Subarachnoid lumbar drains: A case series of fractured catheters and a near miss

PURPOSE: Lumbar subarachnoid catheters for cerebrospinal fluid (CSF) drainage (lumbar drains) are indicated for several medical and surgical conditions. A number of complications can occur from the placement of this type of catheter, including catheter breakage from excessive traction or shearing over the Tuohy needle. CLINICAL FEATURES: Five cases of lumbar subarachnoid catheter breakage/shearing and catheter fragment retention, as well as one near miss, were identified over a one-year period at a single institution. All (n = 6) patients were undergoing neurosurgical procedures. Four patients required surgical retrieval of the catheter fragments. No patient experienced log-term neurological sequelae. DISCUSSION: From these experiences, the following risks factors for catheter rupture are identified: 1) intentional or accidental retraction of the catheter through the needle during placement; 2) faulty use of the guidewire; or 3) use of excessive force during removal of the catheter. Methods to prevent such complications are suggested, including minimal use, or complete avoidance of a guidewire.     

Repeat liver resection for recurrent colorectal metastases: a single-centre, 13-year experience

Objectives: Isolated intrahepatic recurrence is noted in up to 40% of patients following curative liver resection for colorectal liver metastases (CLM). The aims of this study were to analyse the outcomes of repeat hepatectomy for recurrent CLM and to identify factors predicting survival.Methods: Data for all liver resections for CLM carried out at one centre between 1998 and 2011 were analysed.Results: A total of 1027 liver resections were performed for CLM. Of these, 58 were repeat liver resections performed in 53 patients. Median time intervals were 10.5 months between the primary resection and first hepatectomy, and 15.4 months between the first and repeat hepatectomies. The median tumour size was 3.0 cm and the median number of tumours was one. Six patients had a positive margin (R1) resection following first hepatectomy. There were no perioperative deaths. Significant complications included transient liver dysfunction in one and bile leak in two patients. Rates of 1-, 3-and 5-year overall survival following repeat liver resection were 85%, 61% and 52%, respectively, at a median follow-up of 23 months. R1 resection at first hepatectomy (P = 0.002), a shorter time interval between the first and second hepatectomies (P = 0.02) and the presence of extrahepatic disease (P = 0.02) were associated with significantly worse overall survival.Conclusions: Repeat resection of CLM is safe and can achieve longterm survival in carefully selected patients. A preoperative knowledge of poor prognostic factors helps to facilitate better patient selection.     

How severe is diabetes after total pancreatectomy? A case-matched analysis

Objectives

Total pancreatectomy (TP) is associated with significant morbidity and mortality. The severity of postoperative diabetes and existence of ‘brittle diabetes’ are unclear. This study sought to identify quality of life (QoL) and diabetes-specific outcomes after TP.

Methods

Patients who underwent TP were matched for age, sex and duration of diabetes with patients with type 1 diabetes. General QoL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) core quality of life questionnaire QLQ-C30 and the PAN26 tool. Diabetes-specific outcomes were assessed using the Problem Areas in Diabetes (PAID) tool and an assessment of diabetes-specific complications and outcomes.

Results

A total of 123 patients underwent TP; 88 died (none of diabetic complications) and two were lost to follow-up. Of the remaining 33 patients, 28 returned questionnaires. Fourteen general and pancreas-specific QoL measurements were all significantly worse amongst the TP cohort (QLQ-C30 + PAN26). However, when diabetes-specific outcomes were compared using the PAID tool, only one of 20 was significantly worse. HbA1c values were comparable (P = 0.299), as were diabetes-related complications such as hypoglycaemic attacks and organ dysfunction.

Conclusions

Total pancreatectomy is associated with impaired QoL on general measures compared with that in type 1 diabetes patients. Importantly, however, there was almost no significant difference in diabetes-specific outcomes as assessed by a diabetes-specific questionnaire, or in diabetes control. This study does not support the existence of ‘brittle diabetes’ after TP.     

Asymptomatic transmission of Treponema pallidum (syphilis) through deceased donor liver transplantation

A 55‐year‐old woman underwent liver transplantation (LT) with a graft from a deceased donor. Mandatory pre‐donation investigations showed positive syphilis serology that was available only after the transplant, with high Treponema pallidum particle agglutination assay titer compatible with donor syphilis infection. Despite the institution of appropriate post‐exposure prophylaxis, the recipient demonstrated latent seroconversion; however, liver graft function improved without evidence of syphilitic hepatitis or other manifestations of the disease. Through this first reported case of asymptomatic transmission of syphilis following LT, we highlight the investigations and treatment strategies for donor‐derived syphilis in liver transplant recipients. This report supplements the existing limited evidence on safe use of infected grafts from syphilitic donors through appropriate post‐exposure prophylaxis.     

