Wound events in kidney transplant patients receiving de novo everolimus: a pooled analysis of three randomized controlled trials.

Data were pooled from three prospective, multicenter trials in which 1996 de novo kidney transplant recipients were randomized to everolimus 1.5 or 3.0 mg or mycophenolic acid (MPA), with cyclosporine and steroids. Wound healing complications reported as adverse events were retrospectively reviewed in a blinded manner. The incidence of wound healing adverse events was 17.6% (351 of 1996) by day 90 and was similar for everolimus 1.5 mg (16.6% [110 of 661]) vs. MPA (14.3% [95 of 665]) (p = 0.255), but higher with everolimus 3.0 mg (21.8% [146 of 670]) (p < 0.001 vs. MPA). Similar results were observed for wound healing complications reported as serious adverse events. The 12-month incidence of lymphocele was 11.2% with everolimus 1.5 mg and 8.9% with MPA (p = 0.171), but lymphocele reported as a serious adverse event were more frequent with everolimus 1.5 mg (6.5% vs. 3.5%; p = 0.012). The hazard ratio (HR) for any wound healing complication vs. MPA was not significantly higher for everolimus <3 ng/mL (HR 1.33; 95% CI 0.94-1.88; p = 0.104), but increased to 1.46 (95% CI 1.12-1.90; p = 0.005) for 3-8 ng/mL and 1.69 (95% CI 1.20-2.38; p = 0.002) for >8 ng/mL. These results suggest that de novo kidney transplant patients receiving an initial everolimus dose of 1.5 mg do not appear to have a pronounced increased risk of wound healing complications vs. patients receiving MPA.

Portal-endocrine and gastric-exocrine drainage technique in pancreatic transplantation.

BACKGROUND: Pancreas transplant (PTx) is an established treatment for patients with diabetes mellitus. Diagnosis of rejection has continued to be problematic. In 2007, a new technique of PTx with portal-endocrine and gastric exocrine (P-G) drainage was first performed at our institution. This technique facilitates access to pancreas allograft. OBJECTIVE: To report our experience with the first 30 patients who underwent PTx using P-G technique. METHODS: The first 30 patients who underwent PTx between 2007 and 2009 were studied. In these patients, arterial and venous anastomosis was similar to standard portal-enteric (P-E) technique, though contrary to other techniques of enteric drainage, the end of allograft jejunum was anastomosed to the anterior aspect of the stomach. RESULTS: Donor and recipient demographic data, number of antigen matches and immunosuppressant were collected. All patients achieved euglycemia. 3 patients underwent pancreatectomy: 2 due to vessel thrombosis and 1 due to chronic rejection. 3 patients died-2 with functioning pancreatic and renal allografts. 7 patients with CMV and 4 patients with rejection were diagnosed with endoscopy of allograft duodenum and treated. 1-year patient and graft survival was 94% and 85%, respectively. CONCLUSION: This novel technique of PTx has proven to be safe with good patient and allograft survival. Access to donor duodenum and pancreas allograft via endoscopy is unique to this technique and provides the added advantage of life-long easy access to allograft.

Role of FDG-PET in the evaluation and staging of hepatocellular carcinoma with comparison of tumor size, AFP level, and histologic grade.

Fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) has proven to be a valuable tool in the initial diagnosis, staging, and restaging of a variety of cancers. The potential use of FDG-PET in the evaluation and management of hepatocellular carcinoma (HCC) continues to evolve. The purpose of this study was to investigate the effectiveness of FDG-PET for the detection and staging of HCC. In addition, we also assessed the correlation between FDG-PET positivity, tumor size, a-fetal protein level (AFP), and histologic grade. All patients on the hepatobiliary and liver transplant service with biopsy proven HCC that underwent FDG-PET between January 2000 and December 2004 were selected for a retrospective review. Results of the FDG-PET scan were compared with other imaging studies [computed tomography (CT), magnetic resonance imaging (MRI), ultrasonography], intraoperative findings, tumor size, AFP levels, and histologic grade. Of the 20 patients who underwent 18F-FDG PET, increased FDG uptake was noted in 14 scans (70%). These 20 patients fell into 2 groups: 1 for detecting HCC (Group A) and 1 for staging HCC (Group B). There were 7 patients in Group A; only 2 scans (28.6%) showed increased uptake. There were 13 patients in Group B; 12 scans (92.3%) showed increased uptake. In Group B, 11 of the 13 scans (84.6%) provided an accurate representation of the disease process. Two scans failed to accurately portray the disease; one scan failed to show any increase in uptake, and the other scan failed to detect positive nodes that were found during surgery. FDG-PET detected only 2 of 8 tumors (25%) < or = 5 cm in size. All 12 PET scans (100%) in tumors > or = 5 cm and/or multiple in number were detected by FDG-PET. FDG-PET scans with AFP levels < 100 ng/ml were positive in 5 of 9 patients (55.6%). In patients with levels > 100 ng/ml, 6 of 7 patients (85.7%) had positive scans. Histologically, there were 6 well-differentiated, 6 moderately differentiated, and 2 poorly differentiated HCCs. FDG-PET detected 4 of 6 for both well- and moderately differentiated HCCs. Both poorly differentiated HCCs were detected. The intensity was evenly distributed between the different histologic grades. There was a strong correlation of FDG uptake with tumor size. There were 5 HCCs with primary tumors >10 cm in size; 4 showed intense uptake on the scan. In contrast, of the 8 tumors < or = 5 cm in size, 6 were negative for uptake. The sensitivity of FDG-PET in detecting HCC < or = 5 cm in size is low and therefore may not be helpful in detecting all of these tumors. For larger tumors, there is a strong correlation of sensitivity and uptake intensity with tumor size and elevated AFP levels. FDG-PET sensitivity and uptake intensity did not correlate with histologic grade. In the setting of extrahepatic disease, FDG-PET seems to be an effective accurate method for HCC staging; however, whether PET offers any benefit over traditional imaging has yet to be determined.

Everolimus plus reduced-exposure CsA versus mycophenolic acid plus standard-exposure CsA in renal-transplant recipients.

Everolimus allows calcineurin-inhibitor reduction without loss of efficacy and may improve renal-transplant outcomes. In a 24-month, open-label study, 833 de novo renal-transplant recipients were randomized to everolimus 1.5 or 3.0 mg/day (target troughs 3-8 and 6-12 ng/mL, respectively) with reduced-exposure CsA, or mycophenolic acid (MPA) 1.44 g/day plus standard-exposure CsA. Patients received basiliximab +/- corticosteroids. The primary endpoint was composite efficacy failure (treated biopsy-proven acute rejection, graft loss, death or loss to follow-up) and the main safety endpoint was renal function (estimated glomerular filtration rate [eGFR], by Modification of Diet in Renal Disease [MDRD]) at Month 12 (last-observation-carried-forward analyses). Month 12 efficacy failure rates were noninferior in the everolimus 1.5 mg (25.3%) and 3.0 mg (21.9%) versus MPA (24.2%) groups. Mean eGFR at Month 12 was noninferior in the everolimus groups versus the MPA group (54.6 and 51.3 vs 52.2 mL/min/1.73 m(2) in the everolimus 1.5 mg, 3.0 mg and MPA groups, respectively; 95% confidence intervals for everolimus 1.5 mg and 3.0 mg vs MPA: -1.7, 6.4 and -5.0, 3.2, respectively). The overall incidence of adverse events was comparable between groups. The use of everolimus with progressive reduction in CsA exposure, up to 60% at 1 year, resulted in similar efficacy and renal function compared with standard-exposure CsA plus MPA.

Post transplant lymphocele: a single centre experience.

The occurrence of post renal transplant lymphocele is variable and the best approach to treatment is not well defined. The purpose of this study was to find out the incidence of post transplant lymphocele at our centre, identify demographic or surgical factors that may have influenced lymphocele formation, and distinguish the best approach to treatment. The charts of 138 consecutive renal transplant recipients from 1996 to 2001 were retrospectively reviewed. The demographic characteristics, comorbid illnesses, occurrence of lymphocele and its treatment modality were recorded. A total of 36 (26%) patients developed lymphoceles. There was a significant relationship between an increased body mass index (BMI) and lymphocele occurrence (P > 0.01). The recurrence rate with drainage alone was 33%, which decreased to 25% with sclerotherapy. In comparison, both laparoscopic and open surgical marsupialization had a much lower but similar recurrence rate of 12%. The laparoscopic method had less morbidity, a shortened hospital stay, and less infection than open surgery.

