Graft Loss and Poor Outcomes After Living-Donor Liver Transplantation Owing to Arterioportal Shunts Caused by Liver Needle Biopsies

Background

Arterioportal shunts (APS) are well-known critical complications after liver transplantation (OLT). The aims of this study were to assess the frequency and causes of APS after OLT and to analyze APS patients with poor outcomes.

Patients

We evaluated 1415 OLT recipients retrospectively investigating APS cases.

Results

APS were detected in at least 9 patients (0.6%). All patients with APS had a history of posttransplant invasive procedures; percutaneous transhepatic cholangio drainage (n = 6) or needle biopsy (LNB; n = 3). Two patients with poor outcomes showed proximal APS caused by LNBs. The other 7 patients with distal APSs, showed stable conditions. Imaging findings in the 2 proximal APS patients revealed drastic changes in graft hemodynamics. Although they finally underwent re-OLT, their outcomes were poor, owing to fatal complications associated with advanced collaterals.

Conclusion

We concluded that even careful LNBs can cause APS at unexpected points. Earlier, more aggressive treatments are required, especially for proximal APS patients.     

Wound Infection Following Stoma Takedown: Primary Skin Closure versus Subcuticular Purse-string Suture

Background  

Stoma closure has been associated with a high rate of surgical site infection (SSI) and the ideal stoma-site skin closure technique is still debated. The aim of this study was to compare the rate of SSI following primary skin closure (PC) versus a skin-approximating, subcuticular purse-string closure (APS).     

Radiographic and clinical assessment on the accuracy and complications of C1 anterior lateral mass and C2 anterior pedicle screw placement in the TARP-III procedure: a study of 106 patients

Purpose

To investigate the (1) radiographic and clinical accuracy of C1 anterior lateral mass screw (C1ALMS) and C2 anterior pedicle screw (C2APS) placement in the transoral atlantoaxial reduction plate (TARP)-III procedure, (2) screw insertion-associated clinical complications and (3) fusion status between C1 and C2.

Methods

Radiographic and clinical data were obtained from the electronic medical record system. Studies were carried out to assess the accuracy of C1ALMS and C2APS placement, the screw insertion-associated clinical complications and the fusion status between C1 and C2. Placement of the screws was assessed using the modified All India Institute of Medical Sciences outcome-based classification.

Results

Two-hundred and twelve C1ALMS and 207 C2APS in 106 patients were assessed. The ideal accurate rates were 92.0 % (195) and 53.1 % (110), and the acceptable accurate rates were 97.6 % (207) and 87.0 % (180), respectively. One patient died postoperatively due to C2 screw misplacement. There were no symptoms of neurologic and vertebral artery injuries in the rest of the patients. 102 patients (97.1 %) achieved solid fusion between C1 and C2. No instrumentation failure due to delayed union or nonunion was observed.

Conclusion

C1ALMS placement in TARP-III procedures appears to be safe. The cortical breach rate of C2APS is high though clinically the neurovascular complication rate is similar to that of posterior atlantoaxial procedures. Advanced navigation strategies may help improve the accuracy of C2APS placement and decrease potential complications.     

Is a gradual reduction of stiffness on top of posterior instrumentation possible with a suitable proximal implant? A biomechanical study

Background Context

Proximal junctional kyphosis (PJK) is a challenging complication after rigid posterior instrumentation (RI) of the spine. Several risk factors have been described in literature so far, including the rigidity of the cranial aspect of the implant.

Aging exaggerates the blood glucose response to total parenteral nutrition

Objective

To determine the effect of age on the blood glucose and insulin responses to a clinical model of glucose loading (i.e., total parenteral nutrition [TPN] with hypertonic glucose), in patients with a variety of conditions.

Design

A prospective cohort study.

Setting

An adult university hospital.

Patients

Seventy-one consecutive, clinically stable patients receiving central TPN, excluding those with metabolic disease or receiving relevant medications.

Intervention

None.

Main Outcome Measures

Serum levels of glucose, insulin, C-peptide and cortisol determined in peripheral venous blood obtained immediately before initiating TPN and again 48 to 96 hours later; acute physiology score (APS) and habitual level of physical activity (HAL).

