Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy

HYPOTHESIS: Advances in specialized centers for pancreatic diseases have improved surgical morbidity and outcome. In the past, postoperative local complications (pancreatic fistulae) were causing most of the mortality. Now, more patients experience postoperative complications related to their comorbidity. DESIGN: To report a prospective audit of a single center's experience with pancreatic resection during an 8-year period. SETTING: Tertiary referral center focused on pancreatic diseases. PATIENTS AND INTERVENTIONS: Six hundred seventeen consecutive patients underwent pancreatectomy between November 1, 1993, and August 31, 2001. The series included 468 pancreatic head resections (76%), 25 total pancreatectomies (4%), 88 left-sided resections (14%), and 36 others (6%). MAIN OUTCOME MEASURES: Morbidity after pancreatic resection. RESULTS: Postoperative in-hospital mortality was 1.6%, and the additional operation rate was 4.1%. Four patients died of surgical complications and 6 of systemic complications. Systemic morbidity was 18% and consisted primarily of cardiopulmonary complications (13%). The most frequent postoperative complication was delayed gastric emptying (14%), which caused significant prolongation of the hospital stay. No patients died of a postoperative pancreatic fistula, which occurred in 3.2%, and no completion pancreatectomies were necessary. CONCLUSIONS: Pancreatic resections can be performed with considerable safety and a low rate of pancreatic complications. More patients die of systemic complications than in the past, which increases the demand for precise preoperative patient selection. Completion pancreatectomy should no longer be considered in patients with a pancreatic fistula.     

The role of calcification for staging cystic echinococcosis (CE)

The prevalence of calcified cysts and the significance of calcification as a sign of cyst inactivity in cystic echinococcosis (CE) was evaluated. Seventy-eight patients (36 females, 42 males, mean age 40.8 +/- 16.9 years) with CE, having a total of 137 abdominal cysts (116 hepatic, three splenic, one renal and 17 peritoneal cysts), were diagnosed and followed-up by ultrasound during and after albendazole treatment or as part of the watch-and-wait approach recording changes in the cyst wall and content. In 48 patients with 94 cysts, computed tomography (CT) imaging was additionally available and was correlated with ultrasound findings. Cyst wall calcification was classified into (1) "sprinkled", (2) "eggshell-like", and (3) "circular". Calcification of the cyst wall and/or cyst content was detected in 67 echinococcal cysts (48.9% of all cysts) in 39 patients (15 females, 24 males, mean age 40.8 +/- 14.8 years). Of the total of 67 calcified cysts, only 23 were compatible with WHO type CE5, 18 with WHO type CE4. Judged by cyst content, the remaining 26 were of WHO type CE1, CE2 and CE3 (n = 1, n = 8, and n = 17, respectively). During a mean period of 34.3 months (+/- 21.3 months) the majority of cysts (n = 32) did not exhibit any change in cyst content and wall properties. Fourteen cysts showed signs of progressive involution, five cysts (all of WHO type CE3) of renewed activity defined by recurring fluid collection. In 16 cysts, no follow-up was available due to surgery or drop out. Calcification of the cyst is not restricted to the inactive WHO cyst types CE4 and CE5, but occurs in all stages and in up to 50% of cysts. The completeness and, most importantly, the stability of consolidation of cyst content over time predicts cyst inactivity more reliably.     

Dementia prevalence,care arrangement,and access to care in Lebanon: A pilot study

Introduction

In North Africa and the Middle East, studies about dementia prevalence are scarce. A pilot study was conducted in Lebanon to assess dementia prevalence, using the Arabic-validated 10/66 Dementia Research Group (DRG) diagnostic assessment for case ascertainment. The study also examined care arrangement and access to care.

