Recurrent giant liposarcoma of the spermatic cord.

A giant recurrent retroperitoneal liposarcoma of the spermatic cord was removed in a 40-year-old man. The tumor measured 50 cm and weighed 42 Kilograms. Radiotherapy and chemotherapy have little role in this neoplasm. Despite the huge dimension of the mass surgery was successfully undertaken without relapse at 12 months follow-up.

The unsolved problem of fistula after left pancreatectomy: the benefit of cautious drain management.

The aim of the study was to identify factors related to the onset of pancreatic fistula and to define the characteristics of the fistula. The study group was composed of 123 patients who underwent left pancreatectomy since 1996. Pancreatic closure was accomplished by a hand-sewn technique (39 patients) or two kinds of mechanical staplers: Proximate (Ethicon Endo-Surgery, Cincinnati, OH) (46 patients) and Endo-GIA (United States Surgical, Norwalk, CT) (38 patients). Fistula was defined as output greater than 5 ml, with amylase x 5, after day 5. In case of fistula, the drain removal was scheduled at a daily output less than 5 ml. Mortality was 0%, morbidity was 48%, and pancreatic fistula rate was 34%. Fistula rate was 38% after hand-sewn closure, 26% after Proximate, and 39% after Endo-GIA (NS). None of the other factors (separate duct ligation, hand-sewn suture in addition to stapler, spleen preservation, use of pledgetted suture, sex, age, and indication for pancreatectomy) proved to be related to a reduction in the onset of fistula. All fistulas healed spontaneously. Mean fistula duration was 36 days; 92.8% of patients with fistula were discharged with drain. The policy of delayed drain removal allowed a low rate of fistula associated morbidity (16%) and of readmission (4.7%). In conclusion, fistula is an unsolved problem of left pancreatectomy. However, a careful drain management allows a good outcome in patients with fistula.

Gastrointestinal bleeding from enterically drained transplanted pancreas.

Gastrointestinal bleeding has been described as related complication of pancreas transplantation. Of 166 simultaneous pancreas kidney transplantations, 61 were enteric-drained pancreas transplants (eight done with and 53 without Roux-en-Y loop). The patients were divided into two groups according to Roux (group I, n = 8) or no Roux (group II, n = 53) technique. Seven patients experienced anastomotic hemorrhage between the jejunum and duodenal stump (11%), five cases in group I and two in group II (P < 0.001). No relationships between gastrointestinal bleeding duodenal stump and recipient jejunum blood flow, mean pancreatic cold ischemia time, platelet count, and prothrombin time were observed. Donor age over 40 years and abnormal activated partial thromboplastin time constituted risk factors for hemorrhage from the duodenojejunal anastomosis. There were no significant differences in pancreas graft and patient survival rates between the two groups. Anastomotic hemorrhage did not influence patient and graft survival.

Successful endovascular treatment for gastroduodenal artery pseudoaneurysm with an arteriovenous fistula after pancreas transplantation.

The aim of this study was to demonstrate the usefulness of endovascular treatment for gastroduodenal artery pseudoaneurysm with an arteriovenous fistula after simultaneous pancreas-kidney transplantation. We describe the case of a 38-year-old man who underwent successful simultaneous pancreas-kidney transplantation. An asymptomatic pseudoaneurysm of the donor gastroduodenal artery with an arteriovenous fistula was incidentally diagnosed by routine color flow Doppler ultrasound (CDU) examination and confirmed by 3-D gadolinium-enhanced magnetic resonance angiography (MRA) 15 days after transplantation. Selective arteriography (via the right femoral artery) confirmed an arteriovenous fistula and a pseudoaneurysm of the donor gastroduodenal artery. The patient underwent successful endovascular embolization. At 11 months of follow-up, normal pancreatic function was reported. Endovascular treatment for gastroduodenal artery pseudoaneurysm with an arteriovenous fistula after pancreas transplantation obviates the need for surgical intervention.

Successful surgical salvage of pancreas allograft.

BACKGROUND: Early and late complications related to the pancreas after simultaneous kidney-pancreas transplantation (SKPT) frequently result in graft loss. The authors describe a surgical rescue technique that allows salvage of the pancreatic graft when surgical complications appear after the transplant. METHODS: Of 158 patients who underwent SKPT, 7 were identified with posttransplant complications that required surgical salvage of the pancreas allograft. The surgical salvage technique consisted of the following: pancreatoduodenectomy with conversion from whole-pancreas transplant with bladder or enteric diversion to segmental graft with duct injection (three cases) and conversion from whole-pancreas transplant with duct injection (four cases). RESULTS: Five of seven pancreas allografts are still functioning, with a mean follow-up of 28 months (range, 6-42 months). CONCLUSION: The described surgical treatment may be useful for surgical salvage of the pancreatic allograft, without major impairment of endocrine function.

Advantages and disadvantages of enteric versus bladder diversion in simultaneous kidney-pancreas transplantation.

Simultaneous kidney-pancreas transplantation is universally accepted as being the first-choice treatment for insulin-dependent diabetes mellitus in young patients with end stage renal disease. One hundred and fifty-six simultaneous kidney-pancreas transplantations were evaluated, namely, 33 segmental pancreas transplants with duct occlusion using neoprene (group I), 73 whole pancreas transplants with bladder diversion (group II) and 46 whole pancreas transplants with enteric diversion (group III) (37 with systemic venous drainage and 9 with portal diversion). Patient actuarial survival rates at 1, 5 and 10 years were 85%, 78% and 49%, respectively, in group I and 95%, 78% and 65% in group II. In group III the rates were 87% and 72% at 1 and 3 years, respectively. Kidney survival rates at 1, 5 and 10 years were 83%, 72% and 36% in group I and 89%, 78% and 59% in group II. In group III the survival rates were 85% and 72% at 1 and 3 years. Pancreas survival rates at 1, 5 and 10 years were 66%, 37% and 15% in group I and 73%, 67% and 65% in group II. In group III the rates were 87% and 68% at 1 and 3 years. Developments in the fields of organ retrieval technology, clinical immunosuppression and surgical technique have enabled us to improve our success rates, both in terms of organ survival and the quality of life of kidney-pancreas transplant recipients.

Urological complications after simultaneous renal and pancreatic transplantation.

OBJECTIVE: To report the urological complications after simultaneous renal and pancreatic transplantation. DESIGN: Retrospective study. SETTING: Teaching hospital, Italy. SUBJECTS: 143 consecutive patients having simultaneous renal and pancreatic transplantation by one of three techniques. 33 segmental pancreas with duct occlusion, 77 whole pancreas with bladder diversion, and 33 enteric diversion with systemic (n = 26) or portal venous drainage (n = 7). Urological complications were related to the pancreatic transplant, to the renal transplant, or unrelated to the transplant. MAIN OUTCOME MEASURES: Morbidity. RESULTS: After occlusion of the duct and enteric diversion, there were no urological complications related to the pancreatic transplant. On the other hand, among the 77 patients with pancreatic drainage into the bladder, urological complications were common (56/77; 73%). Complications related to the renal transplant were recorded in 6/33 (18%), 26/77 (34%) and 12/33 (36%), respectively. Complications unrelated to the transplant occurred in 6/77 patients (8%) in the bladder drainage group. Five patients after bladder drainage required cystoenteric conversion. CONCLUSIONS: Enteric diversion is a safe alternative to bladder diversion and results in significantly fewer urological complications.