Results

Serum levels of glucose, insulin and C-peptide increased following initiation of TPN (all p < 0.001). The serum glucose level during TPN administration increased as a function of both patient age and severity of illness (APS) (r² = 0.37, all p < 0.01), whereas the serum insulin level was inversely related to age and increased as a function of serum glucose, glucose rate of infusion and HAL (r² = 0.57, all p < 0.05). The serum C-peptide:insulin molar ratio did not vary with age.

Conclusions

Aging and severity of illness interact to exaggerate the increases in blood glucose that accompany TPN with hypertonic glucose. Serum insulin responses to TPN decline with aging, likely reflecting reduced insulin secretion. Diminished insulin responses may contribute to hyperglycemia and represent a diminished anabolic signal in such patients. The acutely ill elderly patient is predisposed to hyperglycemia and should be monitored carefully even when pre-TPN blood glucose values are normal.     

Impact of Lap-Band Size on Weight Loss: Does Gender Matter?

Background

Laparoscopic adjustable gastric band (LAGB) has gone through major design modifications to improve clinical endpoints and reduce complications. Little is known, however, about the effects of LAGB size on clinical outcomes, or whether outcomes differ based on gender. We set out to examine the impact of band size on surgical weight loss, reoperations, comorbidity resolution, and compare outcomes within gender.

Methods

We reviewed our prospectively collected longitudinal bariatric database between 2008 and 2010, and compared patients with BMI 35?C50?kg/m² who had undergone LAGB with the LAP-BAND? APS to those who had the larger APL. Those patients with initial BMI?>?50?kg/m² were excluded to reduce any possible selection bias which favors larger band use in such subjects.

Results

Three hundred ninety-four patients met our inclusion criteria; 230 (58?%) in the APS group and 164 (42?%) in the APL group. Female patients in APS group experienced significantly higher percentage excess body weight loss at 6?months, 1?year, and 2?years in comparison to female patients in APL group (p?Conclusions Male patients might benefit from APL bands, in contrast to female patients who appear to experience superior weight loss with the smaller APS bands. This study provides the first set of evidence to facilitate surgical decision making for band size selection and highlights differences between genders.     

Vorbestehender Schmerz als Komorbidität im postoperativen Akutschmerzdienst

Background

Pre-existing or chronic pain is a relevant risk factor for severe postoperative pain. The prevalence of pre-existing and chronic pain in hospital depends on the time definition used and is approximately 44 % and 33?%, at 3 or 6 months, respectively. The aim of this study was to determine the prevalence and importance of pre-existing pain in patients treated by a postoperative acute pain service (APS) and to evaluate the requirements for treatment and resources as well as its quality in this context.

Material and methods

This study involved an evaluation of all visits by the APS of the University Hospital in Göttingen over an 8-week period including patient subjective quality assessment on the basis of the quality improvement in postoperative pain therapy (QUIPS) questionnaire. Pre-existing pain (>?12 weeks) was assessed by recording patients history of pain by members of the APS. The results from patients with and without pre-existing pain were compared.

Results

A total of 128 patients (38?% female, 62?% male, aged 15-88 years old, mean age 59.8?±?14.4 years) were seen by the APS on 633 occasions. Of these patients 91?% had been admitted to hospital for surgery (66?% for tumor surgery, 8?% joint replacement, 9?% other joint surgery and 16?% other interventions), 50?% had acute postoperative pain without pre-existing pain, 50?% had had pre-existing pain for at least 12 weeks, 31?% had chronic non-cancer pain and 19?% pain possibly related to cancer. Patients with pre-existing pain showed no significant differences in the treatment requirements (e.g. adjustment of medication), use of resources (e.g. number of visits to the APS and time spent in hospital) and quality of care (e.g. pain intensity, functional aspects, side effects and complications) in the setting of the APS. However, there was an additional subsequent support by chronic pain and palliative care services.

