Hand-assisted Laparoscopic Donor Surgery for Living Donor Pancreas and Kidney Transplantation: A Single Center Experience / 대한이식학회지

BACKGROUND: In this era of donor shortage, use of organs from living donors has increased significantly. Nonetheless, less than 1% of pancreas transplantations involve living donors, despite the immunological benefits, reduced cold ischemic time, and decreased waiting time. One reason for the paucity of donors is the high morbidity after open surgery. Using hand-assisted laparoscopic donor surgery (HALDS) can be a favorable technique for living donors. METHODS: Using HALDS, we performed three Simultaneous pancreas-kidney transplantations (SPKs) involving living donors. Two donors were women; one was a man. RESULTS: Their mean age was 34.3±4.7 years, and their body mass index was 23.2±2.36 kg/m². The mean operation time was 241±19.0 minutes and the mean cold-ischemic time of the kidney was 42.7±9.8 minutes, while that of the pancreas was 64.3±5.2 minutes. One donor developed a pancreatic fistula, which was controlled using conservative management. The donors' pancreatic and renal functions were well preserved postoperatively. CONCLUSIONS: HALDS for SPKs can be performed without significant complications if the surgeon has sufficient skill.

Acute ileofemoral artery thromboembolism due to left ventricle thrombi with spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is a very rare cause of peripheral artery thromboembolism. It is especially rare to show symptoms of acute limb ischemia without chest symptoms during a hospital visit. In this case, a rare case of SCAD led to left heart failure and caused left ventricle thrombi, which in turn caused peripheral thromboembolism.

Update on the Treatment of Acute and Chronic Antibody-mediated Rejection / 대한이식학회지

Antibody-mediated rejection (AMR) by preformed and/or de novo human leukocyte antigen alloantibodies is a leading cause of early and late allograft loss. In this review, we describe strategic approaches to various forms of AMR in clinical settings that are not based on pathologic classification, which is controversial for atypical AMR (C4d-, DSA-, subclinical etc.). For acute AMR, a variety of modalities like plasmapheresis, intravenous immunoglobulin, and anti-CD20 antibodies have been utilized singly, or in combination, with variable results; however, no established treatment for chronic AMR is known. Significant research efforts are being made for developing new and novel therapies. Improvements in clinical outcomes can be expected from studies evaluating innovative therapeutic concepts, such as proteasome inhibition or complement-blocking agents.

Outcomes of Pancreas Transplantation: Single-Center Experience in Korea / 대한내과학회지

BACKGROUND/AIMS: Pancreas transplantation (PT) as the ultimate treatment for insulin-dependent diabetes has been the subject of debate clinically. Marked improvements in patient and graft survival, and decreases in postoperative morbidity have been achieved due to technical refinements, improved immunosuppressants, and better postoperative management. Here, we report our 18-year experience with PT performed at our institute. METHODS: All recipients who underwent deceased donor or living donor PT between July 1992 and December 2009 were included. We reviewed the medical records, including operation records, progress, and laboratory findings during follow-up. Graft and patient survival were analyzed using the Kaplan-Meier method. RESULTS: In total, 119 cases of pancreas transplantation were performed between July 1992 and December 2009 at our institute. Indications for pancreas transplantation were type I diabetes in 93 (78.2%) patients and type II diabetes in 16 (13.4%) patients. The transplanted pancreas was obtained from a deceased donor in 108 cases (90.8%) and a living donor in 11 cases (9.2%). Median follow-up duration was 39.3 months posttransplantation (range 0~176 months). Overall graft survival rates at 1, 5, and 10 years were 81.6%, 63.4%, and 57.1%, respectively. Following the introduction of tacrolimus as an immunosuppressant in 1999, graft survival at 1, 5, and 10 years was 89.1%, 72.9%, and 66.2%, and overall patient survival at 1, 5, and 10 years was 93.0%, 86.0%, and 86.%, respectively. CONCLUSIONS: Considering the quality of life and long-term patient survival, PT is an effective treatment strategy in non-obese diabetic patients requiring insulin regardless of the type of diabetes.