Conundrums with FlowPRA beads.

In 1969, a study by Patel and Terasaki persuaded the renal transplant community that a pre-transplant cross-match should always be performed between donor and recipient to detect HLA antibodies and prevent hyperacute allograft rejection. Although the role of the cross-match among nonsensitized patients is controversial, its importance among sensitized recipients is undeniable. Over the past 30 years, more sensitive techniques, such as the flow cytometric cross-match (FCXM), were developed to identify low levels of antibodies undetectable by other approaches. The clinical relevance of a positive FCXM, however, has been hotly disputed, with some investigators maintaining that the FCXM is 'too sensitive' and rules out acceptable donor-recipient combinations. An alternative explanation is that the FCXM is non-specific, and, at least in certain situations, identifies non-HLA antibodies that are clinically irrelevant. Recently, a solid phase immunoassay utilizing purified HLA Class I or Class II molecules bound to microparticles (FlowPRA) was developed. Ideally, use of the FlowPRA for the identification of HLA antibodies in recipient sera would help ascertain whether a positive FCXM with donor cells was truly the result of an HLA-specific antibody. As shown here, this may not always be true. In this study, two unexpected serum patterns were observed. Pattern 1: FlowPRA beads were positive (with an associated HLA Class I specificity) and the FCXM with cells expressing the HLA antigen(s) to which the antibody was directed, was negative. Sequence analysis of the HLA antigens reactive with this unexpected antibody suggests that the epitope recognized resides on the floor of the groove, a site generally not expected to generate antibody activity. Pattern 2: FlowPRA beads were negative yet the FCXM was T and B cell positive. Further analysis of the FlowPRA negative/FCXM positive sera using a flow cytometric cell-based panel reactive antibody (PRA) approach revealed those sera to have specific anti-HLA Class I activity. We suspect that both types of antibodies described above have clinical relevance. Thus, a negative or positive FCXM (when the FlowPRA against donor antigens is positive or negative, respectively) is not always a straightforward interpretation.

Soluble HLA-II expression in African-Americans.

OBJECTIVE: In this study we evaluated the contribution of major histocompatibility complex (MHC) genes to soluble histocompatibility antigen class II (sHLA-II) secretion in African American patients with rheumatoid arthritis (RA). METHODS: A sensitive enzyme-linked immunoassay was used to quantitate sHLA-II in the serum of 7 patients with RA, as well as 28 of their kinships and 49 HLA typed normal African American individuals. RESULTS: Mean sHLA-II values were higher in patients with RA than those in healthy African American individuals (p < 0.05). There were variations in concentrations in individual patients but these were unrelated to any apparent clinical event. The proportion of unaffected family members with detectable levels of sHLA-II was not significantly different than those in normal controls. Neither specific HLA-haplotype, or HLA-allele(s) correlated with high or low sHLA-II secretion. CONCLUSIONS: Our data suggest that sHLA-II molecules are not regulated by MHC linked genes but may be regulated by non-MHC linked genes and racial background may reflect genetic heterogeneity of the expression of this soluble HLA material. These observations contrast with previous observations concerning soluble HLA class I (sHLA-I) molecules in a described population sample which were almost the precise reverse.

Renal cell carcinoma detected in a cadaveric donor after orthotopic liver and contralateral renal transplantation in two recipients: four-year follow-up.

BACKGROUND: Although rare, renal cell carcinoma has been found during renal recovery for cadaveric organ transplantation. Previously, we reported this incidence to be 0.9%. In one cadaveric donor, the liver and left kidney had been transplanted before the discovery of renal cell carcinoma (T1) in the right kidney. METHODS: We retrospectively reviewed the medical records of two patients who had received cadaveric allografts from a donor with a known renal cell carcinoma. RESULTS: Both patients have been followed for 4 years with blood chemistries and chest x-ray every 3 months for year 1, every 4 months for years 2 and 3, and every 6 months thereafter. They also underwent allograft ultrasound every 6 months and an annual CT scan of the abdomen. Both patients have shown no evidence of metastatic disease throughout their follow-up. DISCUSSION: In the rare instance that a patient receives an organ from a cadaveric donor with a known renal cell carcinoma, it is mandatory to follow these patients closely observing for both allograft recurrence and metastatic disease.

