Intestinal obstruction due to internal hernia following pancreas transplantation

Background

Simultaneous pancreas-kidney transplantation has evolved as the best treatment for type 1 diabetic patients at end-stage renal disease. The surgical complication rate is high, which is an important barrier to the success of this procedure. The frequent complications that require relaparotomies include fistulas, graft thromboses, and intra-abdominal abscesses. Intestinal obstructions after pancreas transplantation due to internal herniation are not common.

Purpose

The objective of this article was to review the literature about this problem and describe our personal experience in pancreas transplantation.

Methods

We examined the cases of small bowel obstruction secondary to an internal hernia after following 292 pancreas transplantations in our center from 2000 to 2009 as well as performed a Medline literature review.

Results

Only 2 articles described the diagnosis and treatment of internal hernias after pancreas transplantation. However, both contribution were from the same center reporting the same 3 cases, with surgical versus radiologic perspectives. We have described our 2 cases of young pancreas-kidney transplant patients who presented with acute intestinal obstruction due to internal hernia.

Conclusion

Although internal hernias are rare, they are potentially fatal and difficult to diagnose when they occur after pancreas transplantation. Detection with early surgery demands a high degree of clinical vigilance.     

Hyperdynamic Circulation in Acute Liver Failure: Reperfusion Syndrome and Outcome Following Liver Transplantation

Background/aims

Liver transplantation (OLT) is a valid therapeutic option for patients with fulminant hepatic failure (FHF). The most critical phase during OLT is considered to be graft reperfusion, where in large changes in patient homeostasis occur. The aims of the present study were to evaluate the hemodynamic and cardiac changes among a large series of patients with FHF, to determine independent clinical predictors of the occurrence of postreperfusion syndrome (PSR) and its relationship to clinical and hemodynamic parameters and transplant outcomes.

Methods

Systemic hemodynamic and cardiac functions were evaluated by Swan-Ganz catheterization in 58 patients before OLT. The patients were divided into two subgroups on the basis of PSR, which was defined as a mean arterial blood pressure 30% lower than the immediate previous value lasting for at least 1 minute within 5 minutes after unclamping.

Results

PSR occurred in 24 patients (41%). Significant differences upon bivariate analysis was observed for the Model for End-stage Liver Disease score, which was significantly higher among patients with PSR, namely 32 (range = 18-43) versus 23 (range = 12-32) (P = .001). Higher serum creatinine values were significantly different among patients with PSR: 1.4 (range = 1.2-2.2) versus 2.1 (range = 2.5-3.2) mg/dL (P < .01).

Conclusion

Systemic hemodynamic alterations of FHF progressively worsen with increasing severity of liver disease. PSR developed in approximately 40% of patients; its prevalence was significantly related to the severity of the disease. Finally, patients with renal failure showed greater risk to develop an PSR during OLT.     

New alternatives to the treatment of acute liver failure

Introduction

Acute-on-chronic liver failure (ACLF) is defined as an acute deterioration of a chronic liver disease. The most effective treatment in these patients is orthotopic liver transplantation (OLT), which is highly limited by the donor shortage. The aim of this study was to increase the usefulness of hepatocyte transplantation (HT) as a bridge or alternative to OLT.

Methods

During the last 2 years, we have performed HT in 3 patients with ACLF. The diagnosis was graft cirrhosis due to hepatitis C virus in 2 of them, who were already included on waiting lists for retransplantation, and the third, unknown alcoholic cirrhosis.

Results

After the first HT infusion, we observed an improvement in the clinical condition in all patients, hyperammonemia, and a partial correction of the degree of encephalopathy; 1 patient was retransplanted 6 days after the first HT.

Discussion

The main indications for HT are inborn errors of metabolism in children. Other indications especially in adults, are acute liver failure, ACLF in patients with end-stage-liver disease who are a waiting OLT, and acute liver failure after an hepatectomy. HT may be a new treatment to improve the clinical condition in patients awaiting OLT.     

Early decisions in perforated appendicitis in children: lessons from a study of nonoperative management

Background

In nonoperative management of perforated appendicitis, some children do not respond to treatment. This study sought early identifiers of failure to help in surgical decision making.

