Christoph Wullstein

High levels of C-reactive protein after simultaneous pancreas-kidney transplantation predict pancreas graft-related complications and graft survival

Background. Although pancreas graft-related complications are frequent after simultaneous pancreas-kidney transplantation (SPK), there are no parameters predicting the risk for these complications. Method. A two-center retrospective study was performed in 97 patients who underwent SPK to investigate the peak serum value of c-reactive protein (CRP) during the first 72 hr after SPK in view of graft-related complications and graft survival. Results. Mean peak CRP was 115.6±71.5 mg/L. Mean peak CRP was higher in patients needing relaparotomy (n=31) (136.4 vs. 105.8 mg/L, P =0.048), especially when postoperative bleeding was excluded (P =0.015); in patients with graft pancreatitis (P =0.03); and in patients with graft loss (n=19; P <0.001) compared with patients without these complications. With a cut-off of peak CRP at the level of mean plus 1 SD (187.05 mg/L), there was a significantly higher incidence of relaparotomies (P =0.01; bleedings excluded:P =0.003), graft pancreatitis (P =0.03), and pancreas graft loss (P <0.0001) in patients with high peak CRP compared with patients with low peak CRP. No differences were noticed with regard to rejection rate, mortality, and kidney graft loss. Conclusion. Our findings suggest that peak CRP is a helpful parameter in predicting pancreas graft-related complications and pancreas graft survival after SPK. Our results also stress the importance of early graft damage in pancreas transplantation.

Role of transarterial chemoembolization for hepatocellular carcinoma before liver transplantation with special consideration of tumor necrosis.

Abstract:  Several authors suggest that local ablative therapies, specifically transarterial chemoembolization (TACE), may control tumor progression of hepatocellular carcinoma (HCC) in patients who are on the waiting list for liver transplantation (orthotopic liver transplantation, OLT). There is still no evidence if TACE followed by OLT is able to prevent recurrence of tumor, to prolong survival rate of the patients on the waiting list, or to improve the survival after OLT. We report 27 patients with HCC who underwent OLT. From these patients, 15 were pre‐treated with TACE alone or in combination with percutaneous ethanol injection (PEI) or laser‐induced thermo therapy (LITT). Mean time on the waiting list was 214 d for treated patients and 133 d for untreated patients. Comparing pre‐operative imaging and histopathological staging post‐transplant, we found 13 patients with tumor progression out of which five were treated with TACE. In two of the TACE patients a decrease of lesions could be achieved. In a single patient, there was no evidence of any residual tumor. Only one patient displayed tumor progression prior to OLT despite undergoing TACE. Comparison of outcome in patients undergoing TACE or having no TACE was not statisitically significant (p = 0.5). In addition, our analysis showed that progression either in the total study population or in the TACE group alone is associated with a significant poorer outcome concerning overall survival (p = 0.02 and p = 0.02).

Mangan-enhanced MR imaging for the detection and localisation of small pancreatic insulinoma

Insulinoma is the most common pancreatic endocrine tumor. Localization of small tumors remains a diagnostic challenge. Recently, Mangafodipir-enhanced MR imaging using a whole-body coil has been shown to be effective in the detection and staging of pancreatic cancer [3]. Localization of even small tumors is improved and surgical techniques, such as robotic-assisted surgery, have been made possible.

Value of donor swabs for intra-abdominal infection in simultaneous pancreas-kidney transplantation.

Background. Simultaneous pancreas-kidney transplantation (SPK) has a higher rate of surgical complications compared with other whole organ transplantations. Graft thrombosis and intra-abdominal infections are the most frequent causes for relaparotomy. We evaluated risk factors for abdominal infections after SPK, with emphasis on the value of the routinely taken intraoperative swabs. Methods. Between June 1994 and December 2000, 177 SPK were performed. Immunosuppression consisted of antithymocyte globulin induction and triple-drug maintenance therapy. Routine swabs were taken from the graft perfusion solutions, from the donors’ duodenum, and from the recipients’ bladder and jejunum (in case of enteric drainage). Results. A total of 19 (10.7%) of 177 patients underwent 41 relaparotomies as a result of intra-abdominal infections. Positive microbial results from any donor site and positive duodenal swabs were significant risk factors for intra-abdominal infections after SPK (P =0.01, P =0.02). There was a significantly higher incidence of abdominal infections when Candida was found in the donor duodenal swab (P =0.0048). Patient survival was significantly lower in cases with abdominal infection (P =0.02). Survival rates of patients with and without abdominal infection were 89.5% and 97.4% at 1 year and 72.3% and 92.8% at 5 years, respectively. Conclusions. The results of this study confirm that abdominal infections significantly reduce patient survival and thus jeopardize the success of SPK. Positive donor duodenal swabs have been revealed to be a significant risk factor for a subsequent intra-abdominal infection, especially when Candida was found.

