J. Viganò

Experimental Small Bowel Transplantation From Non–Heart-Beating Donors: A Large-Animal Study

INTRODUCTION The shortage of organs in the last 20 years is stimulating the development of new strategies to expand the pool of donors. The harvesting of a graft from non-heart-beating donors (NHBDs) has been successfully proposed for kidney and liver transplantation. To our knowledge, no studies are available for small bowel transplantation using NHBDs. In an experimental setting of small bowel transplantation, we studied the feasibility of using intestinal grafts retrieved from NHBDs. MATERIALS AND METHODS Twenty five Large White piglets underwent total orthotopic small bowel transplantation and were randomly divided as follow: NHBD group (n = 15) received grafts from NHBDs; heart-beating donor (HBD) group (n = 10) received grafts from HBDs. The NHBD pigs were sacrificed inducing the cardiac arrest by a lethal potassium injection. After 20 minutes (no touch period = warm ischemia), they underwent cardiac massage, laparotomy, and aorta cannulation for flushing and cooling the abdominal organs. In HBDs, the cardiac arrest was induced at the time of organ cold perfusion. In both groups, immunosuppression was based on tacrolimus oral monotherapy. The animals were observed for 30 days. The graft absorptive function was studied at day 30 using the D-xylose absorption test. Histological investigation included HE (Hematoxilin and Eosin) microscopical analysis and immunohistological staining. RESULTS Animals in the NHBD group died due to infection (n = 3), acute cellular rejection (n = 2), technical complications (n = 2), and intestinal failure (n = 8). In the HBD group, all animals but two were alive at the end of the study. The D-xylose absorption was significantly lower among the NHBD compared with the HBD group (P < .05). CONCLUSIONS This study confirmed that intestinal mucosa is sensitive to ischemic injury. When the intestinal graft is harvested from NHBDs, the infectious-related mortality was higher and the absorptive function lower. Histological examination confirmed a higher grade of ischemic injury in the NHBD grafts that correlated with the clinical data. Therefore, this experimental study suggested that non-heart-beating donation may not be indicated for small bowel transplantation.

Preoperative Oral Carbohydrate Load Versus Placebo in Major Elective Abdominal Surgery (PROCY): A Randomized, Placebo-controlled, Multicenter, Phase III Trial

Objective: To explore whether preoperative oral carbohydrate (CHO) loading could achieve a reduction in the occurrence of postoperative infections. Background: Hyperglycemia may increase the risk of infection. Preoperative CHO loading can achieve postoperative glycemic control. Methods: This was a randomized, controlled, multicenter, open-label trial. Nondiabetic adult patients who were candidates for elective major abdominal operation were randomized (1:1) to a CHO (preoperative oral intake of 800 mL of water containing 100 g of CHO) or placebo group (intake of 800 mL of water). The blood glucose level was measured every 4 hours for 4 days. Insulin was administered when the blood glucose level was >180 mg/dL. The primary endpoint was the occurrence of postoperative infection. The secondary endpoint was the number of patients needing insulin. Results: From January 2011 through December 2015, 880 patients were randomly allocated to the CHO (n = 438) or placebo (n = 442) group. From each group, 331 patients were available for the analysis. Postoperative infection occurred in 16.3% (54/331) of CHO group patients and 16.0% (53/331) of placebo group patients (relative risk 1.019, 95% confidence interval 0.720–1.442, P = 1.00). Insulin was needed in 8 (2.4%) CHO group patients and 53 (16.0%) placebo group patients (relative risk 0.15, 95% confidence interval 0.07–0.31, P < 0.001). Conclusions: Oral preoperative CHO load is effective for avoiding a blood glucose level >180 mg/dL, but without affecting the risk of postoperative infectious complication.

Biliary Intraductal Papillary Mucinous Neoplasm: the “Thread Sign”

A 67-year old man was referred to our centre for recurrent acute cholangitis associated to fluctuant jaundice in the last 2 years. His medical history was positive for IBD for which the patient underwent a total proctocolectomy with ileostomy, GIST of the stomach surgically resected, type 2 diabetes mellitus and a renal vein thrombosis. Previous cholangitis was treated by repeated endoscopic stents positioning until the last hospitalization for a severe isolate obstructive jaundice, (total bilirubin 18–83 mg/dl). Spyglass allowed the direct examination of the bile duct with findings of mucinous, frond-like, floating projections suspected for biliary intraductal papillary mucinous neoplasm (B-IPMN). Biopsies were performed but results were inconclusive. After first-line radiological analysis (US), biliary drainage with ERCP has been performed (Fig. 1) with mucoid lumps at the common biliary confluence. In view of surgical intervention, hepatic-specific MRI has been accomplished with peculiar findings. MR cholangiography has presented diffuse biliary dilation particularly of left hepatic lobe (Fig. 2). MRI, in the hepato-biliary phase, showed no contrast signal in the dilated biliary tract. In particular, Fig. 2 highlights pathognomonic Bthread sign^ (dashed red line box) of B-IPMN represented by presence of hypointense striations within the extrahepatic bile duct. These radiological findings are always pathognomonic for B-IPMN. Due to its premalignant status, left hepatectomy has

Saving from unnecessary pancreaticoduodenectomy. Brunner's gland hamartoma: Case report on a rare duodenal lesion and exhaustive literature review

Introduction Brunners gland hamartoma (BGH) is an infrequently encountered, benign, polypoid proliferation of Brunners glands. Usually these lesions are asymptomatic, just only occasionally presenting with duodenal obstruction or bleeding signs and mimicking a tumoral lesion. Case presentation A 72-year-old male, referred for recurrent vomiting and epigastralgia, was investigated and all preoperative findings were suggestive of a tumour of the duodenum. During the scheduled pancreaticoduodenectomy a mass, resultant to a polyp, was palpatory felt inside the duodenum and then successfully and completely resected through a duodenotomy avoiding surgical overtreatment and connected postoperative morbidities. Histological analysis showed hyperplasia of Brunners glands correspondent to a Brunners gland hamartoma. BGH was undiagnosed before surgery, due to its particular sub-mucosal growth simulating an expanding process starting from the duodenum, and secondly due to unsuccessful biopsies performed during endoscopic procedure. Conclusion BGH is a rare lesion featuring, when symptomatic, obstructive or bleeding symptoms. Surgical treatment represents the gold standard approach in case of lesions that are technically impossible to remove endoscopically or in case of an undiagnosed lesion. Herein, we report a case of a patient presenting with a duodenal lesion mimicking, in all preoperative findings, a tumour of the duodenum. Duodenotomy and resection of the BGH provided a definitive cure avoiding surgical overtreatment. An intraoperative deep analysis of all surgical cases still remain crucial for a right therapeutic choice even in a new era for surgical technology. For similar intraoperative findings we recommend this technique.