Neurogenic factors in the impaired healing of diabetic foot ulcers

BACKGROUND: We hypothesize that the reduced innervation of skin can be observed both in clinically neuropathic and non-neuropathic diabetic foot ulcers and can contribute to low inflammatory cell infiltration. MATERIALS AND METHODS: Twenty patients with type 2 diabetes and active foot ulcers, without clinical evidence of peripheral sensory neuropathy (n = 12) and with sensory neuropathy (n = 8) were involved in this study. Biopsies from ulcer margin were examined immunohistochemically. RESULTS: Studies revealed presence of protein gene product 9.5 (PGP9.5)+ nerve endings only in reticular dermis in 3 of 12 non-neuropathic subjects, however, regenerating GAP-43+ endings were seen in dermis of almost all specimens. Lack of substance P+ nerve endings was characteristic for both groups. The reduced distribution of calcitonin gene-related peptide+ nerves in epidermis and dermis was seen mainly in neuropathic group. In neo-epidermis lack of nerve growth factor expression was observed in both groups, whereas neurotrophin 3 immunostaining was characteristic for neuropathic specimens (P < 0.03). Expression of trkA and trkC receptors did not differ significantly between groups. Low inflammatory cell infiltration and moderate presence of fibroblasts was characteristic for all studied specimens. CONCLUSIONS: The observed reduction of foot skin innervation and neurogenic factors expression can be correlated with low inflammatory cell accumulation and subsequently leads to the observed chronicity of diabetic foot ulcer healing process in both neuropathic and non-neuropathic patients.     

Interventional therapy of vascular complications following renal transplantation

Abstract:  Renal transplantation is accepted as the preferred treatment for most cases of end-stage renal disease. Postoperative vascular complications include stenosis or thrombosis of the transplant renal artery or arteriovenous fistulas after biopsy. Impaired arterial perfusion of the transplant may be the leading cause for graft dysfunction or refractory hypertension. Therefore, non-invasive imaging modalities are required to detect and locate vascular complications with high accuracy. Doppler ultrasound is suited as a screening method for the detection of impaired graft perfusion. Magnetic resonance imaging (MRI) is used for an accurate diagnosis of vascular complications and to support decision for appropriate surgical or interventional treatment. Minimal invasive techniques like percutaneous transluminal angioplasty and stent placement have evolved as safe procedures with a high technical success rate reducing substantial morbidity. They can be considered as an alternative to surgical treatment of transplant renal artery stenosis (TRAS). Embolization of severe arteriovenous fistulas is the method of choice if the feeding artery can be occluded through a microcatheter. In selected cases, even catheter-guided fibrinolytic treatment of arterial thrombosis might be considered, if instantaneous surgery is considered a high-risk procedure. This article reviews the imaging features of common vascular complications after renal transplantation with focus on MRI. In addition, interventional radiological techniques are described for the treatment of TRAS, acute thrombotic occlusion, and arteriovenous fistulas.     

Quantitative assessment and determinants of suture-holding capacity of human pancreas

Background

Hard pancreas is welcome by surgeons performing resective pancreatic surgery, because it is believed to offer better suture holding capacity (SHC), thus decreasing the risk for a postoperative leak. However, neither the actual SHC of pancreatic tissue in humans nor its determinants have been studied.

Methods

We directly measured SHC for polydioxanone 5–0 suture and tissue hardness at the pancreatic isthmus in 53 human pancreata using a dynamometer and a durometer. A histologic score based on fibrosis grade, fat content, pancreatic duct size, and signs of chronic pancreatitis was calculated for every sample. We tested the hypothesis that SHC of the pancreas was proportional to tissue hardness, and evaluated the role of different possible histomorphologic determinants of SHC.

Results

Suture-holding capacity correlated perfectly with tissue hardness (r = 0.98; P < 0.001; 95% confidence interval, 0.96–0.99). The histologic score showed a stronger correlation with both parameters than any single histologic parameter. The SHC of transductal sutures was significantly higher than that of pure transparenchymal sutures. The SHC and hardness were significantly lower in patients who developed a clinically relevant pancreatic fistula postoperatively.

Conclusions

A mixture of histomorphologic features of human pancreas determines its tissue hardness and SHC. Involvement of the main pancreatic duct in the suture line appears to increase the mechanical strength of the pancreatic anastomosis.     