Octreotide attenuates impaired microcirculation in postischemic pancreatitis when administered before induction of ischemia.

Background. Ischemia-reperfusion injury of the pancreas causes impairment of microcirculation leading to pancreatitis. Postischemic pancreatitis is the most common reason for graft failure in pancreas transplantation. In animal models, octreotide has been described to have beneficial effects on acute pancreatitis by reducing pancreatic enzyme release and edema formation by preventing the increase of macromolecular extravasation. In contrast to earlier experimental setups, this study investigated the influence of octreotide on ischemia-reperfusion pancreatitis when administered before induction of ischemia. Methods. Sprague-Dawley rats were randomly assigned to three groups: (1) sham-operated animals (sham group, n=7); (2) 1 hr ischemia followed by 1 hr reperfusion (control group, n=7); (3) administration of 50 &mgr;g/kg octreotide intravenously 15 min before ischemia (octreotide group, n=7). At the end of reperfusion, intravital fluorescence microscopy was performed assessing the functional capillary density (FCD), leukocyte–endothelium interaction (LEI), and the microvascular permeability. Finally serum amylase and lipase were measured. Results. The application of octreotide significantly reduced the ischemia-reperfusion-induced reduction of FCD (318.4±44.1 cm/cm2 vs. 257.4±11.7 cm/cm2, P<0.001). The increase of LEI due to ischemia-reperfusion (466.9±52.2 cells/mm2) was reduced in the octreotide group (264.4±55.1, P=0.001). Permeability was significantly lower in the octreotide group (0.56±0.57×10−7 cm/sec vs. 2.2.1±0.54×10−7 cm/sec, P<0.001). The level of serum lipase was reduced significantly after octreotide therapy (72.4±53.4 U/L vs. 136.7±66.5 U/L, P=0.026). Conclusion. Octreotide significantly attenuated pancreatic dysfunction caused by ischemia-reperfusion when given before ischemia. Furthermore, we could prove for the first time a beneficial role of octreotide on preservation of the microvascular barrier for macromolecules.

Prothrombotic disorders in uremic type-1 diabetics undergoing simultaneous pancreas and kidney transplantation

Background. Although prothrombotic disorders (PTD) are known to increase the risk of graft failure in kidney transplantation only, there are no data on PTD in simultaneous pancreas and kidney transplantation (SPK). Methods. Forty-seven SPK performed between September 2000 and July 2002 underwent routine screening for PTD. Data were retrospectively analyzed in view of complications (relaparotomy, graft thrombosis, pancreatitis, rejection) and graft function (HbA1c, serum creatinine) 3 months posttransplantation. Results. Twenty-five of forty-seven (53.2%) patients had 30 PTDs. Homozygous mutations of the MTHFR gene (C677T) were found in six, factor-V Leiden mutation (homo- or heterozygous G1691A) in seven, and prothrombin mutation (20210A) in one patient (group 1). Group 2 consists of deficiencies of protein C (n=1), of protein S (n=12), of antithrombin (n=1), and antiphospholipid syndromes (n=2). Overall, PTD had no influence on graft thrombosis (P =0.36) or rejection (P =0.56). In patients with homozygous mutations, relaparotomies were more often necessary than in patients without mutations (42.9% vs. 11.8%, P =0.046). In group 1, there was a trend toward a higher incidence of graft pancreatitis than in patients without mutations (38.5% vs. 14.7%, P =0.075). Three months posttransplantation, HbA1c was 6.0% in patients with and 5.5% in patients without PTD (P =0.023). With regard to serum creatinine, no significant differences were observed. Conclusion. PTD are frequent in type-1 diabetics receiving SPK and may have a role in relaparotomies, graft pancreatitis, and pancreas graft function.

