Rescue therapy with tacrolimus in simultaneous pancreas/kidney transplantation

Tacrolimus has been effective both in primary and rescue therapy following steroid and OKT3-resistant acute rejection in liver and kidney transplantation. Due to the effects of tacrolimus on glucose metabolism, there has been concern about its use in simultaneous pancreas/kidney transplantation. We report on the results of six patients (three female, three male, age 35.2 ± 7.3 years) converted from cyclosporin A to tacrolimus following simultaneous pancreas/kidney transplantation in steroid-resistant acute rejection. Tacrolimus was induced 2.8 ± 1.7 months (range 1–4.8 months) after transplantation; follow-up was 3–18 months. Following conversion, creatinine levels declined in all patients [3.5 ± 1.2 mg/dl before conversion, 3.0 ± 1.9 mg/dl (n = 6) at three months, 1.4 ± 0.1 mg/dl at 1 year (n = 3)]. Before conversion, fasting blood glucose levels averaged 154 ± 33 mg/dl, with three patients receiving insulin. Three months later no patient required insulin, the mean glucose level being 107 ± 23 mg/dl (n = 6); at 1 year it was 92 ± 9 mg/dl (n = 3). One patient lost his pancreatic graft after 4 months due to a mycotic aneurysm. We conclude that conversion to tacrolimus is a safe and effective treatment in cases of steroid-resistant rejections following pancreas/kidney transplantation.     

Peng’s Binding Pancreaticojejunostomy After Pancreaticoduodenectomy: A French Prospective Study

Background

Pancreatic fistula (PF) is the single most important complication after pancreaticoduodenectomy. Recently, a 0% rate of PF was reported using a binding pancreaticojejunostomy with intussusception of the pancreatic stump. The aim of this study was to assess the safety of this new binding pancreaticojejunostomy in condition most susceptible to PF, i.e. soft pancreas and non-dilated main pancreatic duct.

Methods

Forty-five consecutive patients with soft pancreas and non-dilated main pancreatic duct underwent a binding pancreaticojejunostomy. Post-operative PF was defined according to the International Study Group of Pancreatic Fistula.

Results

Four patients (8.9%) developed a PF. In one case, PF developed on post-operative day 3 due to a technical deficiency. In the three other cases, pancreatic fistula developed after the tenth post-operative day; all the patients had local and/or general co-morbidities before PF occurrence.

Conclusions

Binding pancreaticojejunostomy according to Peng is a safe and secure technique that improves the rate of pancreatic fistula, especially in case of soft texture of the pancreas remnant. However, a 0% rate seems to be hard to achieve because other abdominal and general complications are frequent and can lead to secondary leakage of the pancreatic anastomosis.     

Measurement of the vasoconstrictive substances endothelin,angiotensin II,and thromboxane B2 in cold storage solution can reveal previous renal ischemic insults