Diverticulitis in the young patient.

Although predominantly a disease in older adults diverticulitis does affect younger patients. The disease has been described as not only rare but virulent by some authors, and a young patient age is considered to be a relative indication for early sugery. The goal of this study was to evaluate the experience of the Louisiana State University Health Sciences Center-Shreveport and affiliated hospitals with diverticulitis in young patients. This study was a retrospective chart review of 22 patients with diverticulitis age 40 years and younger over the past 20 years. Inclusion criteria were either a diagnosis of diverticulitis confirmed at surgery or positive CT findings and/or a positive contrast enema. The mean age in this study was 32.1 years (range 16-40). All 22 patients presented with abdominal pain. The next most common symptom was nausea and/or vomiting in 45 per cent followed by fever and chills in 36 per cent. Twelve patients had abdominal CTs on admission, and 87 per cent had positive findings. Eighteen patients underwent an operation. Four patients were treated nonoperatively. Nineteen patients had diverticulitis of the sigmoid colon. The remaining three had right-sided diverticulitis. Two patients underwent right hemicolectomy, and one underwent cecectomy. Of the 15 patients with sigmoid diverticulitis 12 (80%) underwent a two-stage procedure of sigmoid colectomy, end colostomy, and Hartmann's pouch. Three patients (20%) underwent a one-stage procedure of sigmoid colectomy and primary anastomosis. Two of three patients undergoing a one-stage procedure required reoperation. Postoperative complications occurred in 10 of 18 patients for an overall incidence of 56 per cent. Two of these patients had septic complications. Both of these patients had a delay in time from admission until operation: one for 7 days and the other for 10 days. There was one death in the series. Colostomy closure was performed successfully in nine of 12 (75%) patients. The mean time interval before closure was 7.7 months, (range 3-14). Patients with two-stage procedures on initial admission fared better than those with one-stage procedures. The overall mortality was 4.5 per cent. There was a high overall complication rate of 56 per cent in patients undergoing an operation. Two patients who had a delay in time from admission to operation had septic complications. Early surgical intervention should be considered in this clinical setting. In summary, although rare, diverticulitis in the young patient is often a fulminant illness requiring operation early in the disease process.

Iatrogenic and noniatrogenic extrahepatic biliary tract injuries: a multi-institutional review.

