Endoluminal stent graft repair for acute and chronic type B aortic dissection and atherosclerotic aneurysm of the thoracic aorta: an interdisciplinary task

Objective: Endoluminal thoracic aortic stenting is a new therapeutic tool in reducing the operative trauma of the patient. However, the inherent risks of aortic stent grafting are perivascular leakage, stent dislocation, blunt rupture of the aorta, side branch occlusion and neurological sequelae. To reduce these risks, in our institution all stent implantations were performed in close collaboration with our fellow cardiologists under biplane X-ray control supported by simultaneous intravascular and transoesophageal ultrasound imaging. Methods: Between August 1999 and August 2001, endovascular stent graft repair was performed in 34 patients (27 male, seven female) with a mean age of 68.6±7 years (range 58–84). Indication for treatment was an acute Type B aortic dissection in six patients (18%), a symptomatic chronic Type B dissection in 12 patients (35%), a true aneurysm of the descending aorta in seven patients (21%) and an atherosclerotic contained rupture of the descending aorta in nine (26%) patients. Out of six acute type B dissections three patients (8.8%) and one patient (2.9%) out of the chronic dissection group were in severe haemorrhagic shock, ventilated and required high-dose adrenergic support. The others (30 patients, 88.3%) remained symptomatic despite maximum medical treatment. In a special case a combined surgical and endoluminal stent graft repair was performed. Individually manufactured Talent, Medtronic AVE (33), and Gore (1) stents were used. Follow-up examination was performed 1 week after implantation and repeated every 3 months (mean follow-up 8 months, range 1–24). Results: In all patients the aneurysm or the entry of the dissection could be excluded. The observed hospital mortality was 2.9% (one patient). No perivascular leakage, no stent dislocation, no neurological deficit or perfusion impairment was observed. All patients except four were extubated immediately after the procedure and discharged from hospital on postoperative day 2–3. The late procedure-related mortality was 5.8% (two patients) resulting in an overall mortality of 8.8% (three patients). Conclusion: Stent graft repair is a safe and feasible treatment option for selected patients, especially in emergency situations, if the aortic lesions can be clearly identified and localized. The use of biplane X-ray control combined with simultaneous intravascular and transoesophageal ultrasound imaging in an interdisciplinary approach enables a more precise targeting of the stent landing zone, resulting in low morbidity and mortality rates.     

Expression of a novel PDGF isoform, PDGF-C, in normal and diseased rat kidney

Platelet-derived growth factor-C (PDGF-C) is a new member of the PDGF family. Its expression in normal and diseased kidney is unknown. Rabbit antisera were generated against human full-length, core domain, and mouse PDGF-C, and their specificity was confirmed by Western blot analyses. Renal PDGF-C expression was analyzed by immunohistochemistry in normal rats (n = 8), mesangioproliferative anti-Thy 1.1 nephritis (n = 4 each at days 1, 4, 6, and 85), passive Heymann nephritis (PHN, n = 4), puromycin nephrosis (PAN, n = 2), Milan normotensive rats (MN, n = 2), and obese Zucker rats (n = 3). PDGF-C expression was also studied in anti-Thy 1.1 rats treated with PDGF-B aptamer antagonists (n = 5) or irrelevant control aptamers (n = 5). PDGF-C was constitutively expressed in arterial smooth muscle cells and collecting duct epithelial cells. Mesangial PDGF-C was markedly upregulated in anti-Thy 1.1 nephritis in parallel with the peak mesangial cell proliferation. Furthermore, PDGF-CC acted as a potent growth factor for mesangial cells in vitro. Inhibition of PDGF-B via specific aptamers reduced the injury in anti-Thy 1.1 nephritis but did not affect the glomerular PDGF-C overexpression or the mitogenicity of PDGF-CC in vitro. In PHN, PAN, and obese Zucker rats, glomeruli remained negative for PDGF-C despite severe glomerular injury. PDGF-C localized to podocytes at sites of focal and segmental sclerosis in MN. Interstitial PDGF-C expression was increased at sites of fibrosing injury in obese Zucker rats. The use of the different antisera resulted in virtually identical findings. It is concluded that PDGF-C is a novel mesangial cell mitogen that is constitutively expressed in the kidney and specifically upregulated in mesangial, visceral epithelial, and interstitial cells after predominant injury to these cells. PDGF-C may therefore be involved in the pathogenesis of renal scarring.     