Clinical Usefulness of Human Cytomegalovirus Antigenemia Assay after Kidney Transplantation / 감염과화학요법

BACKGROUND: This study was performed to determine the cut-off value and the predictability of symptomatic human cytomegalovirus (HCMV) infection according to the peak value of HCMV antigenemia assay in kidney transplant recipients. MATERIALS AND METHODS: We reviewed the results of HCMV antigenemia assay (Chemicon, CA, USA) in patients who received kidney transplantation at our institution from May 2003 through May 2008, and investigated the existence and the type of HCMV infection by the medical record review. Patients who underwent the test only once during the episode or those who received ganciclovir for more than 48hrs before the test were excluded. The receiver-operator characteristic curve was drawn and the point showing maximum likelihood ratio (LR) was chosen as the cut-off value of symptomatic HCMV infection. RESULTS: A total of 689 episodes were screened and 134 episodes were enrolled. Thirty-three (24.6%) episodes were symptomatic HCMV infection, 23 (17.2%) episodes were associated with HCMV syndrome, and 10 (7.5%) episodes were tissue-invasive diseases. The maximum LR was 7.5 (95% confidence interval, 4.014.2) and the cut-off value was 29.5 cells/200,000 WBC. The sensitivity, specificity, positive predictive value, and negative predictive value were 66.7%, 91.1%, 71.0%, and 89.3%, respectively. CONCLUSIONS: The cut-off value of symptomatic HCMV infection by the peak value of HCMV antigenemia assay in our study was similar with previous results, although the sensitivity was relatively low.

Clinical Usefulness of Human Cytomegalovirus Antigenemia Assay after Kidney Transplantation / 감염과화학요법

BACKGROUND: This study was performed to determine the cut-off value and the predictability of symptomatic human cytomegalovirus (HCMV) infection according to the peak value of HCMV antigenemia assay in kidney transplant recipients. MATERIALS AND METHODS: We reviewed the results of HCMV antigenemia assay (Chemicon, CA, USA) in patients who received kidney transplantation at our institution from May 2003 through May 2008, and investigated the existence and the type of HCMV infection by the medical record review. Patients who underwent the test only once during the episode or those who received ganciclovir for more than 48hrs before the test were excluded. The receiver-operator characteristic curve was drawn and the point showing maximum likelihood ratio (LR) was chosen as the cut-off value of symptomatic HCMV infection. RESULTS: A total of 689 episodes were screened and 134 episodes were enrolled. Thirty-three (24.6%) episodes were symptomatic HCMV infection, 23 (17.2%) episodes were associated with HCMV syndrome, and 10 (7.5%) episodes were tissue-invasive diseases. The maximum LR was 7.5 (95% confidence interval, 4.014.2) and the cut-off value was 29.5 cells/200,000 WBC. The sensitivity, specificity, positive predictive value, and negative predictive value were 66.7%, 91.1%, 71.0%, and 89.3%, respectively. CONCLUSIONS: The cut-off value of symptomatic HCMV infection by the peak value of HCMV antigenemia assay in our study was similar with previous results, although the sensitivity was relatively low.

Comparison of Spleen Preserving Laparoscopic Distal Pancreatectomy with En Bloc Laparoscopic Distal Pancreatectomy

PURPOSE: The purpose of this study is to compare the clinical results of spleen preserving laparoscopic distal pancreatectomy (SPLDP) with en bloc laparoscopic distal pancreatectomy (LDP). METHODS: From March 2005 to August 2008, 52 cases of SPLDP and 84 LDPs were performed at our institution and we retrospectively compared these cases. The enrollment period were chronologically divided to four eras of 10.5 months each. RESULTS: The demographics, including the patients' age, gender and BMI, were not different between the two groups. The final pathologic diagnosis was diverse, and it included cystic tumor, SPT, IPMT, cancer, endocrine tumor, etc and there was no difference between the two groups. The tumor location, operative time, tumor size, perioperative transfusion requirement, the length of the hospital stay and the postoperative complications were not different between the two groups. The mean operative time was gradually shortened by eras (Era 1: 236.3 min, Era 2: 223.6 min, Era 3: 188.8 min, Era 4: 187.9 min) and the proportion of SPLDP was increased by eras from 1.9% to 9.6%, 42.3% and 46.2%, respectively. CONCLUSION: SPLDP might be technically more difficult than LDP, and especially in the initial learning stage of performing laparoscopic pancreatic surgery. After overcoming the learning curve, SPLDP can be performed safely and possibly within a shorter time. SPLDP should be tried whenever possible so that the patients get the maximal benefits of minimal invasive surgery and especially for resecting the more distal pancreatic lesions.