Traumatic and iatrogenic extrahepatic biliary tract injuries are rare but may lead to exceedingly morbid complications. Traumatic extrahepatic biliary tract injuries represent less than 1 per cent of all traumatic injuries. Iatrogenic injuries result in 0.2 to 1 per cent of laparoscopic or open cholecystectomies. The objective of this study was to review the incidence of biliary tract injuries--iatrogenic as well as traumatic--and their subsequent management. A multi-institutional chart review was done including Louisiana State University Health Sciences Center (LSUHSC)-Shreveport, LSUHSC-Monroe, and Richland Parish medical centers. Charts were reviewed for patients with iatrogenic biliary tract injuries and those with biliary tract injuries related to noniatrogenic trauma. The etiology of the biliary tract injury, symptoms of injury, pertinent laboratory and radiologic studies, injury-to-diagnosis time, type of biliary tract injury, injury management, days hospitalized, intensive care unit stay, and complications were reviewed. There are 1500 trauma patients admitted to LSUMC-Shreveport each year. The incidence of biliary tract injury in trauma patients admitted to LSUMC is 0.1 per cent. Traumatic injuries were classified according to the injury scale by Mattox et al. (Trauma 1996; Vol 515). There were five Type II, four Type IV, and two Type V injuries. Five patients underwent cholecystectomy, three had endoscopic retrograde cholangiopancreatography with stent placement, and two had choledochojejunostomy; one patient died from associated injuries. There were no complications of repair. Approximately 220 cholecystectomies are done at LSUMC-Shreveport each year. Eighty-eight per cent are laparoscopic, and 12 per cent are open. The incidence of iatrogenic biliary tract injuries at LSUMC-Shreveport during the past 8 years was 0.2 per cent. Immediate diagnosis of iatrogenic injuries was made in five of 17 cases and eight of 11 trauma cases. Laparoscopic injuries were classified by the Way injury classification (Stewart L, Way LW. Arch Surg 1995;130:1123). There were one Type I, one Type II, and nine Type III injuries. Treatment included suturing of the laceration (n = 1), hepaticojejunostomy (n = 8), and primary repair (n = 2). Open injuries were classified using the Bismuth classification. There were one Type I and three Type III injuries. All were treated with hepaticojejunostomy. There were two iatrogenic injuries unrelated to cholecystectomy. One patient suffered a perforation of the gallbladder during laparoscopic nephrectomy. This patient subsequently underwent cholecystectomy and has done well. The second patient suffered ligation of the intraduodenal portion of the common bile duct during hemigastrectomy and oversewing of a duodenal ulcer. This patient underwent hepaticojejunostomy and has done well. Complications of iatrogenic injury repair included leaking of a repaired laceration (n = 1), failed hepaticojejunostomy (n = 1), and an anastomotic stricture after hepaticojejunostomy (n = 1). Laparoscopic injuries by LSUMC hospitals is 0.2 per cent. Extrahepatic biliary tract injuries resulting from open cholecystectomy were diagnosed later than those occurring during laparoscopic cholecystectomy and were most likely to result in stricture formation. Repair of Way Type II and III injuries is associated with a higher complication rate. Hepaticojejunostomy has a complication rate of 15 per cent. Minor common duct lacerations are amenable to conservative therapy with oversewing and/or endoscopic retrograde cholangiopancreatography with stent placement. Repair of extrahepatic biliary tract injuries with hepaticojejunostomy at a level of good blood supply remains our gold standard for treatment of more severe injuries and strictures.

Pancreatic transplantation and subsequent graft surveillance by pancreatic portal-enteric anastomosis and temporary venting jejunostomy.

OBJECTIVE: To evaluate portal-enteric (PE) pancreas and kidney transplantation with venting jejunostomy (VJ) for its efficacy, safety, and reproducibility. SUMMARY BACKGROUND DATA: Simultaneous pancreas and kidney transplantation for patients with long-standing insulin-dependent diabetes mellitus that progresses to renal failure has revolutionized their treatment and quality of life. A current clinical focus is to refine the technical aspects of this procedure. Simultaneous pancreas and kidney transplantation with PE anastomosis with VJ appears to offer several advantages over bladder drainage. VJ allows initial decompression of the enteric anastomosis, monitoring of pancreatic function by ostomy amylase, and simple access for endoscopic evaluation and biopsy of the allograft. METHODS: Simultaneous pancreas and kidney transplantation with VJ was performed in 21 patients from December 1996 to October 2000 at Willis Knighton/LSU Regional Transplant Center. All patients had long-standing insulin-dependent diabetes mellitus and subsequent renal failure. They were evaluated at the time of surgery by a multidisciplinary transplant team and monitored for numerous factors, including length of hospital stay, immunosuppressive regimen, and ischemia times. All patients had intermittent visual and biochemical evaluation of pancreatic secretions monitored by means of the VJ. RESULTS: Of the 21 patients, 10 were women and 11 were men. Four patients were black and 17 were white. The mean age at transplantation was 38 years; average human leukocyte antigen (HLA) match was one; and average cold ischemia time was 12 hours. The median hospital stay was 16 days. Four episodes of postoperative bleeding requiring exploration occurred in four patients. Postoperative wound infections developed in four patients. There were 12 episodes of rejection in nine patients. All patients with suspected acute pancreatic rejection underwent endoscopy by means of the VJ and duodenal biopsy for evaluation. Two patients lost pancreatic function subsequent to kidney failure, one secondary to noncompliance and the other as a result of hemolytic-uremic syndrome. Patient, kidney, and pancreatic survival rates were 100%, 90%, and 90%, respectively. The mean follow-up period was 25 (range 2-48) months. CONCLUSION: The authors believe that PE pancreatic drainage with VJ is a more physiologic method to perform pancreatic transplantation than bladder drainage. PE drainage allows rapid diagnosis of acute rejection and anastomotic leak and provides a simple way to monitor ostomy amylase and transplant duodenal bleeding. This technique is safe and has minimal associated complications.