Is there still a role for total pancreatectomy?

OBJECTIVE: To evaluate the perioperative and long-term results of total pancreatectomy (TP), and to assess whether it provides morbidity, mortality, and quality of life (QoL) comparable to those of the pylorus-preserving (pp)-Whipple procedure in patients with benign and malignant pancreatic disease. SUMMARY BACKGROUND DATA: TP was abandoned for decades because of high peri- and postoperative morbidity and mortality. Because selected pancreatic diseases are best treated by TP, and pancreatic surgery and postoperative management of exocrine and endocrine insufficiency have significantly improved, the hesitance to perform a TP is disappearing. PATIENTS AND METHODS: In a prospective study conducted from October 2001 to November 2006, all patients undergoing a TP (n = 147; 100 primary elective TP [group A], 24 elective TP after previous pancreatic resection [group B], and 23 completion pancreatectomies for complications) were included, and perioperative and late follow-up data, including the QoL (EORTC QLQ-C30 questionnaire), were evaluated. A matched-pairs analysis with patients receiving a pp-Whipple operation was performed. RESULTS: Indications for an elective TP (group A + B) were pancreatic and periampullary adenocarcinoma (n = 71), other neoplastic pancreatic tumors (intraductal papillary mucinous neoplasms, neuroendocrine tumors, cystic tumors; n = 34), metastatic lesions (n = 8), and chronic pancreatitis (n = 11). There were 73 men and 51 women with a mean age of 60.9 +/- 11.3 years. Median intraoperative blood loss was 1000 mL and median operation time was 380 minutes. Postoperative surgical morbidity was 24%, medical morbidity was 15%, and mortality was 4.8%. The relaparotomy rate was 12%. Median postoperative hospital stay was 11 days. After a median follow-up of 23 months, global health status of TP patients was comparable to that of pp-Whipple patients, although a few single QoL items were reduced. All patients required insulin and exocrine pancreatic enzyme replacements. The mean HbA1c value was 7.3% +/- 0.9%. CONCLUSION: In this cohort study, mortality and morbidity rates after elective TP are not significantly different from the pp-Whipple. Because of improvements in postoperative management, QoL is acceptable, and is almost comparable to that of pp-Whipple patients. Therefore, TP should no longer be generally avoided, because it is a viable option in selected patients.     

Urinary tract infection caused by <Emphasis Type="Italic">Haemophilus influenzae</Emphasis> and <Emphasis Type="Italic">Haemophilus parainfluenzae</Emphasis> in children

There are few reports on urinary tract infections caused by Haemophilus influenzae or Haemophilus parainfluenzae in children. The true incidence is not known, since bacteria of Haemophilus species do not grow in standard urine culture media. With the objective of investigating the occurrence and character of urinary tract infections (UTIs) caused by Haemophilus bacteria in children, we searched the files of our UTI clinic. Over a 24-year period 36 children with Haemophilus spp. bacteriuria were identified out of a total of more than 5,000 UTI episodes. There was a significant gender difference in that Haemophilus influenzae dominated in girls and Haemophilus parainfluenzae in boys. With one exception, all children had important urinary tract abnormalities, such as malformation, gross reflux or bladder dysfunction. Permanent renal damage was seen in 25. We conclude that growth of Haemophilus bacteria in urine is associated with serious urinary tract abnormalities. The inability of bacteria of the Haemophilus species to grow in standard media commonly used for culture of uropathogens suggests that the true frequency of these strains as a cause of urinary tract infections is underestimated.     

