Re-operation in pancreas transplantation.

BACKGROUND: Surgical complications in pancreas transplantation are associated with increased morbidity and graft loss. The purpose of our study was to determine the frequency of re-operation in early and late postoperative of pancreas transplantation and its impact in relation to graft survival, patient survival, and hospital mortality. METHODS: We conducted a retrospective study of 238 pancreas transplants performed from 2001 to 2011. We analyzed surgical complications that led to the early and late re-operations by type of transplantation and its relation to pancreas graft survival, patient survival, and hospital mortality. RESULTS: We studied 61 re-operated patients (25.63%), 58 patients with early re-operation and 3 with late re-operation. The median of re-operations per patient was 1.48 (range, 1 to 5). Seventy-five surgical complications required 90 re-operations. The causes of early re-operations were bleeding (8.8%), pancreas graft thrombosis (6.3%), pancreatitis (2.9%), bowel obstruction (2.1%), leaks (2.1%), and evisceration (1.7%). The hospital mortality rate was 0.43%. Pancreas graft survival at 1 and 5 years is higher in the group of non-re-operated than in the re-operated group (98% vs 74% and 93% vs 57%; P = .0001). Patient survival at 1 year is slightly higher in the non-re-operated group, but with no significant differences (99% vs 97%), and at 5 years the patient survival in the non-re-operated group is higher than in the re-operated group (98% vs 91%; P = .011). CONCLUSIONS: Surgical complications required re-operations that were associated with higher morbidity and lower pancreas graft and patient survival.

The Spanish Pancreatic Club recommendations for the diagnosis and treatment of chronic pancreatitis: part 1 (diagnosis).

Chronic pancreatitis (CP) is a relatively uncommon, complex and heterogeneous disease. The absence of a gold standard applicable to the initial phases of CP makes its early diagnosis difficult. Some of its complications, particularly chronic pain, can be difficult to manage. There is much variability in the diagnosis and treatment of CP and its complications amongst centers and professionals. The Spanish Pancreatic Club has developed a consensus on the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. A list of questions was drafted, and two experts reviewed each question. Then, a draft was produced and shared with the entire panel of experts and discussed in a face-to-face meeting. This first part of the consensus addresses the diagnosis of CP and its complications.

The Spanish Pancreatic Club's recommendations for the diagnosis and treatment of chronic pancreatitis: part 2 (treatment).

Chronic pancreatitis (CP) is a complex disease with a wide range of clinical manifestations. This range comprises from asymptomatic patients to patients with disabling symptoms or complications. The management of CP is frequently different between geographic areas and even medical centers. This is due to the paucity of high quality studies and clinical practice guidelines regarding its diagnosis and treatment. The aim of the Spanish Pancreatic Club was to give current evidence-based recommendations for the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. These experts were selected according to clinical and research experience in CP. A list of questions was made and two experts reviewed each question. A draft was later produced and discussed with the entire panel of experts in a face-to-face meeting. The level of evidence was based on the ratings given by the Oxford Centre for Evidence-Based Medicine. In the second part of the consensus, recommendations were given regarding the management of pain, pseudocysts, duodenal and biliary stenosis, pancreatic fistula and ascites, left portal hypertension, diabetes mellitus, exocrine pancreatic insufficiency, and nutritional support in CP.

[Indications for laparoscopic pancreas operations: results of a consensus conference and the previous laparoscopic pancreas register]. / Indikation zur laparoskopischen Pankreasoperation: Ergebnisse einer Konsensuskonferenz und des bisherigen laparoskopischen Pankreasregisters.

Laparoscopic pancreatic surgery is not common practice in Germany and is only carried out in approximately 20 clinics but with an increasing trend. The reasons for this are manifold, such as the current selection of patients and both skills in laparoscopic and pancreatic surgery are necessary to perform this operation safely. In 2008 a registry called "Laparoscopic pancreatic surgery" was implemented to collect enough data in Germany to find out whether the resection is safe, feasible and beneficial for the patient.For further development of new laparoscopic techniques new data is needed. A group of experts performing laparoscopic pancreatic surgery in Germany supplied their data for the German registry for laparoscopic pancreatic resection and a consensus conference about the indications became necessary. This consensus conference discussed in particular the indications for laparoscopic pancreatic resection. A consensus was found by all members of the conference utilizing currently available evidence-based data.It was suggested that all data of laparoscopic pancreatic surgery should be evaluated in the German Registry. A consensus was made which diseases were either suitable for laparoscopic resection or not suitable or suitable in selected cases.