Methods

Fifty-eight patients with computed tomographic (CT)-proven perforated appendicitis were treated according to a nonoperative protocol. Patients who recovered were considered “successes;” those who did not improve underwent appendectomy and were scored as “failures” of nonoperative treatment.

Results

Thirty-six (62%) of 58 patients responded to treatment and 22 (38%) failed. Three parameters distinguished the 2 groups: the number of band forms on the admission white blood cell count, the body temperature response after 24 hours of treatment, and the areas of the abdomen involved in the CT scan. Patients in whom nonoperative treatment failed stayed in the hospital longer (17 vs 9 days) and had more complications (46% vs 0%).

Conclusions

Because failure of nonoperative management is associated with a high complication rate, it is important to make an early decision about appendectomy. Persistence of fever after 24 hours of treatment, bandemia on admission, and multisector involvement on CT scan identify most patients who fail nonoperative management. When combined with clinical judgment, these are useful indicators to guide early decisions.     

Murine pancreatic duct ligation induces stress kinase activation, acute pancreatitis, and acute lung injury

Background

Acute lung injury is a major determinant of outcomes in acute pancreatitis. We evaluated acute lung injury and stress kinase activation in ligation-induced acute pancreatitis in mice.

Methods

Mice with duct ligation or sham operation were killed after 24 or 48 hours.

Results

In addition to acute pancreatitis, duct ligation was associated with pulmonary morphologic changes indicative of acute lung injury (alveolar septal thickening, congestion, and neutrophil infiltration). Furthermore, immunoblotting showed stress kinase activation in the pancreas and lung after ligation. Although mortality was observed in the ligated group, that is consistent with severe lung injury, it requires further evaluation.

Conclusions

Bile and pancreatic duct ligation in the mouse is associated with pancreatic and pulmonary stress kinase activation and acute inflammatory changes consistent with early acute pancreatitis and acute lung injury. Our findings are important as acute lung injury increases mortality in clinical acute pancreatitis and stress kinases are established proinflammatory signal transducers.     

The optimal initial management of children with suspected appendicitis: a decision analysis

Background/purpose

As abdominal imaging has improved, the use of computed tomography (CT) and ultrasonography (US) for evaluating children with suspected appendicitis has increased. The purpose of this study was to determine the optimal management strategy for evaluating children with suspected appendicitis given the current accuracy of abdominal imaging.

Methods

Decision analysis was used to evaluate 5 management strategies: discharge, observation, CT, US, and appendectomy. Probabilities and time variables were obtained from publications and a chart review. Each approach was evaluated for its impact on length of stay, hospital charges, cost effectiveness and its capacity to minimize perforation and avoid negative appendectomy (risk-benefit).

Results

Discharge was preferred when the probability of appendicitis was low (<0.09 to <0.47), imaging when in an intermediate range and surgery when high (>0.61 to >0.91). A role for observation was found only when the anticipated time of inpatient observation was brief (<9 hours). Although CT was more expensive than US, CT was more cost effective for preventing negative appendectomy and perforation and achieved a better risk-benefit.

Conclusions

CT has an important role in the management of suspected appendicitis. Among children with a low or high likelihood of appendicitis, the cost of imaging tests required to prevent the complications of appendicitis is high.     

Bacterial translocation and infected pancreatic necrosis in acute necrotizing pancreatitis derives from small bowel rather than from colon

Background

The clinical course of acute necrotizing pancreatitis (ANP) is determined by the superinfection of pancreatic necrosis. To date, the pathophysiology of the underlying bacterial translocation is poorly understood. The present study investigated the bacterial source of translocation.

Methods

A terminal loop ileostomy was applied in rats. Selective digestive decontamination (SDD) of either the small bowel or the colon was performed. After 3 days of SDD, severe ANP was induced. At 24 hours, bacterial translocation was assessed by cultures of bowel mucosa, mesenteric lymph nodes, and pancreas using a scoring system (0-4).

