Laparoscopic distal pancreatectomy for solid and cystic pancreatic neoplasms: outpatient postoperative management.

BACKGROUND: Laparoscopic distal pancreatectomy is a challenging procedure that has been reported in the last decade. The aim of this study is to describe our experience with laparoscopic distal pancreatectomy and an outpatient postoperative management after an early hospital discharge. METHODS: Retrospective study of 11 laparoscopic distal pancreatectomies carried out at our institution between November 2005 and June 2007 for cystic and solid pancreatic neoplasms. Mean age was 55.5 years and 10 patients were females. A splenopancreatectomy was carried out in 9 cases, and a spleen-preserving resection was carried out in 2 cases. RESULTS: Mean blood loss was 73.6 mL and mean operative time was 238.3 minutes. Patients were able to tolerate regular diet after a mean of 1.2 days and were discharged with a drain after a mean of 2.3 days. Two patients developed a mild pancreatic fistula that resolved with conservative management. One patient developed a pancreatic pseudocyst that was followed up with an MRI. CONCLUSIONS: Laparoscopic distal pancreatectomy is feasible with a fast postoperative recovery. We recommend close follow-up of the patient in the outpatient clinic and maintaining the intraabdominal drain until a pancreatic fistula can be ruled out based on biochemical analysis of the fluid.

Epiphrenic diverticulum: robotic-assisted transhiatal approach.

Surgery of the epiphrenic diverticulum has been related to high postoperative morbidity. Even through a minimally invasive approach, dissection of the neck-proximal portion of the diverticulum can be difficult. Robotic-assisted (RA) technologies have been developed recently. We describe our experience of RA transhiatal diverticulectomy in 2 patients: (1) A 73-year-old female patient who presented with 2 large esophageal diverticula at the mid esophagus and gastroesophageal junction, and a large hiatal hernia. A RA transhiatal diverticulectomy and Nissen fundoplication were performed, although intense adhesions made a limited thoracotomy necessary. The patient developed a mild esophageal leak, which resolved successfully with conservative treatment; (2) A 63-year-old male patient with a large epiphrenic diverticulum, which was resected using the RA transhiatal approach, and a Toupet fundoplication was also performed. The postoperative course was uneventful. We believe that RA transhiatal management of epiphrenic diverticulum can help during the dissection of the proximal portion of the diverticulum and might reduce postoperative morbidity.

Liver transplantation using uncontrolled non-heart-beating donors under normothermic extracorporeal membrane oxygenation.

Because of the organ shortage, non-heart-beating donors have been proposed as a possible source of grafts for orthotopic liver transplantation (OLT). Despite the widespread use of controlled non-heart-beating donors, there are only a few published studies reporting the outcomes with uncontrolled non-heart-beating donors (UNHBDs). A prospective case-control study on adult patients undergoing OLT was designed. We used normothermic extracorporeal membrane oxygenation (NECMO) in all UNHBDs. Matching 2:1 ratio comparison was performed between a study group (UNHBDs) and a brain death donor (BDD) control group. Between January 2006 and March 2008, a total of 60 patients were included: 20 in the UNHBD group and 40 in the control group. The incidence of ischemic cholangiopathy was 5% (n = 1) for the UNHBD group and 0% for the BDD group (P = 0.15). The rate of primary nonfunction was 10% (n = 2) in UNHBD recipients and 2.5% (n = 1) in BDD recipients (P = 0.21), with graft loss in all of them. Three patients were retransplanted in the UNHBD group (15%), 2 of them because of primary nonfunction and 1 because of ischemic cholangiopathy; no patient was retransplanted in the control group (P = 0.012). After a mean follow-up of 330.4 +/- 224.9 days, 1-year cumulative patient survival was 85.5% for the UNHBD group and 87.5% for the BDD group (P = 0.768). One-year cumulative graft survival was 80% in the UNHBD group and 87.5% in the BDD group (P = 0.774). In conclusion, UNHBDs under NECMO are a potential source of organs for OLT with encouraging outcomes potentially comparable to those obtained with BDDs.

Preformed antibodies detected by cytotoxic assay or multibead array decrease liver allograft survival: role of human leukocyte antigen compatibility.

The significance of human leukocyte antigen (HLA) compatibility and preformed antibodies in liver transplantation remains unclear. The objectives of this study were to evaluate, in a single-center cohort comprising 896 liver transplants, whether the degree of donor-recipient compatibility and preformed antibodies modified graft survival. Univariate Kaplan-Meier analysis demonstrated that donor-recipient HLA compatibility had a marginal impact on allograft survival. As for compatibility at individual antigen loci, 2 mismatches at HLA-A conferred a survival advantage in retransplanted allografts (P = 0.011). HLA-B and HLA-DR loci did not play a significant role in outcome in any pathology. The concordance of results on preformed antibodies detected by complement-dependent cytotoxicity (CDC) and a multiple bead assay (Luminex xMAP) showed a strong correlation between both techniques (P < 0.0001). Both CDC-detected and Luminex-detected antibodies were associated with shorter graft survival within the first year post-transplant (P = 0.01 and P = 0.016, respectively). Positive CDC T crossmatches and Luminex-detected HLA class II antibodies played a significant role in decreasing graft survival (P = 0.043 and P = 0.0019 at 1 year, respectively, and P = 0.005 and P = 0.038 at 5 years, respectively). A correlation was also observed between the presence of preformed Luminex-detected class II or Luminex I and II antibodies and allograft rejection (P = 0.001 and P = 0.042, respectively). In conclusion, although HLA typing is not a prerequisite for transplantation, screening of HLA antibodies with Luminex techniques and CDC crossmatch may be useful in the detection of at-risk patients that could benefit from increased surveillance and tailored therapy following transplantation.