Indicaciones y proceso de evaluación del paciente con diabetes candidato a un trasplante renal, aislado o combinado con trasplante de páncreas / Indications and clinical evaluation of diabetic patient candidates to kidney transplantation alone or simultaneous kidney-pancreas transplantation

El trasplante renal es considerado el tratamiento de elección para pacientes que sufren insuficiencia renal. En pacientes con diabetes mellitus e insuficiencia renal terminal, las opciones de trasplante son el de riñón y páncreas o bien el de riñón aislado. La elección de un trasplante u otro dependerá de la edad y tipo de diabetes del paciente, aunque siempre será esencial realizar un estudio minucioso para determinar las ventajas y desventajas de cada modalidad de trasplante para el receptor. El trasplante de riñón aislado comporta una notable mejoría de la calidad de vida del receptor, pero no influye sobre el control metabólico ni impide las complicaciones crónicas asociadas a la diabetes. El trasplante simultáneo de páncreas y riñón es un procedimiento más complejo, con mayor riesgo quirúrgico y mayor morbilidad en el periodo postrasplante. Sin embargo, conlleva algunos beneficios: se alcanza la independencia de la insulina, se evita la recidiva de la nefropatía diabética sobre el riñón trasplantado, se consigue estabilizar o mejorar las complicaciones secundarias y se mejora el control de los factores de riesgo cardiovascular, con la consiguiente disminución de la morbimortalidad a largo plazo (AU)

Kidney transplantation is accepted as the best option for patients with renal insufficiency. In patients affected with diabetes mellitus and end-stage renal disease, the options include simultaneous kidneypancreas or kidney transplant alone. To choose one of them depends of the age and diabetes type of the patient, although a thorough study will be essential to determinate the advantages or disadvantages of every modality for the recipient. The kidney alone transplantation improve significantly the quality of live of the recipients but has no effect on the metabolic control and does not prevents the chronic complications due to diabetic disease. Simultaneous kidney-pancreas transplantation is a more complex procedure, with a higher surgical risk and morbidity in the post-transplant period. Nevertheless, it shows several benefits as freedom from exogenous insulin, prevention of recurrent diabetic nephropathy on the kidney allograft, stabilization of or improvement in secondary complications, and a better control of the cardiovascular risk factors with the consequent reduction of the long-term morbi-mortality (AU)

Immunosuppression in pancreas transplantation: the Euro SPK trials and beyond.

The Immunosuppression in Pancreas Transplantation was historically based on the fact that the pancreas is an extremely immunogenic organ. Quadruple drug therapy with polyclonal or monoclonal antibodies induction was the mainstay therapy since the introduction of Cyclosporine A. In the modern era of Immunosuppression, Mycophenolate Mofetil replaced Azathioprine while Tacrolimus-another potent calcineurin inhibitor-had-and still has-a difficult challenge to replaced Cyclosporine A, due to its potential diabetogenic effect. Thanks to the first two EuroSPK studies which prospectively tried to answer several questions in that field. But, the future challenge will be in understanding the impact of innate immunity and ischemic reperfusion injuries on the long-term graft function. Hopefully, new drugs will be available and tested to block unspecific deleterious reactions to attenuate the proinflammatory response. It will be the aim of the third Euro SPK Study.

Simultaneous pancreas-kidney transplantation: is the failure of the grafts also simultaneous?