In a rat model, the left kidney was subjected to 60 min of normothermic ischemia followed by 15 min of reperfusion, whereas the right kidney, serving as a paired control, was not rendered ischemic. Both kidneys were then perfused in situ with either Euro-Collins (EC) solution (n=12) or University of Wisconsin (UW) solution (n=6) for 10 min. Each kidney was then harvested and stored at 4°C in its respective solution. After 24 and 48 h of cold storage, the following vasoactive substances were measured in the preservation media: endothelin (ET), angiotensin II (A-II), thromboxane (B₂) (TxB₂), and prostaglandin I₂ (PGI₂). After 24 h in EC solution, left kidneys uniformly produced significantly higher concentrations of each vasoactive substance than right kidneys: ET 1.64±0.3 pg/ml vs 0.82±0.1 pg/ml (P0.009); A-II 20.8±6.2 pg/ml vs 7.75+2.3 pg/ml (P0.007); TxB₂ 100.8±17.7 pg/ml vs 40.1±11.7 pg/ml (P0.04); PGI₂ 638.3±41.1 pg/ml vs 318.3±36.4 pg/ml (P0.001), respectively. At 48 h, a similar pattern of results was obtained as the kidney continued to produce TxB₂ and prostacyclins during the 24–48 h period. In the UW solution, basal levels of ET and A-II were lower than those in EC solution, but similarly increased after initial ischemia. At 24 h, the concentrations produced by the left and right kidneys were as follows: ET 0.66±0.1 pg/ml vs 0.48±0.1 pg/ml (P0.14); A-II 10.36±3.7 pg/ml vs 2.14±0.7 pg/ml (P0.006); TxB₂ 178±53 pg/ml vs 52±23.1 pg/ml (P0.001); and PGI₂ 448.3±49 pg/ml vs 323±44.3 pg/ml (P0.01), respectively. After 48 h, the range of concentrations of each substance was similar to that obtained after 24 h. In further studies, the concentrations of ET and A-II were measured in solution previously used to preserve human kidneys (n=7). The mean concentration of ET and A-II in these samples was 3.82±1.14 pg/ml and 21.3±9.2 pg/ml, respectively, whereas in control media both substances were below the limits of detection. These results demonstrate that vasoconstrictive substances can be measured in the preservation media after a kidney has been stored cold and that higher concentrations are found when the organ has been subjected to prior normothermic ischemia. The measurement of these vasoactive substances before transplantation may reveal that the kidney has been subjected to previous ischemic events. Moreover, these vasoactive substances could be involved in the early recovery of renal function after kidney transplantation.     

The unsolved problem of fistula after left pancreatectomy: The benefit of cautious drain management

The aim of the study was to identify factors related to the onset of pancreatic fistula and to define the characteristics of the fistula. The study group was composed of 123 patients who underwent left pancreatectomy since 1996. Pancreatic closure was accomplished by a hand-sewn technique (39 patients) or two kinds of mechanical staplers: Proximate (Ethicon Endo-Surgery, Cincinnati, OH) (46 patients) and Endo-GIA (United States Surgical, Norwalk, CT) (38 patients). Fistula was defined as output greater than 5 ml, with amylase x 5, after day 5. In case of fistula, the drain removal was scheduled at a daily output less than 5 ml. Mortality was 0%, morbidity was 48%, and pancreatic fistula rate was 34%. Fistula rate was 38% after hand-sewn closure, 26% after Proximate, and 39% after Endo-GIA (NS). None of the other factors (separate duct ligation, hand-sewn suture in addition to stapler, spleen preservation, use of pledgetted suture, sex, age, and indication for pancreatectomy) proved to be related to a reduction in the onset of fistula. All fistulas healed spontaneously. Mean fistula duration was 36 days; 92.8% of patients with fistula were discharged with drain. The policy of delayed drain removal allowed a low rate of fistula associated morbidity (16%) and of readmission (4.7%). In conclusion, fistula is an unsolved problem of left pancreatectomy. However, a careful drain management allows a good outcome in patients with fistula.     

Combined whole pancreas and liver retrieval: comparison between Y-iliac graft and splenomesenteric anastomosis

With the recent increase in the number of liver and pancreas transplants being performed in Europe, many groups have found it necessary to develop techniques for the combined harvesting of whole pancreaticoduodenal and liver grafts. To date we have carried out a total of 35 multiorgan procurements including liver, heart, pancreas, and kidneys. In ten cases we reconstructed the arterial supply of the pancreas with an end-to-end anastomosis between the proximal splenic artery and the distal end of the superior mesenteric artery (SMA), and in eight patients we used a donor Y-iliac graft. Patients were monitored postoperatively by determination of BUN, serum creatinine, blood glucose, serum and urinary amylase levels, and Doppler assessment of the graft was carried out at regular intervals. Mean ischemia/prservation time in both groups was 6 h. All simultaneous kidney and pancreas transplants functioned well initially with none of the patients requiring dialysis. All patients were insulin-free immediately after surgery. One patient in the splenomesenteric group developed venous thrombosis of the graft, requiring removal of the gland, but has subsequently been successfully retransplanted. All remaining patients have been insulin-free for 1–14 months. One patient in the Y-iliac group also developed venous thrombosis of the graft, but all remaining patients in this group have been insulin-free for 1–12 months after transplantation. Both groups were comparable in terms of serum creatinine (1.4±1.0 vs 1.5±0.9 mg%), blood glucose (105±15 vs 104±12 mg%), serum amylase (400±106 vs 410±100 IU/l), and urinary amylase (130,000±54,000 vs 100,000±42,000 IU/l). Therefore, we now prefer to use this simpler technique of splenomesenteric revascularization as a first choice for reconstruction of pancreatic grafts.     

