined to a low baseline level after 24-hour culture. CONCLUSION: Both human and porcine islets deteriorated rapidly in 24-hour cultures, although the in vitro conditions did not induce JNK activation.
Assuntos
Ilhotas Pancreáticas/citologia , Proteínas Quinases JNK Ativadas por Mitógeno/metabolismo , Animais , Morte Encefálica , Sobrevivência Celular/efeitos dos fármacos , Sobrevivência Celular/fisiologia , Células Cultivadas , Humanos , Ilhotas Pancreáticas/efeitos dos fármacos , Ilhotas Pancreáticas/enzimologia , Transplante das Ilhotas Pancreáticas/métodos , Camundongos , Soluções para Preservação de Órgãos/farmacologia , Especificidade da Espécie , Suínos , Doadores de TecidosRESUMO
INTRODUCTION: One of the current issues of clinical islet transplantation is the difficulty to achieve a prolonged insulin-free status. Functional islet mass gradually decreased after transplantation. We developed the SUITO index, which reflects engrafted islet mass. The SUITO (Secretory Unit of Islet Transplant Objects) index more than 26.0 is associated with an insulin-free status. In this study, we have experienced that super-high-dose islet transplantation maintained insulin-free status and a high SUITO index for a prolonged period. MATERIALS AND METHODS: Two islet isolations were performed in February 2007 and January 2008. Ductal injections were performed at the procurement site using the ET-Kyoto solution and pancreata preserved by a two-layer method. Islets were isolated using the modified Ricordi method. Both isolated islets were transplanted into a type 1 diabetic patient. Efficacy of islet transplantation was assessed by the amount of insulin requirements and SUITO index. RESULTS: Islet yields were 514,467 islet equivalents (IE) and 872,174 IE, with purities of 49% and 85% for the first and second islet transplantations, respectively. The patient received a total of 24,327 IE/kg body weight. The immunosuppression was based on the Edmonton protocol. After the second islet transplantation, the average SUITO index for the following 1 month was 48.5, and the patient became insulin-free. At postoperative day 1006, the SUITO index was 44.6 and the patient maintained an insulin-free status with excellent glycemic control. CONCLUSION: Super-high-dose islet transplantation was associated with an high SUITO index and prolonged insulin independence.
Assuntos
Diabetes Mellitus Tipo 1/cirurgia , Sobrevivência de Enxerto/fisiologia , Insulina/metabolismo , Transplante das Ilhotas Pancreáticas/métodos , Gluconatos , Humanos , Derivados de Hidroxietil Amido , Secreção de Insulina , Ilhotas Pancreáticas/metabolismo , Fosfatos , Doadores de Tecidos , Resultado do Tratamento , TrealoseRESUMO
BACKGROUND: The necessity to use multiple donors for achieving insulin independence in clinical islet transplantation is still a major issue. We have developed a modified islet isolation method for non-heart-beating donors (Kyoto method) to significantly increase islet yield. In this study, we further modified the method for brain-dead donors and in addition, introduced a potent anti-inflammatory strategy aiming for single-donor islet transplantation. MATERIALS AND METHODS: Two islet isolations used pancreatic ductal preservation with the modified Kyoto solution and a density-adjusted purification method. Anti-interleukin-1-beta antibody (Anakinra) and anti-tumor necrosis factor-alpha (Eternacept) were administered during and after transplantation. The efficacy of the islet transplantation was assessed by the insulin requirement and SUITO (Secretory Unit of Islet Transplant Objects) index, wherein a value of more than 26.0 seems to be associated with insulin independence. RESULTS: Both isolated islet preparations met the criteria for transplantation. They were transplanted into two type 1 diabetic patients, both of whom became insulin independent with stable glycemic control. The average SUITO index within 1 month was 29.2 and 45.3. CONCLUSION: The islet isolation method combined with a potent anti-inflammation strategy made it possible to achieve single-donor islet transplantation achieving a high SUITO index.
Assuntos
Diabetes Mellitus Tipo 1/cirurgia , Insulina/metabolismo , Transplante das Ilhotas Pancreáticas/métodos , Antirreumáticos/uso terapêutico , Índice de Massa Corporal , Gluconatos/uso terapêutico , Sobrevivência de Enxerto , Humanos , Derivados de Hidroxietil Amido/uso terapêutico , Imunossupressores/uso terapêutico , Secreção de Insulina , Proteína Antagonista do Receptor de Interleucina 1/uso terapêutico , Ilhotas Pancreáticas/citologia , Ilhotas Pancreáticas/fisiologia , Transplante das Ilhotas Pancreáticas/imunologia , Pessoa de Meia-Idade , Ácido Micofenólico/análogos & derivados , Ácido Micofenólico/uso terapêutico , Soluções para Preservação de Órgãos/uso terapêutico , Fosfatos/uso terapêutico , Tacrolimo/uso terapêutico , Doadores de Tecidos , Obtenção de Tecidos e Órgãos/métodos , Trealose/uso terapêuticoAssuntos
Férias e Feriados , Recreação , Especialidades Cirúrgicas , Transplante , Viagem , Humanos , IsraelRESUMO
PURPOSE: The aim of this study was to analyze failures in the operative management of perirectal abscesses resulting in early reoperation. METHODS: This was a retrospective case study of 500 consecutive patients who underwent 627 drainage procedures for a perirectal abscess. RESULTS: Forty-eight patients (7.6 percent of all drainage procedures) required reoperation within ten days of the original procedure. The main factors leading to reoperation were incomplete drainage (23 patients), missed loculations within a drained abscess (15 patients), missed abscesses (4 patients), and postoperative bleeding (3 patients). Incomplete drainage was more common with simple perirectal abscesses, whereas most overlooked collections were located posteriorly. Horseshoe abscesses were associated with a particularly high rate (50 percent) of operative failures. Neither preexisting perianal pathology nor systemic immunosuppressive disease contributed to early failures. CONCLUSION: Surgical errors are the leading cause of early failures in the surgical treatment of perianal abscesses. These errors occur in a limited number of typical patterns and can therefore be identified and taught with an aim to decrease their occurrence.