INTRODUCTION: It is well known that after a simultaneous pancreas and kidney transplantation (SPKT) there is a higher incidence of pancreatic graft loss in the acute period, due to technical problems. However, there is little information about the survival of pancreatic and kidney grafts 1 year after transplantation. AIMS: To analyze the causes of long-term graft loss of SPKT in our hospital and to determine if this loss occurs simultaneously or is isolated. PATIENTS AND METHODS: We analyzed the data of 63 SPKTs performed between February 1983 and October 2005, including the cases with normal renal and pancreatic function after 1 year of transplantation, and with a loss of one or two organs during the follow-up period (8 +/- 4 years). We defined simultaneous SPKT failure as failure that occurs at the same time or when the period between pancreatic and renal graft failure is shorter than 9 months. RESULTS: In 28 patients (44%), there was a simultaneous graft failure, whereas in 35 (56%) the loss of function occurred in only one organ or in both, but separately. Death was responsible for 75% (21/28) of simultaneous graft losses, representing 25% (9/35) of isolated graft failures. Cardiovascular disease was the leading cause of death. In 14 of 35 isolated graft failures, there was loss of renal and pancreatic function (11/14 kidney failed first) with a 2.9 +/- 2.3 years of interval. In 12 cases there was only loss of pancreatic function, whereas in nine cases the affected organ was the kidney. Graft chronic nephropathy and chronic rejection in the pancreas were the main causes of graft failure. CONCLUSIONS: The main cause of simultaneous SPKT failure is patient death; however, among isolated or separated SPKT failures, the kidney failed first, more frequently.

[Parathyroid carcinoma associated to secondary hyperparathyroidism in hemodialyzed patients. Two cases reports]. / Carcinoma de paratiroides asociado a hiperparatiroidismo secundario en pacientes en hemodiálisis.

Parathyroid carcinoma (PC) is an infrequent disease with a subtle initial presentation and a variable course, necessitating a high index of suspicion to make the correct diagnosis. In chronic failure patients on haemodialysis it becomes even more difficult to suspect this entity since the high prevalence of secondary hyperparathyroidism(SHP). Two patients with PC out of a series of 160 patients with moderate-to-severe SHP submitted for parathyroidectomy are reported. Their clinical features are compared with those of the twenty-two cases previously reported in the literature with a discussion of this pathology. Patients with PC showed higher blood levels of iPTH, total calcium, phosphate and total alkaline phosphatase than the SHP population. The final diagnosis of PC was made after histological study revealing capsular or blood vessel invasion.

Carcinoma de paratiroides asociado a hiperparatiroidismo secundario en pacientes en hemodiálisis / Parathyroid carcinoma associated to secondary hyperparathyroidism in patients on dialysis: two cases reports

El carcinoma de paratiroides (CP) es una enfermedad rara caracterizada por la rápida aparición de sus síntomas y su variable evolución, precisando un índice alto de sospecha para su correcto diagnóstico, siendo más difícil de sospechar en los enfermos con enfermedad renal crónica en hemodiálisis, dada la elevada prevalencia de hiperparatiroidismo secundario (HPS) en pacientes en diálisis. Analizamos dos casos de pacientes con CP extraídos de una serie de 160 con HPS moderado-severo sometidos a paratiroidectomía y comparamos sus hallazgos clínicos con los 22 casos publicados previamente con una discusión de su patología. Comparados con la población de HPS, observamos que los pacientes con CP mostraban niveles séricos más elevados de PTHi, calcio, fósforo y fosfatasas alcalinas. El diagnóstico final de CP ha sido siempre histopatológico, mostrando invasión capsular o de los vasos sanguíneos

Parathyroid carcinoma (PC) is an infrequent disease with a subtle initial presentation and a variable course, necessitating a high index of suspicion to make the correct diagnosis. In chronic failure patients on haemodialysis it becomes even more difficult to suspect this entity since the high prevalence of secondary hyperparathyroidism (SHP). Two patients with PC out of a series of 160 patients with moderate-to-severe SHP submitted for parathyroidectomy are reported. Their clinical features are compared with those of the twenty-two cases previously reported in the literature with a discussion of this pathology. Patients with PC showed higher blood levels of iPTH, total calcium, phosphate and total alkaline phosphatase than the SHP population. The final diagnosis of PC was made after histological study revealing capsular or blood vessel invasion

Cytomegalovirus infection in simultaneous pancreas-kidney transplantation.