Successful closure of gastrocutaneous fistulas using the Surgisis? anal fistula plug

Introduction

Gastrocutaneous fistulas remain an uncommon complication of upper gastrointestinal surgery. Less common but equally problematic are gastrocutaneous fistulas secondary to non-healing gastrostomies. Both are associated with considerable morbidity and mortality. Surgical repair remains the gold standard of care. For those unfit for surgical intervention, results from conservative management can be disappointing. We describe a case series of seven patients with gastrocutaneous fistulas who were unfit for surgical intervention. These patients were managed successfully in a minimally invasive manner using the Surgisis^® (Cook Surgical, Bloomington, IN, US) anal fistula plug.

Methods

Between September 2008 and January 2009, seven patients with gastrocutaneous fistulas presented to Wishaw General Hospital. Four gastrocutaneous fistulas represented non-healing gastrostomies, two followed an anastomotic leak after an oesophagectomy and one following an anastomotic leak after a distal gastrectomy. All patients had poor nutritional reserve with no other identifiable reason for failure to heal. All were deemed unfit for surgical intervention. Five gastrocutaneous fistulas were closed successfully using the Surgisis^® anal fistula plug positioned directly into the fistula tract under local anaesthesia and two gastrocutaneous fistulas were closed successfully using the Surgisis^® anal fistula positioned endoscopically using a rendezvous technique.

Results

For the five patients with gastrocutaneous fistulas closed directly under local anaesthesia, oral alimentation was reinstated immediately. Fistula output ceased on day 12 with complete epithelialisation occurring at a median of day 26. For the two gastrocutaneous fistulas closed endoscopically using the rendezvous technique, oral alimentation was reinstated on day 5 with immediate cessation of fistula output. Follow-up upper gastrointestinal endoscopy confirmed re-epithelialisation at eight weeks. In none of the cases has there been fistula recurrence (range of follow-up duration: 30–59 months).

Conclusions

Surgisis^® anal fistula plugs can be used safely and effectively to close gastrocutaneous fistulas in a minimally invasive manner in patients unfit for surgical intervention.     

Glomerular filtration rate after liver transplantation with a low-dose cyclosporin protocol

Cyclosporin nephrotoxicity is a well-known complication in organ transplantation. In successful liver transplantation, a moderate degree of renal impairment is accepted. Whether this impairment is continuously progressive, stabilizes with time, or is reversible is not known. We have prospectively evaluated the glomerular filtration rate (GFR) using ⁵¹CrEDTA plasma clearance in 29 liver transplant patients (11 males and 18 females) with a mean age of 49 years (range 22–62 years). The ⁵¹CrEDTA plasma clearance measurements were performed preoperatively and at 3, 6, 12, 24, and 36 months after the liver transplantation. All but six patients were given sequential, quadruple drug therapy with antithymocyte globulin, azathioprine, steroids, and cyclosporin. Intravenous cyclosporin was avoided and oral cyclosporin started when renal function was stable. Cyclosporin was started in a dose of 8 mg/kg body weight, aiming at whole blood trough levels (specific monoclonal technique) of 200 g/l in the postoperative period; thereafter, the dosage was rapidly tapered down, aiming at whole blood trough levels of less than 100 g/l at 3 months (1.5–2 mg/kg body weight). From a mean preoperative GFR of 89±3 ml/min per 1.73 m², all patients declined in renal function after transplantation to a mean of 64±4 ml/min per 1.73 m² 3 months after transplantation, and starting in the 3rd month the renal function was stable at about 70% of the preoperative value. No correlations were found between cyclosporin weak level or accumulated cyclosporin dose and renal impairment. We conclude that liver transplantation with cyclosporin immunosuppression will induce renal impairment even if cyclosporin blood levels are carefully monitored and kept low. However, with a low-dose regimen, a progressive decline can be avoided.     