Results

Without SDD, pancreatic infection was present in all cases with an average score of 2.67. Colon SDD reduced pancreatic superinfection to 1.67 (not significant). SDD of the small bowel significantly reduced superinfection to 1.0 (P < .005).

Conclusions

Bacterial translocation from the colon is less frequent than translocation from the small bowel. Thus, the small bowel seems to be the major source of enteral bacteria in infected pancreatic necrosis.     

Congenital biliary dilatation may consist of 2 disease entities

Background/Purpose

This study aims to establish the possible mechanisms of pathogenesis of congenital biliary dilatation and to classify the disease accordingly.

Methods

Radiologic features of congenital biliary dilatation and pancreaticobiliary malunion in 107 affected children were examined and correlated with laboratory results. Relative lengths/diameters were calculated to provide comparison between children of different ages. Intraluminal pressures of common bile duct (CBD) were measured intraoperatively.

Results

The minimal relative diameters of distal CBD negatively correlated with the maximal relative diameters/lengths of dilated CBD, the maximal relative diameters of common hepatic duct, and left/right hepatic ducts. The intraluminal pressure in patients with a stenotic distal CBD (stenotic group) was significantly higher than that in patients with a nonstenotic distal CBD (nonstenotic group). The narrower the distal CBD, the more deranged the liver function. Conversely, serum/bile amylase levels were more elevated in the nonstenotic group. Common channel protein plugs were only found in the nonstenotic group, whereas common hepatic duct strictures, intrahepatic duct dilatations, and calculi were detected more frequently in the stenotic group.

Conclusion

We propose to categorize congenital biliary dilatation into 2 subgroups: (1) cystic type with stenotic distal CBD associated with deranged liver function and common hepatic duct stricture and (2) fusiform type with nonstenotic distal CBD associated with pancreatitis and common channel protein plugs. Different underlying pathologies of each group require different operative strategies.     

Long-term follow-up of children with extrahepatic portal vein obstruction: impact of an endoscopic sclerotherapy program on bleeding episodes, hepatic function, hypersplenism, and mortality

Background

Endoscopic sclerotherapy (ES) has been the standard treatment for children with idiopathic extrahepatic portal vein obstruction (EHPVO). Portosystemic shunts are indicated when variceal bleeding cannot be controlled by ES. Recently, mesenteric left portal vein bypass was indicated as a surgical intervention and preventative measure for hepatic dysfunction in children with long-term EHPVO. Nevertheless, there is a lack of published data confirming the extent of hepatic dysfunction, hypersplenism, and physical development in children with long-term follow-up.

Method

We retrospectively verified the long-term outcomes in 82 children with EHPVO treated with ES protocol, focusing on mortality, control of bleeding, hypersplenism, and consequent hepatic dysfunction.

Results

Of the children, 56% were free from bleeding after the initiation of ES. The most frequent cause of rebleeding was gastric varices (30%). Four patients had recurrent bleeding from esophageal varices (4.6%). Four patients underwent surgery as a consequence of uncontrolled gastric varices. There were no deaths. Most patients showed good physical development. We observed a mild but statistically significant drop in factor V motion, as well as leukocyte and platelet count.

Conclusion

Endoscopic sclerotherapy is an efficient treatment for children with EHPVO. The incidence of rebleeding is low, and there was no mortality. Children develop mild liver dysfunction and hypersplenism with long-term follow-up. Only a few patients manifest symptoms of hypersplenism, portal biliopathy, or liver dysfunction before adolescence.     

Does lymphocyte cross-matching predict acute rejection and graft survival in liver transplantation?

Introduction

The role of lymphocyte cross-matches (LCM) remains controversial in the liver transplant field. The aim of this study was to correlate the risk for acute rejection episodes and graft survival in liver transplantation with pretransplant LCM results.

Patients and Methods

We enrolled 184 adult liver transplantation patients, excluding pediatric and second grafts. The 129 living donor and 55 deceased donor liver transplantations were divided into 2 groups: LCM (+); (n = 20) and LCM (−); (n = 164).