Clinical Analysis for the Postoperative Complications of Pancreaticoduodenectomy in the Recent 5 Years

PURPOSE: Pancreaticoduodenectomy (PD) is known to have high morbidity and mortality rates among the various abdominal operations, but there have been few reported current series of pancreaticoduodenectomy from large volume medical centers. The purpose of this study is to analyze the postoperative complications of PD and to assess the risk factors for postoperative morbidity. METHODS: A total of 398 cases of PD were performed by two surgeons from January 2003 to December 2007 at our institution and we retrospectively reviewed the medical records of these cases. RESULTS: 186 (46.7%) of 398 patients underwent pylorus preserving pancreaticoduodenectomy (PPPD) and 212 patients (53.3%) underwent a classic Whipple procedure. The most common indication for this procedure was pancreatic cancer (151 cases, 37.9%) and the second most common was intraductal papillary mucinous tumor (78 cases, 19.6%). The mean age was 57.2 years, ranging from 12 to 81. The mean postoperative hospital stay was 24.7 days. The most common complication was delayed gastric emptying (11.8%) and next was pancreatic fistula (10.3%), bleeding (6.5%) and new onset diabetes mellitus (DM) (4%). Four patients (1%) died of hospital mortality. The patients' age, gender, DM history, hypertension history and serum bilirubin level had no significant influences on the postoperative morbidity rate. CONCLUSIONS: Pancreaticoduodenectomy can be performed safely with an acceptable complication rate and minimal mortality if the surgeon has sufficient surgical experiences and with the advance in anesthesia and postoperative care.

Safety and Efficacy of Early Steroid Withdrawal with Thymoglobuline Induction in Kidney Transplantation / 대한이식학회지

BACKGROUND: We report our experiences of early steroid withdrawal using thymoglobuline induction in kidney transplant patients to verify the efficacy and safety of steroid minimization protocol that can prevent long term complications of steroid. METHODS: From December 2002 to July 2007, 36 kidney transplants were performed at our institution using the steroid early withdrawal protocol with 5 doses induction of thymoglobuline (50 mg IV), and maintaining with tacrolimus/ cyclosporine and mycophenolate mofetil (MMF)/azathioprine. Control group was 80 kidney transplant recipients on conventional triple immunosuppression protocol without antibody induction. RESULTS: Donor and recipient's profiles in both groups were not different except more proportion of diabetic patients and immunosuppression using tacrolimus and MMF in PD free group. The rejection rate was 13.8% and 16.3% in PD free and PD groups respectively. Two years graft and patients survival rate were 96.4%/100% in PD free group and 97.5%/97.5% in PD group. Serum creatinine level was similar between the two groups and WBC count was lower in PD free group up to postoperative 6 months. 72.2% of PD free group remained steroid free by the last follow up. CONCLUSIONS: Early steroid withdrawal with thymoglobulin induction can be applied safely with acceptable success rate with minimizing adverse effects of steroid in kidney transplantation patients. But early steroid withdrawal protocol should be adopted cautiously in immunologically high risk patients.