Conclusion

Pre-existing pain is a common comorbidity in surgery patients treated by the APS. There were no significant differences in treatment requirements and quality of care between the patients. This is in contrast to other studies of postoperative pain management which showed that patients with pre-existing postoperative pain had higher pain intensity. This indicates indirectly that the presence of pre-existing pain should be further evaluated as a potentially useful indication for the support by an APS. However there is an urgent need for further studies to clarify whether this indirect effect can be replicated at other hospitals or in other patient collectives. Also it has to be clarified what benefits pain patients have from this kind of treatment: if they benefit from the APS in general or from the special technique, if there is a long-term effect lasting beyond treatment in the APS or if this group of patients would benefit in general from multiprofessional and non-invasive concepts of acute pain treatment.     

What to expect postoperatively with respect to head tilt in congenital scoliosis

Purpose  

To evaluate the effect of a vertical expandable prosthetic titanium rib (VEPTR) on head tilt in patients with congenital scoliosis.     

Long gap esophageal atresia: an Australian experience

Background

The diagnosis of long gap esophageal atresia (LGEA) may preclude immediate primary anastomosis. We reviewed our experience with this entity for a period of 10 years.

Methods

A retrospective review was undertaken of the medical records of all patients managed for esophageal atresia (EA)/tracheoesophageal fistula (TEF) during the period from 1991 to 2001 at the Children's Hospital at Westmead, Sydney, Australia. Esophageal atresia was defined as long gap when primary repair was considered technically impossible by the surgeon. Also, a questionnaire was sent to all the general pediatric surgeons in Australia to explore their attitude toward LGEA management.

Results

One hundred three patients with EA were managed for that period, 17 (16%) of them were defined as LGEA, with mean gap of 5 cm (SD, 1cm). Eight patients (47%) had TEF. Sixteen patients had gastrostomy tube (GT) insertion at a mean age of 4 days. Six patients had esophagostomy at a mean age of 27 days. Thirteen patients had EA repair at a mean age of 146 days. Four patients died before repair and 2 after repair secondary to associated anomalies. Fifty percent of Australian Pediatric Surgeons (APS) responded to the questionnaire. Forty percent defined LGEA as a gap more than 3 to 4 vertebral bodies, whereas 24% considered the absence of TEF as an indication of LGEA. Fifty-six percent of APS will measure the gap on preoperative chest x-rays, and 80% will assess the gap at thoracotomy for ligation of TEF. Ninety-two will measure the gap by inserting a bougie into the upper pouch and into the lower esophagus via the GT. If LGEA was diagnosed, all APS will perform GT with delayed repair. Seventy-two percent of APS will attempt delayed primary repair within 3 to 6 months of age. Seventy-six percent will perform hiatal dissection, and 48% will use upper pouch myotomies. Forty-eight percent will perform gastric pull up, and 32% will use gastric tube for esophageal replacement.

Conclusions

Long gap esophageal atresia represents a surgical challenge. Mortality rate is high secondary to associated anomalies. There is no consensus among APS regarding the definition of LGEA. In general, the consensus of APS would be that the preservation of the patient's own esophagus should be attempted before considering the use of an esophageal replacement.     

Increased incidence of postoperative infections during prophylaxis with cephalothin compared to doxycycline in intestinal surgery

Background

The Acute Physiology and Chronic Health Evaluation (APACHE) III prognostic system has not been previously validated in patients admitted to the intensive care unit (ICU) after orthotopic liver transplantation (OLT). We hypothesized that APACHE III would perform satisfactorily in patients after OLT

Methods

A retrospective cohort study was performed. Patients admitted to the ICU after OLT between July 1996 and May 2008 were identified. Data were abstracted from the institutional APACHE III and liver transplantation databases and individual patient medical records. Standardized mortality ratios (with 95% confidence intervals) were calculated by dividing the observed mortality rates by the rates predicted by APACHE III. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow C statistic were used to assess, respectively, discrimination and calibration of APACHE III.

Results

APACHE III data were available for 918 admissions after OLT. Mean (standard deviation [SD]) APACHE III (APIII) and Acute Physiology (APS) scores on the day of transplant were 60.5 (25.8) and 50.8 (23.6), respectively. Mean (SD) predicted ICU and hospital mortality rates were 7.3% (15.4) and 10.6% (18.9), respectively. The observed ICU and hospital mortality rates were 1.1% and 3.4%, respectively. The standardized ICU and hospital mortality ratios with their 95% C.I. were 0.15 (0.07 to 0.27) and 0.32 (0.22 to 0.45), respectively. There were statistically significant differences in APS, APIII, predicted ICU and predicted hospital mortality between survivors and non-survivors. In predicting mortality, the AUC of APACHE III prediction of hospital death was 0.65 (95% CI, 0.62 to 0.68). The Hosmer-Lemeshow C statistic was 5.288 with a p value of 0.871 (10 degrees of freedom).