Mirizzi's syndrome: experience from a multi-institutional review.

P.L. Mirizzi described in 1948 a partial or spastic obstruction of the common hepatic duct secondary to an impacted gallstone in the cystic duct or infundibulum of the gallbladder. The modern definition of Mirizzi's syndrome is thought to include four components: anatomic arrangement of the cystic duct at the gallbladder neck such that it runs parallel to the common hepatic duct; impaction of a stone in the cystic duct or neck of the gallbladder; mechanical obstruction of the common hepatic duct by the stone itself or by secondary inflammation; and intermittent or constant jaundice causing possible recurrent cholangitis and, if longstanding, secondary biliary cirrhosis. Intermittent symptomatology may make Mirizzi's syndrome difficult to diagnose preoperatively or intraoperatively. Bilio-biliary fistulas may or may not be present. Diagnosis and choice of operative repair may be best accomplished by open operative technique. Over a 24-year period two faculty members from Louisiana State University (LSU) Medical Center-Shreveport at Monroe and LSU Baton Rouge treated 4180 cases of cholelithiasis at six Louisiana university and private hospitals. Eleven cases of Mirizzi's syndrome were diagnosed on the basis of operative and preoperative notes with detailed description of size and extent of biliobiliary fistulas when they were present. These 11 cases were reviewed and followed from one to 20 years. Presentation, workup, operative findings, choice of operative repair, choice of operative approach, and complications were evaluated by retrospective chart review. Review of the pertinent literature for informative and comparative purposes was also completed. These 11 cases ranged from Csendes Type I to III. There were no Type IV cases. They were ultimately diagnosed and managed by classical open technique. Four laparoscopic procedures were converted to open technique following initial inspection. All four were converted to open as a result of inability to delineate structures in and adjacent to the triangle of Calot due to marked scarring in the subhepatic space. No iatrogenic injuries or major complications occurred. Mirizzi's syndrome occurs in fewer than 0.5 per cent of patients with cholelithiasis. Removal of stones with partial cholecystectomy and use of gallbladder or cystic duct remnant to oversew or repair Mirizzi fistulas should be considered. Roux-en-y hepaticojejunostomy becomes the procedure of choice when the vascularity or viability of the hepatic duct or tissues available for duct repair is questionable. Review of the literature reveals the increase in complications with laparoscopic versus open technique in Mirizzi's syndrome. Although very little direct evidence exists we believe that when this syndrome is diagnosed or strongly suspected open biliary operation is the procedure of choice because the increased potential for major complications with the use of laparoscopic technique far outweighs the potential slight increase in morbidity of an open procedure.

Use of the sestamibi scan to identify hyperplastic parathyroid tissue in the forearm of a patient with MEN1 syndrome.

Hyperparathyroidism is the most common presenting symptom in patients with MEN1 syndrome. Sestamibi scanning is not routinely used in the preoperative evaluation of this type of patient prior to their initial operation. It has been useful, however, in the preoperative evaluation of patients with recurrent hypercalcemia prior to reexploration. We present a case, which illustrates the application of its use during the preoperative evaluation of a patient with MEN1 syndrome and recurrent hypercalcemia.

End-stage renal disease in liver transplants.

Renal dysfunction is one of the most significant problems following orthotopic liver transplantation (OLTx). Since the major risk factor for delayed renal dysfunction following OLTx is presumed to be cyclosporine (CsA) nephrotoxicity, it has been suggested that CsA is the most probably cause of end-stage renal disease (ESRD) in this population of patients. To test this hypothesis the records of OLTx patients in our center who developed ESRD requiring dialysis were reviewed. There were 132 consecutive adult patients with end-stage liver disease (ESLD) who received 146 OLTxs between 1990 and 2000. Five patients (3.4%) developed ESRD requiring dialysis. Four of the five patients developed nephrotic range proteinuria prior to reaching ESRD. Renal biopsy in four patients showed focal segmental glomerulosclerosis, diabetic nephropathy, membranous nephropathy and cyclosporine toxicity. The underlying hepatic and metabolic disease may have played a role in the genesis of glomerular diseases in these OLTx patients. Perhaps if more renal biopsies are performed in OLTx patients with chronic renal failure, we might discover that, although CsA/tacrolimus therapy is a definite risk factor for post-transplantation chronic renal failure, other disease processes may also play a significant role.