Experimental Micro Encapsulation of Pancreatic Islets with Air-driven Droplet Generator and Alginate / 대한이식학회지

PURPOSE: Transplantation of microencapsulated islets is proposed as an ideal therapy for the treatment of type 1 diabetes mellitus without immunosuppression. This is based on the principle that foreign cells are protected from the host immune system by an artificial membrane. The aim of this study is to establish an ideal condition of microencapsulation by using an air-driven droplet generator and alginate in vitro. METHODS: Islets were prepared from Sprague Dawley rat and semi SPF-micro pig. Alginate concentrations were changed from 1.5% to 3.0%, and inflow rate of alginate was varied from 10 mL/hr to 40 mL/hr. CO2 flow rate was regulated from 2.0 L/min to 4.0 L/min. Viability was checked by dithizone and FDA/PI staining. Secretory function was tested with glucose challenge and insulin stimulation index was investigated. RESULTS: The optimal conditions for islet encapsulation were revealed with alginate inflow rate of 10 mL/hr, CO2 flow rate of 2.0 L/min in concentration of 2% alginate. In concentration of 2.5% alginate, alginate inflow rate of 20 mL/hr, CO2 flow rate 3.0 L/min was ideal, and alginate inflow rate of 40 mL/hr, CO2 flow rate of 4.0 L/min showed good conditions of microcapsules in concentration of 3% alginate. Viability of encapsulated islets was higher than 90% in both rat and porcine. In terms of insulin secretion, encapsulated islets secreted insulin in response to glucose in static culture medium. However there was no normal response to low and high glucose challenge with stimulation index of less than 2.0. CONCLUSION: Microencapsulation of islets in rat and pig was successful with air-driven droplet generator and alginate in vitro. Further studies about biocompatibility and glucose control in vivo should be followed to be a useful tool for treatment of diabetes mellitus patients in clinical setting.

Analysis of Long Term Follow Up Result between Cycolosporine Based Azathioprine versus Mycophenolate Mofetil Groups Randomized after Renal Transplant / 대한이식학회지

PURPOSE: Mycophenolate mofetil (MMF) has been used widely due to lesser acute rejection episode, better renal function and graft survival than azathioprine (AZA). But currently, there is controversy that which combination of immunosuppressants is most beneficial and cost-effective for renal transplant, because some authors reported MMF was related to more infectious complications and no actual superiority to AZA in aspect of graft survival. So, the aims of this study is to compare the long term outcome of renal transplants and the infectious complications between two groups treated with AZA and MMF in CSA based immunosuppressant treatment at our hospital. METHODS: We retrospectively reviewed allograft recipients who had been transplanted from January of 1998 to July of 2000. 301 patients were enrolled (AZA=150/MMF=151) and analyzed for the incidence of acute rejection, infectious complication, renal function and graft survival. RESULTS: Patients treated with MMF had fewer episodes of acute rejection (AR) within 3 months; 4/151 (2.6%) in MMF versus 15/150 (10%) in AZA (P=0.017), but after 3 months there was no difference in the incidence of AR. However, the patients treated with MMF had more infectious complications such as pneumonia, cytomegalovirus (CMV) infection, but there were no differences in urinary tract infection. There were also no differences in creatinine level at postoperative 1 week, discharge, 1 year, 3 year and 5 year. Graft survival and patient survival after 1 year and 5 showed no statistical differences between two groups. CONCLUSION: MMF combined with CsA was more effective in the prevention of acute rejection within 3 months than AZA, but there was no long term significant difference in renal function, graft and patient's survival. Due to higher incidence of pneumonia and CMV infection in MMF group, it is necessary to choose the combination of immunosuppressants (AZA versus MMF) more appropriately considering efficacy of immunosuppression and infectious complication as well.

Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy

BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic distal pancreatectomy were compared. METHOD: From March 2005 to June2007, we studied 95 patients at Asan Medical Center. These patients had benign pancreatic disease in the distal pancreas, e.g. a cystic neoplasm. These patients underwent a distal pancreatectomy with or without spleen-preservation using laparoscopic or exploration surgery. We divided these patients into two groups i.e. laparoscopy (n=60) and exploration (n=35), and compared the outcomes of the two groups retrospectively. RESULT: There was no difference in demographic features between the two groups. Laparoscopic resection required a median time of 208 mins, compared with 190 mins for the open resection. (p>0.05) The laparoscopic patients started a liquiddiet on postoperative day three, and required a median hospital stay of 11 days, compared with 4.5 days and 16 days for the open resection surgery, respectively. (p0.05) The pancreatic fistula rate was lower in the laparoscopic patient group than in the open group. (8.3% vs. 14.3%) (p>0.05) The rate of spleen-preservation was higher in the laparoscopy group than the open group. (25% vs. 5.7%), (p>0.05) CONCLUSION: The results of this study showed that the laparoscopic distal pancreatectomy had a similar surgical time, an early start of the diet, a shorter hospital stay, and a higher spleensaving rate, compared to exploration surgery. Therefore, considering the benefits of laparoscopic surgery, it appears to be the preferred approach, with or without spleen-preservation, for treating benign distal pancreatic disease.