The use of low dose octreotide prophylaxis in pancreatic transplants with enteric drainage. Results of a prospective randomized single center trial

AIM: The aim of this study was to investigate the effect of octreotide in the perioperative course of pancreas transplants drained into the bowel in terms of fistula formation, pancreatitis, hemorrhage and thrombosis, and to compare the results to patients not receiving octreotide in a prospectively, randomized single center trial. PATIENTS AND METHODS: Forty pancreas transplant recipients were prospectively randomized to either receive or not to receive octreotide 0.1 mg subcutaneously at the time of operation and 3x/d there after until post-operative day 7. The incidence of pancreatic leakage from the anastomosis and the content of peritoneal fluid drainage regarding amylase and lipase concentrations collected by abdominal drains were registered on day 0-10. Both groups were comparable for age, sex, onset of diabetes, surgical procedure and immunosuppressive regimen. RESULTS: There were 35 simultaneous pancreas-kidney transplants and five solitary pancreas transplants, two in the octreotide and three in the control group two pancreas after kidney, one pancreas after liver pancreas, one pancreas after simultaneous pancreas kidney transplantation, one pancreas transplant alone. All had enteric drainage. Twenty patients received octreotide and 20 did not. In one patient, receiving octreotide the pancreas had to be removed for septic complications because of an enteric fistula arising from the anastomosis (1/20 = 5%). The incidence in patients on octreotide vs. non-octreotide was 1 vs. 0 for pancreatitis, 2 vs. 3 for hemorrhage, 2 vs. 1 for thrombosis and 2 vs. 0 for pancreatic fistulae resulting in an actual overall 12 months patient survival of 100% in both groups and a pancreas survival of 85% vs. 95%. For primary simulaneous pancreas kidney the pancreas graft survival was 93%. The amylase and lipase concentrations of fluid collections drained into the peritoneum on day 0 to 10 post-operatively indicating pancreatic fistulization was comparable in both groups. CONCLUSION: The use of octreotide following pancreas transplantation did not prevent pancreatic fistula formation from the anastomosis neither from the pancreatic capsule in pancreas transplantation with enteric drainage. Further studies are required to finally evaluate the benefit of this prophylactic treatment.     

Incidence and treatment of pancreatic fistula after simultaneous pancreas kidney transplantation

Background

Simultaneous pancreas and kidney transplantation (SPK) is associated with great postoperative morbidity, including the need for relaparotomy in up to 40% of cases. Because the pancreatic graft is known to be the major cause of the high morbidity, we examined the incidence and treatment of pancreatic fistula (PF) in this retrospective analysis.

Methods

From January 2004 to July 2010, we transplanted 52 pancreas grafts, including 50 SPK, 1 pancreas after kidney, and 1 pancreas transplantation alone. There were 22 female and 30 male patients with an overall mean age of 42.4 ± 7.4 years. The mean duration of diabetes was 27.3 + 8.1 years, mean duration of dialysis was 24.2 ± 28.6 months, and 14 cases were pre-emptive transplantations. All procedures were performed using systemic venous and enteric drainage.