Roux-en-Y venting jejunostomy in pancreatic transplantation: a novel approach to monitor rejection and prevent anastomotic leak.

INTRODUCTION: Pancreatic transplantation (PTx) with portal venous delivery of insulin and enteric drainage of the exocrine secretion is more physiologic than bladder-systemic (BS) drainage. With portal-enteric (PE) PTx, the diagnosis of acute rejection (AR) requires a percutaneous biopsy. The roux-en-y (RNY) venting jejunostomy in patients with PEPTx offers a novel approach to monitor rejection and prevent anastomatic leaks. METHODS: From January 1996 to December 1998, we performed 17 simultaneous kidney/pancreas transplants (SKPTx). The initial 4 patients underwent BS drainage and the subsequent 13 patients underwent RNY venting jejunostomy with PE drainage. All patients were treated with quadruple therapy. There were 9 males, 14 patients were Caucasian with a mean age of 32 yr (range 30-54 yr), and a mean pre-transplantation duration of diabetes of 25 yr. Six patients underwent endoscopic donor duodenal biopsy through the jejunostomy to rule out clinically suspected AR. Gastrograffin was inserted into the jejunostomy to examine the integrity of anastamosis when indicated. In 9 out of 13 patients, the venting jejunostomy was taken down 9-12 months post-transplantation after allograft function was stable. RESULTS: Actual patient, kidney, and pancreas graft survival rates were 100, 100 and 94%, respectively, after a mean follow-up of 16 months. Renal allografts functioned immediately in 89% of patients. The mean length of hospital stay was 19 d. Four (23%) patients (2 with BS drainage and 2 with PE drainage) suffered an AR episode in the first month, and 4 (23%) patients had five AR from 3-36 months post-transplantation. Other complications were post-operative bleeding in 3 patients, wound infection in 2 patients and a proximal duodenal stump leak in 1 patient. In patients with clinical rejection, endoscopy through the venting jejunostomy showed inflamed, friable doudenal mucosa and doudenal biopsy findings were compatible with AR. CONCLUSION: These preliminary results suggest that RNY venting jejunostomy with PE drainage can be used safely to diagnose and monitor pancreas AR and to diagnose and prevent anastamotic leaks. This technique will be even more useful to visualize transplanted duodenal mucosa, collect pancreatic secretions (amylase) for analysis and perform endoscopic retrograde cholangiopancreatography if needed to obtain pancreatic biopsies.

The use of contaminated donor organs in transplantation.

INTRODUCTION: Organ transplantation has become an accepted means of treating end-stage organ disease in recent years with acceptable patient and graft survival. Transplant recipients have an increased risk of infectious complications due to multiple factors including decreased host resistance from chronic end-stage organ failure as well as from the immunosuppression required to prevent graft rejection. HYPOTHESIS: Therefore, the use of contaminated allografts could result in life-threatening infections in organ recipients. METHOD: In this study, transplant patients receiving organs from donors with positive blood or urine cultures, from 1993 to 1997, were retrospectively reviewed. RESULTS: There was a total of 599 organ donors in our state. Forty-six (7.5%) had positive blood cultures and 25 (4.5%) had positive urine cultures. A total of 179 patients received organs from these contaminated donors, 36 of which were transplanted at our center. In this group, there were 16 kidney, 9 liver, and 11 heart transplants. Both donors and recipients received prophylactic broad-spectrum antibiotics, which were adjusted based on culture and sensitivity results. The most common organisms isolated from the blood were staphylococci followed by streptococci and Gram-negative organisms. Three of the 9 liver transplant patients in the series died with a mortality of 33%. Two of the 3 patients who died had sepsis but the responsible organisms were different from those recovered from the donor. The rest (66%) did well and have acceptable liver function. None of the 16 renal transplant recipients developed an infection and all survived. One patient developed acute irreversible rejection requiring transplant nephrectomy. There was one death in the heart transplant group resulting in a mortality of 9%. This death was not attributed to infectious processes. Three of 11 heart transplant patients grew organisms in the post-operative period that were similar to those found in the corresponding donors. However, no patient suffered significant morbidity or mortality from these infections and all recovered. The recipients of contaminated organs had levels of organ function similar to those of randomly chosen recipients of non-contaminated organs, and both groups had similar lengths of hospital stay. CONCLUSION: Only 3 of 36 organ recipients had infections caused by organisms found in the contaminated donor organs for a rate of 8%. Contaminated donor organs seem to fare as well as non-contaminated donor organs and there was no increase in morbidity or mortality. Contamination of organs should not be an absolute contraindication to the use of these organs in transplantation.