Alpha-Melanocyte Stimulating Hormone Protects Pancreatic Islet Dysfunction by Peripheral Blood Mononuclear Cells in vitro / 대한이식학회지

PURPOSE: The alpha-melanocyte-stimulating hormone (alpha-MSH) has been shown to interact with various cells of the immune and inflammatory system and down-regulate either the production or the action of the pro-inflammatory cytokines. In this study, we investigated the potential of alpha-MSH on preventing pancreatic islet cell from death and dysfunction by inflammatory cytokines released from peripheral blood mononuclear cells (PBMCs) in rat. METHODS: Rat pancreatic islets were co-cultured with PBMCs, stimulated by phorbol myrstic acid and ionomycin. alpha-MSH was treated to PBMCs for 2 hours before co-culture. Viability and apoptosis of islets were observed by MTT and FACS. Inflammatory cytokines and nitric oxide (NO) were measured. Insulin release from islet co-cultured with mononuclear cells was checked for the islet function. RESULTS: In comparison to control group, viability of islets with alpha-MSH treated mononuclear cells was increased and apoptosis was reduced significantly. Inflammatory cytokines such as TNF-alpha and IL-1beta were reduced in alpha-MSH-treated group. NO production in alpha-MSH-treated group was decreased. Insulin secretory function of islet was recovered in condition of alpha-MSH treatment. CONCLUSION: This study demonstrates that alpha-MSH protects cell death and preserves the secretory function of pancreatic islet cells from the pro-inflammatory reaction of mononuclear cells, and may have the potential to improve the graft survival in clinical islet transplantation.

Surgical Treatment of Acute Necrotizing Pancreatitis

PURPOSE: Acute necrotizing pancreatitis (ANP) causes severe symptoms and shows a high mortality rate 10-40%. Proper operative strategies for the treatment of ANP are still disputed. The aim of this study was to review our experience of 29 cases of ANP, and to examine the possibility of using systemic inflammatory response syndrome (SIRS) criteria as a prognostic factor. METHODS: The medical records of 29 patients with ANP operated on at the Asan Medical Center between 1998 and 2005 were retrospectively reviewed. The patients were categorized by the presence or absence of SIRS before operation. 16 patients had SIRS preoperatively (SIRS group), and 13 did not (NSIRS group). The patients comprised of 27 men and 2 women, with a mean age of 44.7 years. RESULTS: The surgical indications were sepsis syndrome, persistent pancreatitis with severe pain and late complications. The infection rates were 94% and 62% in the SIRS and NSIRS groups, respectively. Diet was started 12.6 and 7.8 days after surgery in the SIRS and NSIRS groups respectively. Postoperative hospitalization in the SIRS and NSIRS groups were 57.8 and 30.9 days, with 3 and 1 mortalities respectively. In the SIRS group, 13 patients (81%) had necrosectomy and drainage, and 3 (19%) a pancreatic resection. In the NSIRS group, 7 patients (54%) had necrosectomy and drainage, and 6 (46%) a patinets resection. CONCLUSION: SIRS might be useful in predicting the prognosis of ANP after surgery. Necrosectomy and drainage procedures, but not in the early period of diseases, can be performed safely to avoid surgical complications and preserve the endocrine function.