Simultaneous pancreas-kidney transplantation in patients with antiphospholipid syndrome

Background. Graft thrombosis is one of the main reasons of graft loss following simultaneous pancreas–kidney transplantation (SPK). Although antiphospholipid syndrome (APLS) is known as a high risk for graft thrombosis in kidney transplants alone, little is known about APLS in SPK. Methods. Between September 2000 and December 2001, 45 SPK were performed. The treatment and clinical course of 2 patients with APLS is presented. Results. In one patient, APLS was known before transplantation. After SPK, she was treated by systemic heparin followed by coumarin. Both grafts are doing well 5 months posttransplant. The second patient underwent SPK without knowledge of APLS. The patient developed a deep vein thrombosis 5 weeks posttransplant. Hypercoagulability screening revealed APLS. Treatment consisted of systemic anticoagulation. Grafts were not affected. Conclusion. SPK can successfully be performed in APLS patients if anticoagulation is performed consistently. To reduce the risk of graft thrombosis, a pretransplant screening for APLS would probably be of benefit.

Telerobotics in laparoscopic general surgery

SummaryBACKGROUND: Telerobotic systems are considered to further improve laparoscopic surgery. They may have some advantages over conventional laparoscopic instruments such as increase in the degree of freedom and 3-D vision. On the other hand, loss of tactile sensitivity and enormous costs are limiting features of these devices. Currently, 2 systems are in use, the Da Vinci® and the Zeus® system. METHODS: Our review focuses on the present use of telerobotic systems in laparoscopic general surgery. RESULTS: Due to the limited number of systems currently in use and the unlikelihood of their becoming more widespread, there have so far been few reports on large-scale trials, and larger randomised studies are missing. Results available so far indicate feasibility and effectiveness in almost all fields of surgery. CONCLUSIONS: Considering that we are still at the very beginning of evaluating this technique, more data will be required to further determine the role of telerobotics in general surgery.ZusammenfassungGRUNDLAGEN: Möglicherweise kann der Einsatz von Robotersystemen einige Limitationen der konventionellen Laparoskopie, wie z. B. begrenzte Freiheitsgrade und 2-dimensionale Sicht, kompensieren und damit komplexe laparoskopische Operationen erleichtern. Andererseits sind die Systeme teuer und es fehlt bisher das Tastempfinden. Aktuell sind zwei Systeme erhältlich, das Da Vinci®- und das Zeus®-System. METHODIK: Im Rahmen dieses Reviews wird der aktuelle Stand der Verwendung von Telemanipulatoren in der Allgemeinchirurgie dargestellt. ERGEBNISSE: Aufgrund der bisher begrenzten Verbreitung dieser Systeme liegen wenige größere Erfahrungsberichte vor und größere randomisierte Studien fehlen. Die bisherigen Erfahrungen zeigen die Durchführbarkeit und Sicherheit zahlreicher Operationen in vielen Bereichen der Chirurgie. SCHLUSSFOLGERUNGEN: Die Evaluation dieser Systeme beginnt erst und weitere Untersuchungen werden die Wertigkeit von Telemanipulatoren in der laparoskopischen Allgemeinchirurgie zeigen müssen.

Telerobotic-assisted laparoscopic spleen-preserving partial resection of the pancreatic tail for insulinoma.

Laparoscopic pancreatic resection is rarely described. Telerobotic-assisted laparoscopy may offer some advantages for resection of the pancreatic tail. A 49-year-old woman was diagnosed with insulinoma located in the pancreatic tail. Telerobotic-assisted laparoscopic spleen-preserving resection of the pancreatic tail was performed. Operation time was 195 minutes. The postoperative course was uneventful. The previously described advantages of a telerobotic approach with extended range of motion and three-dimensional view make more complex operations like pancreatic resection possible and may offer extended indications for laparoscopic surgery.