INTRODUCTION: In this open-label multicenter study, 205 simultaneous pancreas-kidney (SPK) transplant recipients between 1998 and 2000 were randomly assigned to tacrolimus or cyclosporine-microemulsion (ME). All patients received concomitant rATG induction therapy, mycophenolate mofetil and short-term corticosteroids. We report the 3-year data related to the occurrence, severity and effect of cytomegalovirus (CMV) infections. The type of CMV prophylaxis and treatment was at the discretion of the investigator. RESULTS: The overall incidence of CMV infection was 34% with no difference in incidence between the tacrolimus and cyclosporine-ME treatment arms. Statistically significant fewer CMV infections occurred among patients who received ganciclovir (22%) than those who did not receive prophylaxis (42%; P = .0075) or were treated with acyclovir (43%; P = .0066). The CMV infection rate according to donor recipient CMV serological status was: D-/R- group 11%, which was lower than the D-/R+ group at 40% (P = .0035), the D+/R+ group at 37% (P = .0024), or the D+/R- group at 52% (P = .00001). Among the last three groups, the infection rate was lower in patients on ganciclovir than those with no prophylaxis or on acyclovir (22% vs 64%; P = .00001). The incidence of acute rejection episodes was higher among patients without ganciclovir prophylaxis. No difference was observed in actuarial patient, kidney, or pancreas survival rates between patients with versus without infection. CONCLUSIONS: Ganciclovir prophylaxis effectively prevented CMV infection in SPK transplant recipients, especially in higher risk groups. An effect of CMV prophylaxis on the incidence of rejection is possible.

[Hospital registry of pancreatic tumors. Experience of the Hospital Clínic in Barcelona (Spain)]. / Registro hospitalario de tumoraciones pancreáticas. Experiencia del Hospital Clínic de Barcelona.

OBJECTIVE: To describe the characteristics of patients included in the pancreatic tumor registry of the Hospital Clínic of Barcelona. PATIENTS AND METHOD: All patients with pancreatic tumors attended between July 1990 and March 2003 were registered. Data collection included: age, gender, date of diagnosis, diagnosis, histology, size, location and tumor stage, and treatment. The correlation between tumor stage and age, date of diagnosis, and tumor location was also evaluated. RESULTS: Six hundred thirty patients with pancreatic tumors were included, representing an incidence of 60 patients/year. The mean age was 66 years and the male-to-female ratio was 1,18:1. The most frequent lesion was malignant tumor of the pancreas (92%), and the most frequent histological type was pancreatic ductal adenocarcinoma (73%). The most frequent location was the head of the pancreas (64%). In 28% of the patients, pancreatic cancer was diagnosed in stage I and II. Resection was performed in 31% of patients, whereas 48% of the patients received no treatment. The ratio between local (stage I)/disseminated (stage IV) disease was 0,34. The ratio between stage I/IV increased with age, diagnosis prior to 1994, and tumor location in the head of the pancreas. CONCLUSION: Hospital tumor registries can be used to define the profile of the attended population, which can help to delineate the best diagnostic-therapeutic strategy and can be useful in clinical research.

Macrovascular events after kidney-pancreas transplantation in type 1 diabetic patients.

BACKGROUND: There are few studies concerning the effect of kidney-pancreas transplantation (KPTx) on the progression of macrovascular disease in type 1 diabetic patients. The aim of our study was to retrospectively evaluate the incidence of macrovascular events after functioning KPTx. MATERIALS AND METHODS: We studied 146 patients (96 men and 50 women) who had undergone KPTx from February 1983 to September 2001, with more than 1 year of evolution of both grafts functioning normally. The mean follow-up of the patients after KPTx was 5+/-3 years. RESULTS: Before KPTx, 29 patients displayed 42 macrovascular events. During the follow-up after transplantation, intermittent claudication remained in 25 patients (86.2%) with 11 new macrovascular events (1 stroke, 1 angina pectoris, 1 myocardial infarction, and 8 minor amputations) in 10 patients (34%). Among the 117 patients without antecedent macrovascular events prior to KPTx, 38 (32.5%) experienced a total of 63 macrovascular events (26 intermittent claudication, 4 stroke, 8 angina pectoris, 7 myocardial infarction, 11 minor amputations, and 7 major amputations). Before transplantation, 88.4% of the patients presented with hypertension, 42.5% a history of smoking, and 14.4% previous treatment for dyslipidmia. After transplantation, we observed an important reduction in the percentage of patients with hypertension (48.6%) and smoking (25.5%), without a change in the prevalence of dyslipemia (19.9%). Hypertension after transplantation was clearly associated with the appearance or persistence of macrovascular events. CONCLUSION: In our experience, 43% of the transplant recipients present with macrovascular events. It is important to note the elevated prevalence of cardiovascular risk factors in the patients who underwent KPTx.