Influence of donor histology on outcome in patients undergoing transplantation for hepatitis C

BACKGROUND: Risk factors for graft loss and recipient death in liver transplantation for hepatitis C virus (HCV) have been extensively investigated. Donor age was defined as one of the most important predictors of outcome in these patients; however, the mechanism leading to more severe recurrent hepatitis has not yet been investigated. METHOD: In a retrospective analysis, histological findings of 79 donor liver grafts were assessed according to criteria inflammation, fibrosis, fatty degeneration, and necrosis. These findings were correlated with the histological and clinical course of HCV-positive liver graft recipients. RESULTS: The overall 1-, 5- and 10-year graft survival figures were 85%, 77%, and 60%, respectively. We could not identify any correlation between outcome, fat content, and necrosis in the donor liver. However, stage 3 and 4 fibrosis 1 year after liver transplantation was significantly increased in the group of patients receiving a graft from a donor with portal inflammation (P<0.05). Additionally, the occurrence of intrahepatic inflammation was significantly increased in older donors (P<0.05) and donors with prolonged intensive care hospitalization (P<0.05). CONCLUSION: A number of risk factors for detrimental outcome in HCV-positive patients after liver transplantation have been identified. In particular, older donor age significantly impaired outcome in recent analysis, but due to donor shortage it is not possible to provide young grafts for all HCV-positive patients. Our data show that donor histology is helpful in identifying patients with more severe recurrent hepatitis prior to transplantation, and that especially in older donors, prolonged intensive care hospitalization should be avoided.     

Changes in disc height and posteroanterior displacement after fusion in patients with idiopathic scoliosis: a 9-year follow-up study

INTRODUCTION: In scoliosis patients treated with long segment spinal fusion, degenerative changes like retrolisthesis and disc space narrowing below fusion have been observed. However, there is disagreement concerning their incidence and dependency on the location of the lowest instrumented vertebra. MATERIALS AND METHODS: To evaluate temporal changes in disc height and posteroanterior displacement (indicating listhesis) below fusion, 40 patients with adolescent idiopathic scoliosis, mainly treated with Cotrel-Dubousset instrumentation, were retrospectively investigated in this longitudinal study with a follow-up of on average 9.2 years (median 9.4 y) after surgery. Disc height and displacement were measured from lateral radiographs by means of distortion-compensated roentgen analysis (DCRA). Additionally, a mathematical model was developed to determine the influence of vertebral tilt in scoliosis on disc height and displacement. RESULTS: Overall, no significant decrease in disc height was observed during follow-up. Concerning listhesis a small but significant retrolisthesis was found in segments L2/L3 and L3/L4. Compared with normative data, there was no significant listhesis for the L5/S1 segment. Nevertheless, separating the study group into subsamples of identical distal fusion level revealed a significant correlation between the amount of posteroanterior displacement at L5/S1 and the location of the lowest instrumented vertebra. With a reduction of free motion segments, listhesis increased into posterior direction. Taking the tilt correction into account led to considerably increased values of disc height whereas displacement was affected only to a minor degree. CONCLUSIONS: Long segment spinal fusion in young patients with idiopathic scoliosis did not lead to disc space narrowing during 9.2 years follow-up. However, the observed increase in retrolisthesis potentially indicates the initiation of a degenerative process. These only minimal changes might be referred to the preservation of a physiologic lumbar lordosis. Without correction for vertebral tilt disc space narrowing is overestimated.     

Effect of Surgery on the Outcome of Midgut Carcinoid Disease with Lymph Node and Liver Metastases

