Chirag S. Desai

Novel Technique of Total Pancreatectomy Before Autologous Islet Transplants in Chronic Pancreatitis Patients

i d c v c a l s U t t Chronic pancreatitis is a disease characterized by progressive destruction of the pancreatic exocrine tissue, leading to fibrosis and calcification of the pancreas. Patients develop severe and debilitating chronic abdominal pain and have an extremely poor quality of life. Pain is a major cause of morbidity, but exocrine and endocrine insufficiency is severe as well. Chronic pancreatitis may be a sequela of acute recurrent pancreatitis; causes include anatomic defects resulting in obstruction of the pancreatic duct, use of drugs (especially, chronic alcohol abuse), and underlying genetic or autoimmune disorders of the pancreas. Often, no speific cause can be identified in a proportion of patients, specially in the Asia-Pacific region. Treatment methods have included pancreatic enzyme replacements, pain management, ERCP with stenting, and decompressive surgical procedures of the pancreatic duct, partial resection, and total pancreatectomy. A comprehensive review of the subject was recently published. In paients with chronic pancreatitis (instead of a primary maignancy), the decision to perform a total pancreatectomy is ot an easy one because of the extensive nature of the urgery and the resulting endocrine deficiency, which alost always results in brittle insulin-dependent diabetes ellitus. But the development of autologous islet (autoiset) transplants has provided an opportunity to prevent evelopment of insulin-dependent diabetes mellitus in uch patients. Their quality of life is improved by undergong both procedures: the total pancreatectomy addresses heir pain, and the autoislet transplant maintains their enocrine function. Total pancreatectomy is not a new procedure. Billroth performed the first reported pancreatectomy for pancreatic cancer in 1884; more than 80 years later, Warren performed the first pancreatectomy for intractable pain and

Intestinal retransplantation: analysis of Organ Procurement and Transplantation Network database.

Background. We evaluated the outcomes of intestinal retransplantation in children and adults in the United States. Methods. The United Network for Organ Sharing data were analyzed from October 1987 to August 2009. Results. In adult isolated intestinal transplant (ITx) retransplants (n=41), patient survival was 80.1%, 47.4%, and 28.5% at 1, 3, and 5 years, which was worse than primary isolated ITx (P=0.005). For liver ITx (L-ITx) retransplants (n=31), patient survival was 63.1%, 56.1%, and 46.8% and was not significantly different than primary L-ITx. In pediatric isolated ITx retransplants (n=28), patient survival at 1, 3, and 5 years was 80.7%, 74%, and 57.5%; graft survival was 76.4%, 56.6%, and 44%. In L-ITx retransplants (n=49), patient survival was 42%, 42%, and 42%; graft survival was 39%, 39%, and 39%. Patient and graft survival in adult L-ITx retransplants were better in era 2 (January 2001–August 2009) than era 1 (October 1987–December 2000) (P=0.01). Among pediatric L-ITx retransplants, outcomes were worst in children younger than 2 years (n=12). In regression analysis, prior hospitalization was a negative predictor for all the groups of patients (relative risk, 5.4). Conclusion. Patient and graft survival in adult isolated ITx are less favorable after a retransplant compared with a primary transplant. Patient and graft survival are also poor in pediatric L-ITx after a retransplant, especially for children younger than 2 years of age. L-ITx retransplant results improved significantly in era 2 in adult recipients.

Isolated intestinal transplants vs. liver‐intestinal transplants in adult patients in the United States: 22 yr of OPTN data

Desai CS, Gruessner AC, Khan KM, Fishbein TM, Jie T, Rodriguez Rilo HL, Gruessner RWG. Isolated intestinal transplants vs. liver‐intestinal transplants in adult patients in the United States: 22u2003yr of OPTN data.

MRI prediction of islet yield for autologous transplantation after total pancreatectomy for chronic pancreatitis.