Results

The incidence of clinically relevant PF was 16/52 (30.8%), including 11 (68.8%) that were treated conservatively with a drain. Five patients (31.2%) needed relaparotomy: 2 due to enteric leakage, 2 due to acute abdominal pain with graft pancreatitis observed at laparotomy, and 1 due to acute hemorrhage. In 3 cases, graft pancreatectomy was necessary. Comparing the patients with (PF+) versus without (PF−) fistulas, there was no significant difference in cold ischemia time (10.9 ± 2.6 hours vs 10.4 ± 4.4 hours; P = .633), donor age. We found a significantly higher peak C-reactive protein (CRP) level in the patients with pancreatic fistula (3661.4 ± 3474.8 U/L vs 821.8 ± 1293.7 U/L, P = .022). The lipase concentration measured in the drainage fluid postoperatively showed a significant difference between the 2 groups (3661.4 ± 3474.8 U/L vs 821.8 ± 1293.7 U/L; P = 0.006). Also, the amylase concentration was higher in the PF+ group (1747.3 ± 3346.7 U/L vs 265.3 ± 254.9 U/L; P = .097). Graft loss occurred in 4/16 cases (25.0%) of PF+ and 7/36 (19.4%) of PF− (P = .719).

Conclusion

The incidence of PF after pancreas transplantation is high and seems to be associated with ischemia-reperfusion injury reflected by peak-CRP. In most cases a conservative treatment is successful. The occurrence of a PF does not significantly impair graft survival.     

Distal pancreatectomy with duct-to-mucosa pancreaticogastrostomy: a novel technique for preventing postoperative pancreatic fistula

Background

Management of the pancreatic remnant after distal pancreatectomy remains a clinically relevant problem and a significant clinical challenge. We evaluated the safety and efficacy of duct-to-mucosa pancreaticogastrostomy for preventing pancreatic fistula development after distal pancreatectomy.

Methods

Twenty-one patients underwent distal pancreatectomy using the duct-to-mucosa pancreaticogastrostomy and the clinical data were collected prospectively. Pancreatic fistula was defined and classified according to the international study group definition.

Results

The median surgical time was 236 minutes, with a median intraoperative blood loss of 250 mL. Morbidity was 5% and mortality was nil. The postoperative pancreatic fistula rate of clinically relevant grade B or C fistulae was 0%, although the biochemical grade A fistula rate was 29%. Delayed gastric emptying developed in only 1 patient (5%).

Conclusions

Duct-to-mucosa pancreaticogastrostomy may be a safe and effective technique for preventing pancreatic fistula development after distal pancreatectomy when performed by experienced surgeons who are skilled in this technique.     

Acute and long-term changes in plasma levels of atrial natriuretic factor in patients with renal replacement therapy

In 14 patients on hemodialysis who received kidney grafts from living related donors, plasma levels of immunoreactive atrial natriuretic factor (Ir-ANF) were determined in a sequence covering the last hemodialysis treatment, the day of transplantation, and a follow-up period of 6–12 months. The geometric mean value before dialysis was 196 pg/ml, the range 32–634. Weight loss during dialysis was 1.5±1.1 kg (mean±SD), but only a nonsignificant reduction in Ir-ANF levels occurred. On the day of transplantation, plasma Ir-ANF levels increased from 143 pg/ml before to 391 post-transplantation (P=0.02, n=12), probably in response to deliberate volume expansion. Post-transplant Ir-ANF levels correlated significantly to diuresis during the first 24 h, which ranged from 3.7 to 17.81 (mean 6.6; r=0.65, P=0.02). On day 2, mean 24 h diuresis decreased to 3.3±1.41. Most patients had reached their true dry weight by day 5, but Ir-ANF levels remained high, the geometric mean being 180 pg/ml. During further follow-up and preserved graft function (GFR range 34–88 ml/min per 1.73 m² body surface area), Ir-ANF levels declined to a geometric mean of 63 pg/ml by 2–6 months and to 36 at 12 months post-transplant. We conclude that plasma Ir-ANF levels are chronically elevated in patients with chronic renal failure but may be further stimulated by acute overhydration. Transplanted kidneys initially respond to the increased levels but adapt within a day. Even with good graft function, normalization of plasma Ir-ANF requires several weeks or months.     