Results

There were no differences in the demographic features, such as gender and recipient age, original disease, Model for End-Stage Liver Disease score, donor type, number of human leukocyte antigen mismatches, and cold ischemia times. There were no hyperacute rejection episodes in the LCM (+) group. Also, posttransplant complications such as acute rejection episode, biliary complication, or hepatic artery thrombosis were not different. Acute rejection episodes occurred in 5.0% of the LCM (+) group and 15.2% of the LCM (−) group (P = .317). Bile duct complications after transplantation arose in 20.0% of the LCM (+) group and in 32.9% of the LCM (−) group (P = .312). The 2 groups showed no difference in graft survival rate analyzed by the Kaplan-Meier method according to LCM results.

Conclusion

Pretransplant LCM results were not associated with overall graft survival or acute rejection episodes in this study.     

Conscious recovery response in post-hepatic transplant as a function of time-related acute hepatic encephalopathy

Background

H Coma due to acute hepatic failure produces a high mortality rate with rapid progression of cerebral edema and brain herniation. Early transplantation increases survival of patients with acute hepatic encephalopathy. In previous studies, scant attention has focused on the conscious recovery time after living donor liver transplantation (ldlt) and whether the conscious recovery time was directly proportional to the length of coma before transplantation.

Patients and methods

We have reported herein three adult patients with decompensated chronic end-stage liver disease who underwent right lobe LDLT. Their general conditions had markedly deteriorated; two patients displayed massive ascites. All three subjects displayed grade IV encephalopathy with endotracheal intubation and intensive care management. Their biochemical data revealed hyperammonemia, marked cholestasis, and coagulopathy.

Results

After LDLT the patients recovered from coma at a mean time similar to that in coma. Preoperatively the patients exhibited acute deep coma with respiratory failure on preoperative days 5, 3, and 1 with consciousness regained on postoperative day 5, 3 and 1, respectively.

Conclusion

We suggest that patients with acute deep coma (grade IV), who were formerly regarded as irreversible, benefit with LDLT, preventing worsening of complications, and that shows a time-dependent recovery the pretransplant comatose status.     

Percutaneous Treatment of Liver Failure and Acute Mesenteric Ischaemia

Introduction

Synchronous embolism to the superior mesenteric artery (SMA) and coeliac axis (CA) is a rare disease.

Report

A 67-year-old man with atrial fibrillation developed acute liver failure due to an embolic occlusion of the CA and SMA, with a severe coagulation disorder. He was successfully managed with percutaneous stent placement and an exploratory laparotomy was not needed. He remains symptom-free 1 year after the procedure, and duplex follow-up showed stent patency.

Conclusion

Endovascular techniques in patients with liver failure, no signs of peritonism, early diagnosis and high operative risk seem feasible and should be used if possible, as first-line option.     

Complications of peptic ulcer disease in children and adolescents: minimally invasive treatments offer feasible surgical options

Purpose

Surgery for complications of peptic ulcer disease (PUD) carries a significant morbidity and even mortality. The aim of this study was to determine the efficacy, safety, and outcome of children and adolescents undergoing minimally invasive treatment of bleeding and perforation complicating PUD.

Methods

One hundred thirty-two consecutive patients aged 6 to 17 years managed endoscopically for bleeding and laparoscopically for perforation from January 1999 to February 2006 were reviewed.

Results

Thirty children had significant endoscopic stigma of recent hemorrhage. Primary endoscopic hemostasis was achieved in most cases except one requiring further endoscopic hemostasis. Seventeen patients with perforation underwent laparoscopic patch repair. Four patients were converted to open repair because of technical difficulty and the large size of the ulcer. All patients had a course of proton pump inhibitors postoperatively. Ninety percent of patients had Helicobacter pylori infestation. Triple therapy was given. Two patients defaulted triple therapy and presented later with recurrent ulcer bleeding. All others remained asymptomatic on follow-up (average, 32.6 months).

Conclusions

Endoscopic hemostasis of bleeding peptic ulcer is effective and safe in children. With stringent criteria, laparoscopic patch repair of perforation can be applied safely to most pediatric patients. Eradication of H pylori and subsequent antiulcer medication are integral in the management of complicated PUD.     