Role of superoxide in hemorrhagic shock-induced P-selectin expression.

Superoxide has been implicated in the regulation of endothelial cell adhesion molecule expression and the subsequent initiation of leukocyte-endothelial cell adhesion in different experimental models of inflammation. The objective of this study was to assess the contribution of oxygen radicals to P-selectin expression in a murine model of whole body ischemia-reperfusion, i.e., hemorrhage-resuscitation (H/R), with the use of different strategies that interfere with either the production (allopurinol, CD11/CD18-deficient or p47(phox)-/- mice) or accumulation [intravenous superoxide dismutase (SOD), mutant mice that overexpress SOD] of oxygen radicals. P-selectin expression was quantified in different regional vascular beds by use of the dual-radiolabeled monoclonal antibody technique. H/R elicited a significant increase in P-selectin expression in all vascular beds. This response was blunted in SOD transgenic mice and in wild-type mice receiving either intravenous SOD or the xanthine oxidase inhibitor allopurinol. Mice genetically deficient in either a subunit of NADPH oxidase or the leukocyte adhesion molecule CD11/CD18 also exhibited a reduced P-selectin expression. These results implicate superoxide, derived from both xanthine oxidase and NADPH oxidase, as mediators of the increased P-selectin expression observed in different regional vascular beds exposed to hemorrhage and retransfusion.

Laparoscopic colon resections: a five-year retrospective review.

In recent years, laparoscopic surgery has become a matter of growing interest. It has been shown that laparoscopic colectomy is well tolerated and safe for benign disease. However, there is some uncertainty about using this method for malignant disease when curative resection is the aim. These uncertainties mainly consist of spread of cancer to port site, long-term survival, and adequacy of resection. The majority of laparoscopic colectomies are technically assisted procedures in which anastomosis is performed outside the abdomen. However, some surgeons are now performing this surgery totally laparoscopically with the anastomosis performed inside the abdomen. Laparoscopic colectomy is currently practiced with great frequency by general surgeons. Its performance requires a steep learning curve and a large number of cases to obtain proficiency. The indications for laparoscopic colectomy are different from one institution to another. In some institutions all patients with colorectal disease are candidates for laparoscopic colectomy and in others it may be limited to benign disease only. The purpose of this review is to analyze all laparoscopic colectomies performed at our medical center since 1992. We conducted a retrospective chart review of both hospital and clinic charts of patients who underwent colectomies at our hospital. A total of 338 patient charts were reviewed. In a comparison of both laparoscopic (n = 285) and converted (n = 53) methods, the age and operative time were about the same. Age average and operating room time average were similar for both groups. With laparoscopy, there was a 3-day drop in length of hospital stay as well as a 1-day-earlier regaining of bowel function. Hospital cost dropped 5000 dollars average for the laparoscopic colectomy. The conversion rate at our center was 15 per cent. Complication rates were lower in the laparoscopic group. Recurrence of cancer at the port site (0.7%) was no higher than in the converted group (incisional recurrence, 1.8%). We conclude that laparoscopic colectomy does show an improvement in return of bowel function, hospital cost, and shorter hospital stay. Long-term follow-up will be necessary to determine the effectiveness of laparoscopic colon resection for colorectal cancer.