Conclusion

APACHE III discriminates poorly between survivors and non-survivors of patients admitted to the ICU after OLT. Though APACHE III has been shown to be valid in heterogenous populations and in certain groups of patients with specific diagnoses, it should be used with caution – if used at all – in recipients of liver transplantation.     

Clinical and prognostic significance of antinuclear antibodies in primary antiphospholipid syndrome: A multicenter retrospective study

IntroductionThe antiphospholipid syndrome (APS) (1) is defined by the development of vascular thrombosis, or pregnancy morbidity in the presence of persistent antiphospholipid antibodies (aPL). Antinuclear antibodies (ANA) can be detected in primary APS patients without any clinical systemic autoimmune disease. The presence of ANA antibodies could confer a specific phenotype in primary APS.ObjectiveTo evaluate the characteristics of APS patients with antinuclear antibodies without other autoimmune disease (ANA positive APS patients) in comparison with primary APS without ANA or secondary APS patients with associated systemic lupus erythematosus (SLE).MethodsClinical and biologic data from 195 APS were retrospectively collected and patients were classified as primary APS with positive ANA (ANA-positive APS), primary APS without any ANA (ANA-negative APS), and SLE-associated APS (SLE-APS).ResultsFourty patients (21%) were classified into ANA-positive APS group, 77 (39%) in ANA-negative APS and 78 (40%) in SLE-APS. In ANA-positive APS patients, 20 patients (51%) had arterial thrombosis, 14 (41%) had veinous thrombosis and 19% had obstetrical complications. There was no difference between the three groups for the frequency of thrombotic manifestations and obstetrical complications. ANA-positive APS patients had more non-criteria manifestations than ANA-negative APS (48% versus 25%; P ≤ 0.01). ANA-positive APS had more triple aPL positivity (59% versus 18%; P < 0.001) and more thrombosis and obstetrical recurrences (63% versus 36%; P < 0.01) in comparison with ANA-negative APS patients. ANA-positive APS had more triple aPL positivity than SLE-APS patients (54% versus 33%; P < 0.05). ANA-positive APS and SLE-APS patients had similar clinical manifestations, and recurrences. Despite a limited follow-up (28 months (11–50)) none of the ANA-positive APS develop SLE. Antiplatelet and anticoagulant therapies were similar for the three groups. SLE-APS patients received more immunomodulatory therapies.ConclusionANA positivity in patients with APS enables to individualize a subset of patients with a more severe phenotype. Whereas the ANA positivity does not seem to be associated with the risk to develop SLE, prospective studies with a longer follow-up are necessary, in particular to evaluate the effect of additional therapies in this subset of APS.     

Injections of Botulinum Toxin A into the detrusor to treat neurogenic detrusor overactivity secondary to spinal cord injury

Background  

To present a comprehensive experience of botulinum toxin A (BTX-A) injected into the detrusor muscle in patients with spinal cord injuries (SCI) causing neurogenic detrusor overactivity.     

Proanthocyanidin to prevent formation of the reexpansion pulmonary edema

Background  

We aimed to investigate the preventive effect of Proanthocyanidine (PC) in the prevention of RPE formation.     

Laparoscopic conversion of Roux-en-Y gastric bypass to biliopancreatic diversion

Background  

This report describes the laparoscopic conversion of a Roux-en-Y gastric bypass (RYGBP) to biliopancreatic diversion (BPD).     

Dysphagia and Gastroesophageal Junction Resistance to Flow Following Partial and Total Fundoplication

Background  

Esophageal peristalsis and basal gastroesophageal junction (GEJ) pressure correlate poorly with dysphagia.     

How to Avoid Postoperative Liver Failure: A Novel Method

Background  

Postoperative liver failure (PLF) is the most feared and severe complication after extensive liver resections.     