Isoamylase levels in bone marrow transplant patients are affected by total body irradiation and not by graft-versus-host disease

The mean total serum amylase levels in patients was 3.2±0.5 kat/l (±SE) before total body irradiation (TBI) prior to bone marrow transplantation of which 50% was due to pancreatic isoamylase and 50% salivary isoamylase. Total serum amylase increased to a maximum of 100.3±12.3 kat/l on the first day after TBI and most of this increase was due to an increase in salivary isoamylase (90.0±12.1 kat/l). In association with this, all patients had clinical symptoms of parotitis. An increase in pancreatic isoamylase was found in 27% of the patients; however; none of them had clinical symptoms of pancreatitis. Serum amylase levels returned to normal within 5 days after TBI but then decreased to subnormal values, remaining below the normal range for 3 weeks. Pancreatic isoamylase returned to pre-irradiation levels 1.5 months after TBI, while salivary isoamylase remained low for the rest of the observation time. TBI of 7.5 Gy at 26 cGy/min gave significantly lower salivary amylase at 2 days after TBI compared with 10 Gy at 4 cGy/min: 32±4 versus 76±13 kat/l (P<0.05). At 2.5 and 6 months after TBI significantly higher total amylase levels were recorded for patients treated with 7.5 Gy of TBI compared with 10 Gy: 2.5±0.4 and 2.7±0.3 versus 2.0±0.5 and 0.8±0.3 kat/l, respectively (P<0.01, P<0.05, respectively). Acute or chronic GVHD did not affect acinar cells in this investigation.     

Significant arterial complications after pancreas transplantation—A single‐center experience and review of literature

Arterial fistulas and pseudoaneurysms are rarely described significant arterial complications associated with pancreas transplantation that sometimes present with herald or catastrophic bleeding. We herein describe our institutional case series with a focus on management and outcomes. Of 2256 pancreas transplants, 24 arterial complications were identified in 23 recipients. Chart review was performed to describe the clinical characteristics, treatments, and outcomes of the complications (pseudoaneurysm, arterial enteric/cystic/ureteric fistula, or arteriovenous fistula). Of these 23 patients, 57% had a failed allograft at the time of the complication. Nine patients underwent primary surgical repair of 10 complications, 13 were treated by endovascular methods, and one patient by medical management. In total, 3 embolized patients rebled, 2 of which had failed allografts prior to treatment. Of those with graft function that were treated by embolization alone, all retained graft function. Diagnosis of arterial complications requires a high degree of suspicion and should involve early systemic angiography to evaluate the pancreatic vasculature. Management can be endovascular or surgical and should be individualized. We report our center's evolution from a predominantly surgical to endovascular approach as a definitive vs stabilizing therapy, with selective coiling mostly reserved for well‐defined peripheral lesions in patients with a functioning allograft.     

Intraperitoneal drainage after pancreatic resection: a review of the evidence

Background

Despite a growing body of literature supporting the limited use of prophylactic intra-abdominal drainage for many procedures, drain placement after pancreatic resection remains commonplace and highly controversial.

Materials and methods

Literature available in the PubMed was systematically reviewed by searching using combinations of keywords and citations in review articles regarding prophylactic drainage after pancreatic resection, early removal of intraoperatively placed drains after pancreatic resections, and risk factors and predictive tools for pancreatic fistula.

Results

Prospective randomized studies on prophylactic drainage after pancreaticoduodenectomy or distal pancreatectomy have not shown any benefit in decreasing pancreatic fistula, total complications, length of hospital stay, or readmission rates. Frequency of complications was significantly higher in patients receiving routine drainage. This was recently supported by retrospective studies; however, patients with risk factors for pancreatic fistula (soft pancreatic texture, prolonged operative times, and increased blood loss) were more likely to have prophylactic intra-abdominal drainage. Alternatively, if a drain is placed, prospective randomized studies demonstrate that early removal is safe in patients with postoperative day 1 drain amylase values <5000 U/L and associated with a lower rate of fistula.