ObjectiveThe relationship between magnetic resonance imaging (MRI), histopathology, and islet yield was examined for chronic pancreatitis patients undergoing total pancreatectomy and autologous islet cell transplant (TP-AIT) to determine if the yield can be predicted by pre-operative MRI.MethodsMRI sequences and histopathology were scored and compared for patients from whom ≤2,500 islet equivalents/kg were obtained with those from whom >2,500 islet equivalents/kg were obtained.ResultsTwenty patients, 14 female, mean age 40.20xa0±xa012.5xa0years, (range 19–63) underwent MRI before TP-AIT; mean 3,724xa0±xa0891 islet equivalents/kg body weight, median 2,970, (range 76–17,770) were procured. There was no correlation between islet cell numbers and pancreas weight, HgbA1c, or c-peptide. The most common MRI sequence abnormality was the delayed interstitial phase, 14/18 (78xa0%). The other common MRI sequence abnormalities were, precontrast T1W 3D GRE sequence, 13/19 (68xa0%), and the arterial perfusion phase, 11/18 (61xa0%). The pancreatic duct was dilated in 10/20 (50xa0%). Parenchymal atrophy was noted in 10/20 (50xa0%). Median scores for individual MRI sequences were greater in patients with an islet cell yield of ≤2,500 islet equivalents/kg; for the delayed interstitial phase the difference was significant (median 2.5, range 1–3 versus median 0.5, range 0–3, Pxa0=xa00.034). Histologically the most common feature was fibrosis, (17/17, 100xa0%); the score for fibrosis was greater for patients with an islet cell yield of ≤2,500 islet equivalents/kg (median 6.0, range 5–7 versus median 4.0, range 3–7, Pxa0=xa00.024).ConclusionA diminished islet yield may be predicted on the basis of the delayed interstitial phase MRI sequence.

Single-incision robotic-assisted living donor nephrectomy: case report and description of surgical technique

The introduction of laparoscopic surgery, and more recently of robotics, has increased the number of living donor kidney transplants. This approach has already improved living donor acceptance rates. Even newer developments in the field have now been introduced with the purpose of further reducing postoperative pain and length of hospital stay, while offering better cosmetic results. In particular, single‐incision surgery has gained popularity by improving the well‐known benefits of minimally invasive surgery. In this case report, we present the first single‐incision robotic‐assisted living donor nephrectomy.

Age-based disparity in outcomes of intestinal transplants in pediatric patients

Outcomes of intestinal transplants (ITx; n = 977) for pediatric patients are examined using the United Network for Organ Sharing data from 1987 to 2009. Recipients were divided into four age groups: (1) <2 years of age (n = 569), (2) 2–6 years (n = 219), (3) 6–12 years (n = 121) and (4) 12–18 years (n = 68). Of 977 ITx, 287 (29.4%) were isolated ITx and 690 (70.6%) were liver and ITx (L‐ITx). Patient survival for isolated ITx at 1, 3 and 5 years, 85.3%, 71.3% and 65.0%, respectively, was significantly better than L‐ITx, 68.4%, 57.0% and 51.4%, respectively, (p = 0.0001); this was true for all age groups, except for patients <2 years of age. The difference in graft survival between isolated ITx and L‐ITx was significant at 1 and 3 years (Wilcoxon test, p = 0.0012). After attrition analysis of graft survival of patients who survived past first year, 3 and 5 years, graft survival for L‐ITx patient was significantly better than those for isolated ITx. Isolated ITx should be considered early before the onset of liver disease in children >2 with intestinal failure but is not advantageous in patients <2 years.

Development of diabetes mellitus in living pancreas donors and recipients

Previously, recurrence of insulin-dependent diabetes mellitus after pancreas transplants was only sporadically reported. Newer data, however, indicate recurrence rates as high as 5%. After identical-twin pancreas transplants, diabetes recurs in the absence of immunosuppressive therapy – strong evidence that it is an autoimmune disease. After deceased donor pancreas transplants, immunologic markers (autoantibodies, autoreactive T cells) herald recurrence. Selective destruction of β cells, still relatively uncommon, is not restricted to MHC compatibility. The development of diabetes in living pancreas donors is rare; it can be largely avoided by meticulous metabolic evaluation before donation and prevention of obesity after donation.