Radiographic and Histologic Response to Neoadjuvant Radiotherapy in Patients With Soft Tissue Sarcoma

Background  

Limited data exist regarding the radiographic and histologic response of soft tissue sarcoma (STS) to neoadjuvant radiotherapy (RT).     

Colonic manometry via appendicostomy shows reduced frequency, amplitude, and length of propagating sequences in children with slow-transit constipation

Background/Purpose

We wish to define colonic motor function in children with slow-transit constipation (STC) using manometry catheters introduced through appendiceal stomas, previously sited for controlling fecal retention by colonic irrigation.

Methods

We undertook 24-hour pancolonic manometry of 6 children (5 boys; mean, 11.5 years; SD, 3.0) using a multilumen silastic catheter. Results were compared to nasocolonic motility studies obtained in healthy young adults.

Results

Antegrade propagating sequences (APSs) originated less frequently in the cecum compared to controls. There were fewer APS (mean ± SEM: STC, 13 ± 6 per 24 hours; controls, 52 ± 6 per 24 hours; P < .01) and high-amplitude propagating contractions (HAPCs: STC, 5 ± 2 per 24 hours; controls, 9.9 ± 1.4 per 24 hours; P < .05). The amplitude of APS and HAPC was less in STC (APS, 39 ± 9 mm Hg; controls, 54 ± 3 per 24 hours; P < .05) (HAPC: STC, 94 ± 10 mm Hg; control, 117 ± 3 mm Hg; P < .01), whereas the amplitude of retrograde propagating sequences was greater in STC (43 ± 6 mm Hg; control, 27 ± 1 mm Hg; P < .01). The distances propagated by HAPC were significantly less in STC (36 ± 4.5 vs 47 ± 2.3 cm, controls; P < .05), and there was no evidence of a region-specific difference in propagation velocity of APS. Neither meal ingestion nor waking significantly increased colonic motor activity in patients with STC.

Conclusions

Despite the small numbers available to be studied, we found that children with STC in whom an appendicostomy had been placed show significant abnormalities in pancolonic motor function.     

Pain assessment by pupil dilation reflex in response to noxious stimulation in anaesthetized adults

Background

In response to noxious stimulation, pupillary dilation reflex (PDR) occurs even in anaesthetized patients. The aim of the study was to evaluate the ability of pupillometry with an automated increasing stimulus intensity to monitor intraoperative opioid administration.

Methods

Thirty‐four patients undergoing elective surgery were enrolled. Induction by propofol anaesthesia was increased progressively until the sedation depth criteria (SeD) were attained. Subsequently, a first dynamic pupil measurement was performed by applying standardized nociceptive stimulation (SNS). A second PDR evaluation was performed when remifentanil reached a target effect‐site concentration. Automated infrared pupillometry was used to determine PDR during nociceptive stimulations generating a unique pupillary pain index (PPI). Vital signs were measured.

Results

After opioid administration, anaesthetized patients required a higher stimulation intensity (57.43 mA vs 32.29 mA, P < .0005). Pupil variation in response to the nociceptive stimulations was significantly reduced after opioid administration (8 mm vs 28 mm, P < .0005). The PPI score decreased after analgesic treatment (8 vs 2, P < .0005), corresponding to a 30% decrease. The elicitation of PDR by nociceptive stimulation was performed without changes in vital signs before (HR 76 vs 74/min, P = .09; SBP 123 vs 113 mm Hg, P = .001) and after opioid administration (HR 63 vs 62/min, P = .4; SBP 98.66 vs 93.77 mm Hg, P = .032).

Conclusions

During propofol anaesthesia, pupillometry with the possibility of low‐intensity standardized noxious stimulation via PPI protocol can be used for PDR assessment in response to remifentanil administration.     

Effect of co-transplantation of mesenchymal stem cells and hematopoietic stem cells as compared to hematopoietic stem cell transplantation alone in renal transplantation to achieve donor hypo-responsiveness

Introduction  

We evaluated donor hypo-responsiveness in renal allograft recipients to donor adipose tissue-derived mesenchymal stem cell (h-AD-MSC) +hematopoietic stem cell transplantation (HSCT) vs. HSCT alone.