Endovascular aortic crossclamp: a novel way to reduce warm ischemia time in DCD donors.

Strategies like donation after cardiac death (DCD) have become more widely accepted to increase potential organ supply and decrease waiting list time. Warm ischemia time (WIT) is a key prognostic factor for organ function. Any process that can decrease WIT could decrease the number of discarded organs as well as improve graft and patient survival. A novel endovascular aortic crossclamping technique in DCD donors is described. Six kidneys and two livers were recovered from three donors. Mean WIT from extubation to aortic crossclamp was 25 +/- 8 minutes. Time from initial glidewire placement to crossclamp was less than 2 minutes. All the organs were adequately flushed; back table examination confirmed clean venous effluent and no signs of thrombosis. Four kidneys were transplanted. Two kidneys were discarded after DCD was prolonged and WIT was 60 minutes. The two livers were not allocated. The WIT can be manipulated after cardiac activity has stopped. The endovascular crossclamp is a novel and feasible technique that can decrease WIT after cardiac death by reducing the surgical time to aortic crossclamp.

Procedure for prolapsed hemorrhoids for treatment of rectal mucosa prolapse following anorectoplasty for imperforate anus.

Surgical management of imperforate anus and rectal mucosal prolapse has evolved significantly over the last two decades. The procedure for prolapsed hemorrhoids (PPH) is now widely used primarily for rectal mucosal prolapse and internal hemorrhoids. We describe the use of PPH in the management of symptomatic rectal mucosal prolapse in a 39-year-old man with a history of a high imperforate anus and pelvic floor reconstruction. At 4-year follow up, the prolapse has not recurred and the preoperative symptoms have resolved. To the best of our knowledge, this is the first report on the use of a PPH in the management of rectal mucosal prolapse in a patient with these characteristics.

Magnetic resonance cholangiopancreatography accurately detects common bile duct stones in resolving gallstone pancreatitis.

BACKGROUND: There is controversy about the optimal method to detect common bile duct (CBD) stones in patients with mild resolving gallstone pancreatitis. The aim of this study was to evaluate magnetic resonance cholangiopancreatography (MRCP) in detecting choledocholithiasis in this group of patients. STUDY DESIGN: A prospective randomized trial was conducted. Patients randomized to group 1 (n = 34) underwent laparoscopic cholecystectomy (LC) and intraoperative cholangiography (IOC). Those randomized to group 2 (n = 29) had preoperative MRCP, of these, patients with negative MRCP underwent LC and IOC, patients with positive MRCP had preoperative ERCP followed by LC. RESULTS: Sixty-three patients were randomized (34 to group 1 and 29 to group 2). CBD stones were found in 5 patients in group 1. CBD exploration was performed in 2 patients, preoperative ERCP in 1, and postoperative ERCP in the other 2. MRCP showed CBD stones in 4 patients in group 2. There were two false-positive MRCPs. Four patients with a negative MRCP did not have IOC or ERCP, the remaining 21 patients with a negative MRCP had a negative IOC. The MRCP sensitivity was 100% (95% CI, 16-100%), specificity 91% (95% CI, 72-99%), positive predictive value 50% (95% CI, 7-93%), negative predictive value 100% (95% CI, 84-100%), and accuracy 92% (95% CI, 74-99%). CONCLUSIONS: Patients with resolving gallstone pancreatitis and a negative MRCP do not need preoperative ERCP or IOC. Only patients with a positive MRCP will require preoperative ERCP.

Recent trends in the management of combined pancreatoduodenal injuries.

In an effort to better characterize the natural history of pancreatoduodenal injuries, we present a review of clinical experiences in the treatment of combined traumatic pancreatoduodenal injuries, focusing on patients in extremis. Records of patients with abdominal trauma admitted to a level 1 trauma center from 1997 to 2001 were reviewed. Of 240 patients who sustained a pancreatic or duodenal injury, 33 had combined pancreatoduodenal injuries. Eighty-two per cent of the patients (27/33) in this series had penetrating injuries, 72 per cent (24) sustained gunshot wounds (GSW). Thirty-one patients were male, and the mean age was 33 years (range, 7-74). These patients presented with an average Injury Severity Score (ISS) of 22 +/- 12 and an average Glasgow Coma Score of 14 +/- 2. Overall length of stay was 39 +/- 59 days (range, 0-351 days). These 33 patients underwent a total of 57 laparotomies with an average of 1.7 operations per patient (range, 1 to 5 operations). Eighty-four per cent of the patients had an associated gastrointestinal injury and 45 per cent had a major vascular injury. Thirteen of the 33 (39%) patients presented in extremis, all 13 underwent an abbreviated laparotomy. The complication rate was 36 per cent, including fistula, abscess, pancreatitis, and organ dysfunction. There were 6 hospital deaths for a mortality rate of 18 per cent. Pancreatoduodenal injuries are associated with a variety of other serious injuries, which add to the overall complexity of these patients. Abbreviated laparotomy may be helpful when managing combined pancreatoduodenal injuries in patients who are in extremis.

Intraductal oncocytic papillary neoplasm of the extrahepatic biliary tree: first report.

Tumors with oncocytic differentiation may occur in a variety of organs, but are extremely rare in the biliary system. Intraductal oncocytic papillary neoplasms (IOPNs) were first described in the pancreas to differentiate a rare subset of pancreatic neoplasm from the intraductal papillary mucinous neoplasms (IPMNs). IOPN of the extrahepatic biliary tree has not been previously described. We describe the first case of an intraductal oncocytic papillary neoplasm at the bifurcation of the common hepatic duct in a 52-year-old white male with a two-year history of intermittent biliary obstruction.