Assuntos
Abscesso/cirurgia , Drenagem , Doenças Retais/cirurgia , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Complicações Intraoperatórias , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Reoperação , Estudos Retrospectivos , Falha de TratamentoAssuntos
Ascomicetos , Candidíase/etiologia , Dermatomicoses/etiologia , Infecções Oculares Fúngicas/etiologia , Transplante de Fígado/efeitos adversos , Adulto , Candidíase/patologia , Dermatomicoses/patologia , Infecções Oculares Fúngicas/patologia , Feminino , Humanos , Masculino , Sepse/etiologiaRESUMO
BACKGROUND: Intravenous administration of recombinant activated human clotting factor VII (rFVIIa) has been used successfully to prevent bleeding in hemophilia patients undergoing elective surgery, but not in previously normal trauma patients. This study was conducted to determine whether rFVIIa was a useful adjunct to gauze packing for decreasing blood loss from grade V liver injuries in hypothermic and coagulopathic swine. METHODS: All animals (n = 10, 35 +/- 2 kg) underwent a 60% isovolemic exchange transfusion with 6% hydroxyethyl starch and were cooled to 33 degrees C core temperature. The swine then received a grade V liver injury and 30 seconds later, either 180 microg/kg rFVIIa, or saline control. All animals were gauze packed 30 seconds after injury and resuscitated 5.5 minutes after injury with lactated Ringer's solution to their preinjury mean arterial pressure. Posttreatment blood loss, mean arterial pressure, resuscitation volume, and clotting studies were monitored for 1 hour. Histology of lung, kidney, and small bowel were obtained to evaluate for the presence of microvascular thrombi. RESULTS: At the time of injury, core temperature was 33.3 degrees +/- 0.4 degrees C, hemoglobin was 6 +/- 0.7 g/dL, prothrombin time was 19.1 +/- 1.0 seconds, activated partial thromboplastin time was 29.0 +/- 4.8 seconds, fibrinogen was 91 +/- 20 mg/dL, and platelets were 221 +/- 57 x 105/mL, with no differences between groups (p > 0.05). Clotting factor levels confirmed a coagulopathy at the preinjury point. The posttreatment blood loss was less (p < 0.05) in group 1 (527 +/- 323 mL), than in group 2 (976 +/- 573 mL). The resuscitation volume was not different (p > 0.05). One-hour survival in both groups was 100%. Compared with the control group, rFVIIa increased the circulating levels of VIIa and, despite hypothermia, shortened the prothrombin time 5 minutes after injection (p < 0.05). Laboratory evaluation revealed no systemic activation of the clotting cascade. Postmortem evaluation revealed no evidence of large clots in the hepatic veins or inferior vena cava, or microscopic thrombi in lung, kidney, or small intestine. CONCLUSION: rFVIIa reduced blood loss and restored abnormal coagulation function when used in conjunction with liver packing in hypothermic and coagulopathic swine. No adverse effects were identified.
Assuntos
Transtornos da Coagulação Sanguínea/complicações , Modelos Animais de Doenças , Fator VII/uso terapêutico , Hemorragia/tratamento farmacológico , Hemorragia/etiologia , Hipotermia Induzida/métodos , Fígado/lesões , Proteínas Recombinantes/uso terapêutico , Animais , Bandagens , Transtornos da Coagulação Sanguínea/sangue , Pressão Sanguínea , Terapia Combinada , Avaliação Pré-Clínica de Medicamentos , Transfusão Total , Fator VII/efeitos adversos , Fator VIIa , Fibrinogênio/metabolismo , Hemorragia/sangue , Soluções Isotônicas/uso terapêutico , Tempo de Tromboplastina Parcial , Tempo de Protrombina , Distribuição Aleatória , Proteínas Recombinantes/efeitos adversos , Ressuscitação/métodos , Lactato de Ringer , Método Simples-Cego , Análise de Sobrevida , Suínos , Trombose/etiologia , Trombose/patologia , Fatores de Tempo , Ferimentos e Lesões/classificação , Ferimentos e Lesões/complicações , Ferimentos e Lesões/mortalidadeRESUMO
Temporary closure of the abdomen with a synthetic mesh and multiple planned relaparotomies are the essentials of the modern strategy for treating severe intra-abdominal sepsis or pancreatic necrosis. One of the complications associated with mesh closure of the abdomen is facial necrosis at the wound edges leading to evisceration. Tension of the strictures between mesh and facia called local ischemia, which combined with infection leads to the facial disintegration and separation of the mesh from the abdominal wall. A modified technique of suturing the mesh was developed in our department and its technical details are presented. Twenty-four patients treated with the "open abdominal technique and planned relaparotomies" are presented. The new technique was used in 9 patients for closure of evisceration after mesh separation.
Assuntos
Laparotomia/métodos , Telas Cirúrgicas , Adulto , Idoso , Idoso de 80 Anos ou mais , Fáscia/patologia , Fasciotomia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Necrose , Polietilenos , Polipropilenos , Complicações Pós-Operatórias/patologia , Reoperação , Deiscência da Ferida Operatória/etiologia , Técnicas de SuturaRESUMO
The paper reports on two peculiar clinical observations of diffuse acute peritonitis in which the abdominal cavity was contaminated by perianorectal suppurative acute processes, insufficiently solved surgically. The diagnosis difficulties, peculiarities of the surgical treatment, and their special seriousness are revealed.