Influence of Liver Histopathology on Transaminitis Following Total Pancreatectomy and Autologous Islet Transplantation

BackgroundIn type 1 diabetics undergoing allogenic islet transplants, transaminitis and portal vein thrombosis (PVT) after transhepatic portal infusion of islets may be related to infusion pressure and the purity of islets. Complications of intraoperative portal infusion of islets in patients with chronic pancreatitis undergoing a total pancreatectomy (TP) and autologous islet transplant (AIT) and the relationship to liver histopathology have not been examined.AimThe purpose of this study was to examine complications of intraportal infusion of autologous islets after TP.MethodsData on 26 TP-AIT patients were analyzed.ResultsInfusion of islets [mean 304,473xa0±xa0314,557 islet equivalents, median volume 300xa0mL (50–600)] resulted in mean postinfusion PV pressure of 9.15xa0±xa010.09 cmH2O which correlated with infused islets equivalents (r2xa0=xa033.6, Pxa0=xa00.002) and volume (r2xa0=xa030.4, Pxa0=xa00.005). Of 23 patients undergoing liver biopsy, 8 (35xa0%) were normal, 10 (43xa0%) had steatosis, and 5 (22xa0%) periportal fibrosis. Peak alanine aminotransferase (ALT; median 1xa0day after infusion) differed among the three histologic groups (Pxa0=xa00.025). The difference in ALT was statistically significant between steatosis (showed the greatest increase) and the other two groups, but not between the normal and fibrosis groups. No correlation was found between the portal pressure increase at infusion and other variables. Two patients that developed PVT on day 1 had the highest infusion pressures; a third occurred on day 5.ConclusionPreexisting liver pathology is a contributing factor in the rise in liver enzymes but does not correlate with development of PV thrombosis.

Summer syncope syndrome redux

BACKGROUNDnWhile antihypertensive therapy is known to reduce the risk for heart failure, myocardial infarction, and stroke, it can often cause orthostatic hypotension and syncope, especially in the setting of polypharmacy and possibly, a hot and dry climate. The objective of the present study was to investigate whether the results of our prior study involving continued use of antihypertensive drugs at the same dosage in the summer as in the winter months for patients living in the Sonoran desert resulted in an increase in syncopal episodes during the hot summer months.nnnMETHODSnAll hypertensive patients who were treated with medications and admitted with International Classification of Diseases, 9th Revision code diagnosis of syncope were included. This is a 3-year retrospective chart review study. They were defined as cases if they presented during the summer months (May to September) and controls if they presented during the winter months (November to March). The primary outcome measure was the presence of clinical dehydration. The statistical significance was determined using the 2-sided Fishers exact test.nnnRESULTSnA total of 834 patients with an International Classification of Diseases, 9th Revision code diagnosis of syncope were screened: 477 in the summer months and 357 in the winter months. In patients taking antihypertensive medications, there was a significantly higher number of cases of syncope secondary to dehydration during the summer months (40.5%) compared with the winter months (29%) (Pxa0= .04). No difference was observed in the type of antihypertensive medication used and syncope rate. The number of antihypertensives used did not increase the cases of syncope in either summer or winter.nnnCONCLUSIONSnAn increased number of syncope events was observed in the summer months among people who reside in a dry desert climate and who are taking antihypertensive medications. The data confirm our earlier observations that demonstrated a greater number of cases of syncope among people who reside in a dry desert climate who were taking antihypertensive medications during summer months. We recommend judicious reduction of antihypertensive therapy in patients residing in a hot and dry climate, particularly during the summer months.

Wandering Kidney in Dual-Kidney Transplant Recipient Presents a Pitfall in the Interpretation of Renal Scintigraphy

A 26-y-old patient with end-stage renal disease and recent dual transplantation of cadaveric kidneys en bloc presented with increasing abdominal pain and a rising level of serum creatinine. An anterior-view 99mTc-mercaptoacetyltriglycine renogram demonstrated the typical overlap of the lower pole of the superior kidney and the upper pole of the inferior kidney. The renogram was consistent with vasomotor nephropathy. Subsequent imaging 1 wk later for worsening symptoms demonstrated a single reniform structure in the expected location of the inferior transplanted kidney, which was interpreted as a loss of perfusion to the superior kidney. Correlation with subsequent CT and sonography showed normal perfusion to both transplanted kidneys and that the superior kidney had wandered inferiorly, completely overlapping the inferior kidney on the anterior projection. The increasing prevalence of dual kidney transplantation warrants special attention to the potential for a wandering kidney.