A study of the metabolites of ischemia-reperfusion injury and selected amino acids in the liver using microdialysis during transplantation

BACKGROUND: Preservation and ischemia-reperfusion injury still impact the outcome of orthotopic liver transplantation. The authors used microdialysis with a view to monitoring its effect on graft function. METHODS: A microdialysis catheter was inserted into the graft immediately after reperfusion and perfused with an isotonic solution for 48 hr. Metabolites of the ischemia-reperfusion injury and selected amino acids were studied. There were 18 patients, with a median age of 52 years (range, 38-62 years), 8 of whom were men. Lactate, pyruvate, glycerol, and glucose levels were measured. In addition, alanine, arginine, citrulline, gamma-aminobutyric acid (GABA), glutamate, glutamine, glycine, and taurine were determined. RESULTS: All grafts functioned well. High lactate, pyruvate, and glycerol levels were observed in the immediate postoperative period. These showed a significant rapid decrease and stabilized to baseline levels. Alanine, glutamate, GABA, and taurine levels declined significantly to baseline values. Arginine levels were low immediately postreperfusion and then increased, reaching significantly higher values beyond 19 hr. CONCLUSIONS: These data may represent "normal" changes seen in the immediate posttransplant period because all grafts functioned well. Two important metabolic fates of arginine in the liver are in the detoxification of ammonia by means of the urea cycle, and in the synthesis of nitric oxide (NO). Low extracellular arginine may reflect influx of the amino acid into hepatocytes, resulting in formation of NO in the presence of inducible NO synthase or conversion to ornithine in the presence of arginase in the urea cycle. As the organ stabilizes, restriction of arginine uptake may give rise to the observed increase in extracellular arginine.     

Primary hepatocellular cancer in the explanted liver: outcome of transplantation and risk factors for HCC recurrence.

AIM: To evaluate the risk of recurrence of hepatocellular cancer (HCC) after liver transplantation (LT). METHODS: The clinical records of 104 patients with HCC in the explanted liver were examined. RESULTS: HCC recurrence occurred in 12 patients. Recurrence was observed in all patients with a single nodule greater than 5 cm. Among the 5 patients with more than 3 tumours with a maximum diameter of 4.5 cm, no recurrence occurred. The survival rates were 81% and 64% at 1 and 5 years, respectively; the recurrence-free survival at 1 and 5 years was, respectively, 93% and 82%. Pre-LT alpha-fetoprotein (AFP) increased at a greater magnitude in patients who experienced recurrence, compared to those who did not. Tumour diameter, differentiation, satellitosis, AFP and the magnitude of AFP increase were predictive of recurrence. The 1- and 5-year recurrence-free survival for the 68 patients who had a single nodule up to 5 cm, or up to 3 nodules all less than 4.5 cm and with a maximum cumulative diameter of 8 cm, or more than 3 nodules all less than 2.5 cm, were 95% and 92%, respectively. For the 13 patients not meeting these criteria, the 1- and 5-year recurrence-free survival was, respectively, 75% and 54% (log Rank test p=0.019). CONCLUSIONS: Patients with more than 3 small HCC nodules before LT could still have a good outcome without recurrence. A rapid increase in AFP could be useful in identifying patients with a greater risk of post-LT HCC recurrence.     

Treatment of hydatid disease of the liver. Evaluation of a UK experience

BACKGROUND: Hydatid disease of the liver though endemic in many countries, is rare in the UK. We evaluated a 16-year experience of treating hydatidosis using a management protocol combining surgery with anti-scolicidals. PATIENTS AND METHODS: There were 30 patients. 14 (47%) males, median age 41 (range 25-72) years, of whom 21 (70%) were symptomatic. Diagnosis was by serological tests and imaging. All had disease confined to the liver and received peri-operative anti-scolicidal drug therapy. RESULTS: The initial 4 (13%) patients received praziquantel combined with albendazole for 2 weeks and the following 26 (87%) patients received two cycles of albendazole 400 mg twice daily for 28 days, with a 14-day break in between. However, 2 (7%) patients could not tolerate albendazole, one due to GI side effects and the other developed deranged liver functions. These 2 patients subsequently received praziquantel for 2 weeks. All patients underwent surgery. Subtotal cystectomy was carried out on 29 (96%) patients and 1 patient required a segmentectomy. Cystobiliary communications were identified in 15 (50%) of patients which were oversewn using fine absorbable sutures. Of these, 7 had the bile ducts decompressed using a T tube, with only 1 developing a post-operative bile leak. In comparison, 8 were not drained of which 6 leaked (p = 0.03). The median post-operative hospital stay was 8 days (range 5-24). Patients who developed post-operative bile leaks, however, needed prolonged abdominal drainage for a median of 21 days (range 18-24). Two (7%) patients developed histologically proven recurrent disease. The median follow-up was 56 months (range 3-87). CONCLUSION: Surgery combined with anti-scolicidal therapy proved effective. Cystobiliary communications are common and, when identified, should result in the biliary system being drained, to avoid post-operative bile leaks.     

A simple scoring system to evaluate the effects of cold ischemia on marginal liver donors

BACKGROUND: Exactly what constitutes a marginal donor remains ill defined. The authors set out to create a scoring system that objectively classifies a donor as marginal or nonmarginal and to define what the maximum acceptable preservation period is for the marginal liver to minimize early graft dysfunction. METHODS: The authors performed an analysis on data collected prospectively of 397 cadaveric liver transplants. Both univariate and multivariate analyses were performed on donor, recipient, and perioperative factors with relation to early allograft dysfunction. A score was developed that classified donors into marginal and nonmarginal populations, and the influence of cold ischemia was determined for each group. RESULTS: Multivariate analysis-determined donor age and steatosis (moderate to severe) were independent predictors of deranged function. This enabled the authors to produce a scoring system to differentiate marginal donors with respect to risk of early allograft dysfunction as follows: Formula=(20.06xsteatosis)+(0.44xdonor age), cutoff 23.1. In the marginal group, the cutoff value of cold ischemia time was 12.6 hr. CONCLUSIONS: The authors developed a scoring system that classified an organ as marginal or nonmarginal depending on the donor age and degree of steatosis. Marginal livers have a strong risk of developing early allograft dysfunction with increasing cold ischemia times and should be transplanted within 12 hr. Cold ischemia time was not found to be an important factor in the development of early allograft dysfunction in nonmarginal donors.