Evaluation of liver function for hepatic resection for hepatocellular carcinoma in the liver with damaged parenchyma

Background

Liver functional parameters, including the Child—Pugh score and indocyanine green clearance (ICG), and volumetric parameters influencing postoperative liver function were evaluated with the aim of obtaining standardardized criteria for selecting patients for, and deciding the extent of, hepatectomy for hepatocellular carcinoma (HCC).

Materials and methods

The study population consisted of 120 patients with HCC undergoing hepatic resection excluding those with more than 3000 ml of intraoperative bleeding. Patients were classified as grades A, B, or C on the basis of, respectively, a Child—Pugh score of 5 or 6, 7-9, or ≥10 and were assigned to group D (postoperative liver dysfunction) or group N (no complication). Postoperative complications included massive ascites, pleural effusion, or hyperbilirubinemia. For each grade, the standardized estimated liver remnant ratio (STELR) was determined as the ratio of the liver remnant volume (estimated by computerized tomography) to the standardized total liver volume (STLV), estimated from the body surface area using the equation: liver volume [cm³] = 706 × body surface area [m²] + 2.4. The ICG retention rate at 15 min after injection (ICGR15) was then plotted against the STELR for each grade and a demarcation line separating patients in groups N and D was determined statistically by discriminant analysis.

Results

For grade A patients, the equation of the demarcation line was ICGR15 = 27.5 × STELR + 1.9 (Wilks’ Lambda: 0.667, P < 0.001), indicating that, for safe hepatic resection in patients with an ICGR15 of 10%, the STELR should be greater than 0.29. In contrast, for grade B patients, the equation was ICGR15 = 72 × STELR − 22.1 (0.589, P < 0.001), indicating that, in patients with a 10% ICGR15, the STELR should be greater than 0.44, a larger value than in grade A patients. The number of grade C patients was too small for analysis.

Conclusions

By combining the Child—Pugh score, ICG clearance, and liver volumetric parameters, criteria for the selection of patients for hepatic resection for HCC were established.     

Hereditary pancreatitis in children: surgical implications with special regard to genetic background

Purpose

Hereditary pancreatitis (HP) is the primary etiology of chronic pancreatitis during childhood, progressing through recurrent episodes of acute pancreatitis and finally leading to pancreatic insufficiencies. Hereditary pancreatitis is because of mutations of the cationic trypsinogen (PRSS1) gene. Some other genes, such as SPINK1 or CFTR, have been associated with familial idiopathic chronic pancreatitis. The aim of our study was to clearly define diagnostic and therapeutic strategies for HP patients, through an analysis of our study group and a review of the literature.

Methods

All children admitted from 1995 to 2007 with a final diagnosis of hereditary pancreatitis were restrospectively included in the study. We analyzed all medical records with special attention given to cases involving genetic screening (PRSS1, SPINK1, and CFTR genes).

Results

Ten children were included. Eight had HP with PRSS1 mutation, 2 of them without a familial history of chronic pancreatitis. The 2 others patients had SPINK1 mutations. Three HP patients were operated on for acute complications of pancreatitis and are well with a mean follow-up of 5.5 years. No patient had pancreatic insufficiencies or weight loss.

Conclusions

Hereditary pancreatitis is associated with severe pancreatitis, with a greater risk of developing pancreatic cancer. It must therefore be diagnosed correctly and treated to prevent its considerable complications.     

Biological Changes After Liver Transplantation According to the Presence or Not of Graft Steatosis

Aim

To assess the consequences of graft steatosis on postoperative liver function as compared with normal liver grafts.

Patients and methods

From January 2005 to December 2007, liver transplant patients were prospectively included, excluding those who experienced arterial or biliary complications or presented acute rejection. All patients had a surgical biopsy after reperfusion. Patients were compared according to the rate of macrovacuolar steatosis: namely above or below 20%.

Results

Fifty-three patients were included: 10 in the steatosis group and 43 in the control group. No significant difference was observed in terms of morbidity, mortality, and primary non- or poor function. Nevertheless, biological changes after the procedure were significantly different during the first postoperative week. Prothrombin time, serum bilirubin, and transaminases were significantly increased among the steatosis group compared with the control group (P < .05).