Conclusions

The current literature supports a strategy of selective drainage and early drain removal after pancreatic resection in low-risk patients.     

Stapler vs suture closure of pancreatic remnant after distal pancreatectomy: a meta-analysis

Background

Suture closure and stapler closure of the pancreatic remnant after distal pancreatectomy are the techniques used most often. The ideal choice remains a matter of debate.

Methods

Five bibliographic databases covering 1970 to July 2009 were searched.

Results

Sixteen articles met the inclusion criteria. Stapler closure was performed in 671 patients, while suture closure was conducted in 1,615 patients. The pancreatic fistula rate ranged from 0% to 40.0% for stapler closure of the pancreatic stump and from 9.3% to 45.7% for the suture closure technique. There were no significant difference between the stapler and suture closure groups with respect to the pancreatic fistula formation rate (22.1% vs 31.2%; odds ratio, .85; 95% confidence interval, .66-1.08), although there was a trend toward favoring stapler closure. In 4 studies including 437 patients, stapler closure was associated with a trend (not statistically significant) toward a reduction in intra-abdominal abscess (odds ratio, .53; 95% confidence interval, .24-1.15).

Conclusions

No significant differences occur between suture and stapler closure with respect to the pancreatic fistula or intra-abdominal abscess after distal pancreatectomy, though there is a trend favoring stapler closure.     

Stump closure of a thick pancreas using stapler closure increases pancreatic fistula after distal pancreatectomy

Background

The appropriate surgical stump closure after distal pancreatectomy (DP) is still controversial. This study investigated the benefits and risks of stapler closure during DP.

Methods

The risk factors of pancreatic fistulas were investigated in 122 DPs among 3 types of stump closure: hand-sewn suture (n = 32), bipolar scissors (n = 45), and stapler closure (n = 45).

Results

There was no significant difference in the incidence of pancreatic fistula between the 3 types of stump closure (hand-sewn suture [44%] vs bipolar scissors [37.7%] vs stapler closure [35.5%]). By using receiver operating characteristics curves, 12 mm was the best cutoff value of the thickness of the pancreas for pancreatic fistulas after DP using stapler closure. Three factors (ie, male sex, body mass index >25 kg/m², and stapler closure) were independent risk factors of pancreatic fistulas after DP with a pancreas thicker than 12 mm.

Conclusions

A pancreas thicker than 12 mm significantly increased the incidence of pancreatic fistulas after DP using stapler closure.     

C-Reactive Protein on Postoperative Day 1 Is a Reliable Predictor of Pancreas-Specific Complications After Pancreaticoduodenectomy

Background

Postoperative pancreatic fistula and pancreas-specific complications have a significant influence on patient management and outcomes after pancreatoduodenectomy. The aim of the study was to assess the value of serum C-reactive protein on the postoperative day 1 as early predictor of pancreatic fistula and pancreas-specific complications.

Methods

Between 2013 and 2016, 110 patients underwent pancreaticoduodenectomy. Clinical, biological, intraoperative, and pathological characteristics were prospectively recorded. Pancreatic fistula was graded according to the International Study Group on Pancreatic Fistula classification. A composite endpoint was defined as pancreas-specific complications including pancreatic fistula, intra-abdominal abscess, postoperative hemorrhage, and bile leak. The diagnostic accuracy of serum C-reactive protein on postoperative day 1 in predicting adverse postoperative outcomes was assessed by ROC curve analysis.