Effects of immobilization stress on kidneys of Wistar male rats: a morphometrical and stereological analysis

This paper verifies the morphological changes induced by immobilization stress on the kidney of rats by using stereological methods. Fifteen 4-week-old Wistar male rats were randomly assigned to control (n = 7) and stressed (n = 8) groups. Stress stimuli were performed over 5 weeks by immobilization of the rats for 2 h daily in a rigid opaque plastic cylinder that restrained their movements. Increases in the adrenal mass index (p < 0.05) and decreases in serum testosterone levels (p < 0.05) demonstrated the efficacy of the stressor stimuli. Stressed rats presented diminished body weight gain when compared to controls (p < 0.05). The mean values of kidney weight, kidney volume, kidney volume index and glomerular volume density were significantly lower in the stressed group (p < 0.05); nevertheless, no significant difference was found in the cortical/medullar ratio or in the volume-weighted mean glomerular volume. The number of glomeruli per kidney was 45% lower in the stressed group (p < 0.0001), but no change in serum creatinine levels was found. However, the morphological alterations may have serious implications predisposing individuals to renal disease and hypertension in adult life.     

Initial prevalence of anal human papilloma virus infection in liver transplant recipients

Although liver transplant recipients are at increased risk of human papilloma virus (HPV)‐related anal cancer, limited data are available regarding the initial prevalence of anal HPV infection in this population. Anal swabs collected from 50 liver transplant recipients within the first three postoperative weeks were subjected to real‐time polymerase chain reaction for detection of the four HPV genotypes: 6, 11, 16, and 18. Predictors of any, low‐risk, and high‐risk anal HPV infection were evaluated. Overall, the prevalence of any anal HPV infection was 18.0%, with the corresponding rates for high‐ and low‐risk HPV genotypes being 8.0% and 10.0%, respectively. Infection with any type of anal HPV was higher in patients with hepatitis B virus (HBV) infection (P = 0.027), ≥3 sexual partners (P = 0.031), and alcoholic liver disease (P = 0.063). HBV infection was the only factor significantly associated with high‐risk HPV infection (P = 0.038). Male sex (P = 0.050), age ≥52 years (P = 0.016), ≥30 sexual partners (P = 0.003), age at first intercourse ≤18 years (P = 0.045), and time since first intercourse ≥38 years (P = 0.012) were identified as predictors of low‐risk HPV infection. These results indicate that HPV vaccination of liver transplant candidates and screening for anal HPV infection in high‐risk groups should be considered.     

Patient versus informant reported quality of life in the earliest phases of Alzheimer's disease

OBJECTIVES: The study investigated if patient and informant reported Quality of Life (QoL) differed in early Alzheimer's disease (AD). In addition, we examined whether anosognosia had an impact on the agreement between patient and informant ratings of QoL and whether anosognosia, dementia severity, depression and behavioural symptoms were significantly correlated to QoL in early AD. METHODS: From a prospective research program including newly referred patients (age >60 years and MMSE > or = 20), 48 patients with very early AD were included. QoL was assessed using the QoL-AD and EQ-5D scales. Anosognosia was rated on a categorical scale by an examiner. MMSE, Geriatric Depression Scale, Danish Adult Reading Test and Frontal Behavioural Inventory were also administered. RESULTS: On most QoL measures patients rated their QoL higher than their informants. Anosognosia was not associated with QoL but significantly with an inverse impact on the agreement between patient and informant ratings of QoL. Self-reported QoL was significantly correlated to depression but not to age, dementia severity, behavioural symptoms or memory impairment. Informant ratings of QoL were significantly correlated to behavioural symptoms and informant ratings on the EQ-5D Visual Analogue Scale were significantly correlated to patient reported depression. CONCLUSION: Patients with early AD generally reported higher QoL than their informants. This disagreement was associated with the presence of anosognosia. Self-reported QoL did not correlate with the MMSE score. Behavioural changes and depressive symptoms may be associated with low QoL.