We have evaluated survival and tumor-related symptoms in the presence of mesenteric lymph node and liver metastases in relation to surgical procedures in 314 patients (148 women, mean age at diagnosis 61 years; 249 with liver metastases) treated for midgut carcinoid tumors. Of the operated patients, 46% presented with severe abdominal pain and intestinal obstruction and were operated on before the diagnosis. Medical treatment (somatostatin analogs, interferon-a) was initiated in 67% and 86%, respectively. Surgical attempts included small intestine or ileocecal/right-sided colon resection with excision of mesenteric lymph node metastases. Most of the patients (n = 286) had mesenteric lymph node metastases; 33% of them had unresectable mesenteric lymph node metastases and underwent surgery without mesenteric dissection. Patients who underwent resection for the primary tumor had a longer survival than those with no resection (median survival 7.4 vs. 4.0 years; p <0.01). Patients who underwent successful excision of mesenteric metastases had a significantly longer survival than those with remaining lymph node metastases. Patients operated on for a primary tumor but with remaining lymph nodes but no liver metastases and who subsequently received interferon and somatostatin analog treatment had a median survival of 7.4 years. Resection of the primary tumor and the mesenteric lymph node metastases led to a significant reduction in tumor-related symptoms. Surgery to remove the primary intestinal tumor including mesenteric lymph node metastases is supported by the present results, even in the presence of liver metastases. Liver metastases and significant preoperative weight loss are identified as major negative prognostic factors for survival.     

Factors influencing survival after bypass procedures in patients with advanced pancreatic adenocarcinomas

BACKGROUND: Patients with occult metastasis or locally nonresectable pancreatic cancer found during surgical exploration have a limited life expectancy. We sought to define markers in these patients that could predict survival and thus aid decision making for selection of the most appropriate therapeutic palliative option. METHODS: In a prospective 4-year single-center study, 136 consecutive patients with obstructive pancreatic cancer and intraoperative diagnosis of nonresectable or disseminated pancreatic cancer underwent a palliative surgical bypass procedure. Potential factors predicting survival were evaluated. RESULTS: Ninety-eight patients had metastatic disease and 38 locally advanced disease. Surgical morbidity rate was 16 %, re-operation rate 1%, and overall in-hospital mortality 4%. Univariate analysis showed American Society of Anesthesiologists (ASA) score, pain, operation time, presence of metastasis, and levels of leukocytes, albumin, C-reactive protein (CRP), carcinoembryonic antigen (CEA), and carbohydrate antigen (CA) 19-9 were associated significantly with survival. The multivariate analysis identified ASA score, presence of liver metastasis, pain, CA 19-9, and CEA levels as independent indicators for poor survival. Patients with none or 1 of these risk factors had a median survival of 13.5 months, whereas patients with 4 or 5 risk factors had a median survival of 3.5 months. CONCLUSIONS: The clinical markers identified predict poor outcome for patients with palliative bypass surgery and therefore aid the appropriate selection of either surgical bypass or endoscopic stenting in these patients.     

Calcineurin inhibitor dose‐finding before kidney transplantation in HIV patients

Kidney transplantation in HIV‐infected patients is associated with a higher rate of graft rejection as well as an increased toxicity of the immunosuppressive therapy. Specifically, the use of the calcineurin inhibitor tacrolimus is problematic because of a narrow therapeutic range, a high interindividual variability of trough levels, and multiple interactions with combination antiretroviral therapy (cART). Our objective was to establish the optimal individual immunosuppressive dose for the time after kidney transplantation. We administered a temporary course of immunosuppressive therapy in three HIV‐infected patients with end‐stage renal disease (ESRD) after wait‐listing and prior to transplantation for deceased donor kidney transplantation. Starting with a tacrolimus dose of 1 mg twice daily, the dose was titrated to reach a tacrolimus trough level of 8–12 ng/ml. HIV had been diagnosed 7–14 years prior. All patients had no detectable HIV‐1 RNA while on cART. All three patients had been on chronic dialysis for 4, 7, and 10 years. In two patients, the intended tacrolimus trough levels of 8–12 ng/ml were achieved within a month. The required tacrolimus dose ranged from 0.5 mg thrice weekly to 10 mg daily. In one case, ventricular tachycardia occurred, so the immunosuppressive therapy was switched to cyclosporine A. So far, two patients have been transplanted successfully. In summary, dose‐finding of immunosuppressive therapy with tacrolimus in patients on cART before renal transplantation is feasible and appears useful to minimize immunosuppressive therapy‐related complications in the post‐transplantation period.