Results

Six patients (5%) died and 87 (79%) experienced postoperative complications (pancreatic-specific complications: n?=?58 (53%); pancreatic fistula: n?=?48 (44%)). A soft pancreatic gland texture, a main pancreatic duct diameter <?3 mm and serum C-reactive protein ≥?100 mg/L on postoperative day 1 were independent predictors of pancreas-specific complications (p?<?0.01) and pancreatic fistula (p?<?0.01). ROC analysis showed that serum C-reactive protein ≥?100 mg/L on postoperative day 1 was a significant predictor of pancreatic fistula (AUC: 0.70; 95%CI: 0.60–0.79, p?<?0.01) and pancreas-specific complications (AUC: 0.72; 95%CI: 0.62–0.82, p?<?0.01). ROC analysis showed that serum C-reactive protein ≥?50 mg/L at discharge was a significant predictor of 90-day hospital readmission (AUC: 0.70; 95%CI: 0.60–0.79, p?<?0.01).

Conclusions

C-reactive protein levels reliably predict risks of pancreatic fistula, pancreas-specific complications, and hospital readmission, and should be inserted in risk-stratified management algorithms after pancreaticoduodenectomy.

     

Percutaneous drainage of pancreatic fistula following pancreatectomy with CT-fluoroscopic guidance

Purpose

To evaluate the clinical utility of percutaneous drainage of pancreatic fistula following pancreatectomy with real-time CT-fluoroscopic guidance.

α-Human-ANP response to preanesthetic volume expansion and subsequent renal transplantation in diabetic and nondiabetic uremic patients

-Human atrial natriuretic peptide (ANP) concentrations were measured in 11 diabetic patients with uremia and in 16 nondiabetic uremic controls undergoing renal transplantation after preanesthetic volume expansion with 1000 ml saline solution within 10 min. Two diabetic and seven nondiabetic patients received grafts from living donors and the rest from cadaveric donors. Volume expansion induced a significant increase in the cardiac filling pressures (P(0.001), which were kept at that level especially at declamping, which was preceded by mannitol infusion. The baseline mixed venous ANP levels were significantly higher in the diabetic (252±6 pg/ml) than in the nondiabetic group (103±14 pg/ml; P(0.05). In the nondiabetic group, ANP increased to 177±40 pg/ml as a response to volume loading (P(0.05); it was not clearly changed in the diabetic group. Arterial ANP increased from 267±55 to 343±75 pg/ml in the diabetic group (P(0.05) and from 102±17 to 147±31 pg/ml in the nondiabetic group (P(0.05). During transplantation, mixed venous ANP decreased to 125±55 pg/ml in the diabetic and to 80±10 pg/ml in the nondiabetic group (P(0.001). About 30% of circulating ANP was taken up by the transplant irrespective of postoperative graft function. Two patients in each group showed delayed diuresis requiring postoperative dialysis therapy (22% of all cadaveric transplantations). ANP levels at declamping had no correlation to the outcome of kidney function.     

Anal fistula plug and fibrin glue versus conventional treatment in repair of complex anal fistulas

Introduction

High transsphincteric fistulas are difficult to treat because fistulotomy of involved sphincter muscle results in incontinence. We compare our outcomes for anal fistula plug, fibrin glue, advancement flap closure, and seton drain insertion.

Methods

This is a retrospective study of patients treated for high transsphincteric anal fistulas. The primary outcome was full healing at 12 weeks postoperatively.

Results

Between 1997 and 2008, 232 patients with anal fistula were identified in the St. Paul's Hospital Anal Fistula Database. Postoperative healing rates at the 12-week follow-up for the fistula plug, fibrin glue, flap advancement, and seton drain groups were 59.3%, 39.1%, 60.4%, and 32.6%, respectively (P < .0001).

Conclusions

Closure of the primary fistula opening using a biological anal fistula plug and anal flap advancement result in similar fistula healing rates in patients with high transsphincteric fistulae. These 2 strategies are superior to seton placement and fibrin glue. Given the low morbidity and relative simplicity of the procedure, the anal fistula plug is a viable alternative treatment for patients with high transsphincteric anal fistulas.