Ulrich T. Hopt

Delayed gastric emptying after pylorus-preserving pancreatoduodenectomy is strongly related to other postoperative complications

Patients undergoing pylorus-preserving pancreatoduodenenectomy (PPPD) have a risk of up to 50% for developing delayed gastric emptying (DGE) in the early postoperative course. From 1994 to August 2002, a total of 204 patients underwent PPPD for pancreatic or periampullary cancer (50%), chronic pancreatitis (42%), and other indications (8%). Retrocolic end-to-side duodenojejunostomy was performed below the mesocolon. DGE was defined by the inability to tolerate a regular diet after day 10 (DGE10) or day 14 (DGE14) postoperatively, as well as the need for a nasogastric tube at or beyond day 10 (DGE10GT). Postoperative morbidity was 38%, 30-day mortality was 2.9%, and median postoperative length of stay was 15 days. DGE occurred in 14.7% (DGE10), 5.9% (DGE14), and 6.4% (DGE10GT), respectively. After further exclusion of 21 patients (10.3%) with major complications and no possible oral intake (because of death, reoperation, or mechanical ventilation), the frequencies of DGE10, DGE14, and DGE10GT in the remaining group of 183 patients were 9%, 2%, and 2%, respectively. Multivariate analysis revealed postoperative complications (P < 0.001), the presence of portalvenous hypertension (P < 0.01), and tumors as indications for surgery (P < 0.01) as independent risk factors for DGE10. The overall incidence of DGE was low after PPPD. In those patients experiencing DGE, however, other postoperative complications were the most important factor associated with its occurrence.

Postoperative oral glucose tolerance and stimulated insulin secretion: a predictor of endocrine graft function more than 10 years after pancreas-kidney transplantation.

Background. After pancreas transplantation, endocrine function is determined by the insulin secretory capacity of the transplanted pancreas. The authors evaluated the predictive value of postoperative oral glucose tolerance test (OGTT) and stimulated insulin secretion on long-term endocrine function. Methods. Forty-one patients after pancreas-kidney transplantation with systemic venous drainage were studied. Patients were categorized to have normal glucose tolerance (NGT) or impaired glucose tolerance (IGT) (World Health Organization criteria: NGT, <7.8 mM; IGT, 7.8–11.1 mM 120 min after glucose intake) and high or low total insulin secretion. Mean follow-up of graft function and patient outcome was 10.2±0.5 years after OGTT. Results. Patients with IGT had grafts with a longer ischemia time and a significantly worse urine amylase excretion as compared with patients with NGT. Using Kaplan-Meier survival analysis, patients with NGT had better long-term pancreatic function as compared with IGT in the follow-up after performing the first OGTT (mean, 10.9±0.2 vs. 8.8±0.9 years of graft function; P =0.02), but there was no difference in patient survival and kidney graft function. Also, high insulin secretion predicted significantly longer pancreas graft function as compared with low insulin secretion (P =0.04). Conclusions. Although IGT does not lead to poorer long-term patient survival and kidney graft function, it does predict compromised long-term endocrine function of the transplanted pancreas. Therefore, postoperative OGTT are useful tools for identification of patients at risk of long-term endocrine graft failure after pancreas transplantation.

Temporary small bowel interposition for urinary drainage after partial necrosis of the renal graft pelvis following living related renal donation

SINCE THE ADVENT of kidney transplantation, urological complications have been a major concern. The published incidence varies between 2% and 33% in different series. Due to the limited arterial perfusion of the ureter exclusively from the renal vessels following nephrectomy, an ischemic injury to the ureter commonly leads to necrosis with consecutive urinary leakage of the ureteroneocystostomy or to fibrosis resulting in urinary obstruction. We report a case of corrective surgery to restore urinary continuity using a vascularized intestinal segment in a modified Monti procedure after partial necrosis of the graft pelvis following living related renal transplantation.

Matrix Metalloproteinase-9 als Marker für den Verlauf und die Prädiktion von Komplikationen der akuten Pankreatitis in Tiermodell und klinischem Alltag

Introduction: The prediction of the course of acute pancreatitis and its arising complications is of clinical importance. Matrix metalloproteinase-9 (MMP-9) plays a key role in the leukocyte mediated inflammation cascade and the development of pulmonary complications in acute pancreatitis. Aim of this study was to judge the predictive value of MMP-9 for evaluation of the progression of acute pancreatitis and the development of pulmonary complications in an animal model and patients. Methods: In an established animal model mild oedematous (n = 12) and severe necrotizing pancreatitis (n = 48) were induced by i.v.cerulein or i.v.cerulein and intraductal application of glycodesoxycholic acid (GDOC). 6,12,24 and 72 hours after induction serum MMP-9 was determined in ELISA and pulmonary injury and alveolar leakage were quantified by histology and extravasation of Evans blue. According to Altanta criteria and CT scan, 24 patients with necrotizing and 12 patients with edematous pancreatitis were included in the study. Pulmonary complications were classified as a decrease in paO2 2000 ng/ml). The negative predictive value was 96%. Conclusion: MMP-9 in serum allows a valid grouping to severe and mild courses of acute pancreatitis with a good predictive value for the development of pulmonary complications in the necrotizing disease. MMP-9 is a valid single marker for the evaluation of progression and the development of complications in acute pancreatitis.