Insulin-releasing Neuroendocrine Carcinoma of the Gallbladder Presenting with Hypoglycemic Symptoms

A 52-year-old woman with a meningioma was transferred to our hospital due to abdominal mass and hypoglycemic symptoms. Abdominal computed tomography confirmed thickening of the gallbladder wall, with a 10 x 7 cm mass occupying the right inferior and medial segment of the liver. Her fasting glucose was low on hypoglycemic attack, with a serum insulin level of 173 mIU/ml (normal; 5~20 mIU/ml). Other radiologic tests, including portal venous sampling, did not localize the insulin producing lesion in the pancreas. The preoperative diagnosis was one of a malignant gallbladder tumor infiltrating the liver, with the possibility of nesidioblastosis; therefore, extended cholecystectomy and distal pancreatectomy were performed as the frozen biopsy of the pancreas confirmed an increase of cells in the islet of Langerhans. In permanent specimens, the pancreas showed normal histology and the gallbladder lesion showed a neuroendocrine carcinoma combined with an adenocarcinoma, with positive immunostaining for CD56, chromogranin A and synaptophysin. The special immunostaining for insulin was positive. The patient was in a glucose intolerant state with administration of small dose of oral hypoglycemic agents after operation. Metastases of the lesion to the skull and spine were observed two months after surgery. We report non-islet cell insulin releasing neuroendocrine carcinoma, combined with an adenocarcinoma of the gallbladder, presenting with hypoglycemic symptoms

Laparoscopic-assisted resection of ileal lipoma causing ileo-ileo-colic intussusception

Adult intussusception is rare, and the majority of cases has an underlying cause that requires surgical resection. We report a case of a 39 yr-old man with ileo-ileo-colic intussusception caused by ileal lipoma that was successfully managed by a laparoscopic-assisted surgical maneuver. Using a three-cannula technique, ileo-colic intussusception was reduced laparoscopically. Then, through a 4-cm transverse incision in the right lower quadrant abdomen, ileo-ileal intussusception was reduced manually, and a resection of the tumor-bearing ileal segment and end-to-end anastomosis was performed extracorporeally. Although the role of laparoscopy in managing intussusception is not clearly defined, laparoscopy may be an alternative approach to the surgical treatment of adult intussusception in selected cases.

Suture Omentopexy of Perforated Duodenal Ulcer: Laparoscopic vs. Open Surgery

PURPOSE: Perforated duodenal ulcer can be treated by variable methods ranging from non-operative management to immediate definitive acid-reduction surgery. With the current availability of potent H2 blocker, proton pump inhibitor, and effective Helicobacter pylori (H. pylori) eradication regimens, ulcer recurrence is usually low and the need for definitive surgery has been reduced. Furthermore, the introduction of laparoscopic closure makes the principles of conventional surgical approach weakened at present and surgeons are faced with the choice of definitive surgery or omental patch repair, open or laparoscopic surgery. The aims of this study were to evaluate the feasibility and efficacy of laparoscopic omental patch repair in comparison with conventional surgery and to investigate the status of H. pylori infection and the role of eradication of H. pylori. In addition, we tried to introduce our unique surgical experience using a 3-port technique. METHODS: We treated 31 patients of perforated duodenal ulcer laparoscopically and compared with 30 patients operated by conventional omental patch repair. The patients treated by laparoscopy were evaluated for H. pylori status postoperatively. H. pylori infected patients received 1 or 2 weeks course of Omeprazole plus Amoxicillin and Clarithromycin. RESULTS: Laparoscopic repair was successful in 26 cases and the conversion rate was 16.1%. There was no statistically significant difference in terms of operative time and mortality. Morbidity was comparable between both groups, but the wound infection was more common in the open group. The clinical course and hospital stay were significantly shorter in the laparoscopic group. H. pylori infection rate was 47% and there were 2 cases of ulcer recurrence and 2 cases of reperforation in H. pylori negative patients. CONCLUSIONS: Laparoscopic closure of perforated duodenal ulcer using a 3-port technique is a technically feasible and safe alternative to open repair, with early recovery and low morbidity. H. pylori is positive in about half of perforated duodenal ulcer patients and should be eradicated in positive patients. Other risk factors on ulcer perforation should be identified.