Conclusion

This case-controlled study including a small number of patients, described postoperative biological changes among liver transplantations with steatosis in the graft.     

Combined Lung and Liver Transplantation—University Hospital Reina Sofia Experience: Two Case Reports

Objective

To analyze the results of combined lung and liver transplantation.

Methods

We performed two combined lung and liver transplantations for patients with cystic fibrosis with chronic respiratory failure accompanied by advanced liver disease. In each case, all thoracic and abdominal organs were obtained from a single donor by means of standard harvest techniques. In the recipient, a two-stage procedure was adopted with completion of the bilateral lung transplantation before the liver operation. Immunosuppression consisted of three-drug therapy used for isolated lung transplantation.

Results

The patients were both boys of 13 and 15 years old. Episodes of acute pulmonary rejection were successfully treated with intravenous steroids. Neither lung disorder was associated with a liver rejection episode. Airway complications that occurred in both cases were managed endoscopically.

Conclusion

Combined transplantation of lung and liver is a feasible and therapeutically effective procedure for patients with cystic fibrosis complicated by advanced liver disease. Herein we have described our experience in two of the only three cases of combined liver and lung transplantation performed in Spain to date. Patient and graft survivals were comparable to isolated liver or isolated bilateral lung transplantations.     

Colecistectomía laparoscópica en pacientes mayores de 80 años

Introduction

The increasing aging of the population also increases the prevalence of symptomatic gallbladder diseases. It is important to analyse their surgical treatment in the elderly.

Methods

All the laparoscopic cholecystectomies performed in our surgery department on patients aged 80 years-old or over from 1992 to 2007 were included in this study.

Results

Laparoscopic cholecystectomy was performed on 133 patients 80 years-old and over, with 63% of them women, and an average age of 83.23 years. Biliary colic (29%) and acute pancreatitis (44%) were the main reasons for surgery. Associated diseases were found in 73% of them. Only 7.5% needed urgent surgery, even although 71% were admitted urgently. There were 13.5% conversions to open surgery, 17% morbidity and 2.3% mortality.

Conclusions

Laparoscopic cholecystectomy can be recommended in symptomatic gallbladder disease in the elderly.     

Influence of simultaneous pancreas and preemptive kidney transplantation on severity of postoperative complications

Background

Simultaneous pancreas and preemptive kidney transplantation (SPpreKT) seems to be the optimal treatment for the patients with diabetes type 1 who are progressing to end-stage renal disease. On the other hand, surgical complications with a high rate of relaparatomy are a limiting factor in pancreas transplantation.

Objective

Comparison of severity of surgical complications was performed between a group of preemptive (SPpreKT group) and nonpreemptive recipients of SPKT (SPKT group).

Methods

Between 1988 and 2010, we performed 112 SPKTs including 25 preemptive recipients (22.3%). The SPKT Group included 87 recipients (77.7%). The severity of complications was classified according to a modified Clavien scale: grade I, no complication; grade II, drug therapy; grade IIIA, invasive intervention not requiring general anesthesia; grade IIIB, invasive intervention requiring general anesthesia; grade IVA, graft failure; and grade IVB, death.

Results

Among the SPpreKT group, 64% of recipients were free from postoperative complications compared with 40.3% of the SPKT group (P < .01). Among the SPKT group, 52 recipients (59.7%) developed 58 postoperative complications, including 15 (17.3%) deaths due to graft pancreatitis (80%) or pancreatic fistula (20%). Among the SPpreKT group, 9 recipients developed 9 complications. None of the preemptively transplanted group subjects experienced a lethal complication. Among the SPpreKT group, the most severe complication was graft pancreatitis leading to graft removal in 2 recipients.

Conclusions

Recipients of preemptive SPKT developed significantly fewer postoperative complications, especially deaths. However the rates of mild (II, IIIA) and moderate (IIIB) complications as well as graft failures (IVA) were similar to the nonpreemptive group.