Correlates of cognitive impairment in elderly residents of long term care institutions in the metropolitan area of Guadalajara, Mexico.

AIM: To determine the prevalence of cognitive impairment and to examine the correlation between demographic and social factors, the activities of daily living (ADL), and depression with cognitive function in elderly Mexicans living in nursing homes. DESIGN: Cross-sectional. SETTING: Fourteen nursing homes in Guadalajara. PARTICIPANTS: Data were drawn from a random sample of 451 elderly, aged 60-104 years. MEASUREMENTS: The Spanish versions of MMSE (Folstein), ADL index (Barthel), and the Geriatric Depression Screening (GDS) (Yesavage); demographic factors were obtained. RESULTS: The prevalence of cognitive impairment was 52.3%, with a cut-off of 19/20 (Bohnstedt). Cognitive impairment was significantly related to gender, educational level, activity participation, pension, ADL, and depression. CONCLUSION: The results indicate a higher prevalence of cognitive impairment than in other Mexican studies. The data are consistent with previous findings that cognitive impairment in the elderly is more common among females, those with a low level of education, the lack of participation in social/leisure activities, ADL dependencies, and depression.

Reflexiones sobre algunas realidades y perspectivas de la cirugía y de los cirujanos del siglo XXI / Reflections on some features and indicators for damage control surgery

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Laparoscopic pancreatic surgery in patients with chronic pancreatitis.

BACKGROUND: In recent years, technological advances and technical refinements to laparoscopic instruments have encouraged some surgeons to explore the application of laparoscopic methods to benign disorders of the pancreas. The aim of this report was to evaluate the feasibility and outcome of laparoscopic pancreatic surgery in patients with chronic pancreatitis. METHODS: One group of five patients with disease of nonalcoholic origin localized in the body-tail of the pancreas underwent distal pancreatectomy with preservation of the splenic vessels; a second group of six patients with symptomatic pancreatic pseudocysts (alcoholic origin in four cases and idiopathic in two cases) underwent laparoscopic transgastric drainage. For distal pancreatectomy and spleen salvage, the patient's positioning was half-lateral decubitus with the left side up. Four ports were used. A comparison was made with 41 patients with chronic, pancreatitis who underwent conventional open distal pancreatectomy. For the patients with laparoscopic distal pancreatectomy, the mean operative time was 4 h (range 3-5). RESULTS: There were no pancreatic-related complications, but one patient was reoperated for perforation of duodenal ulcer. The mean hospital stay was 6 days and the mean time to resume normal daily activities was 3 weeks. Laparoscopic pseudocyst drainage was performed in four patients via laparoscopic anterior gastrostomy and two patients via laparoscopic intraluminal cystogastrostomy. The mean operative time was 100 min (range 60-160). There was no morbidity. The mean hospital stay was 5 days, and the mean time to resume normal daily activities was 2 weeks. CONCLUSION: This study provides information about the possibilities of performing laparoscopic surgery in patients with chronic pancreatitis. Laparoscopic distal pancreatectomy with preservation of the splenic vessels and laparoscopic transgastric drainage are feasible and safe techniques. They offer obvious advantages, such as reduction of the parietal damage to the abdomen, a shorter hospital stay, and an earlier postoperative recovery than can be obtained with conventional open pancreatic resection.

Outcome of laparoscopic pancreatic surgery: endocrine and nonendocrine tumors.

Laparoscopic pancreatic surgery (LapPS) for management of benign pancreatic tumors has still not been defined. This paper evaluates the feasibility and outcome of LapPS in patients with endocrine pancreatic tumors (EPTs) and cystic neoplasms of the pancreas (CyNP). Eighteen patients with benign pancreatic tumors underwent LapPS between January 1998 and May 2001. The indications were 10 EPTs (6 sporadic insulinomas, 1 multiple insulinoma of multiple endocrine neoplasia type 1, 2 nonfunctioning tumors, 1 VIPoma) and 8 CyNPs (3 serous cystadenomas, 5 mucinous cystic neoplasms). The laparoscopic procedure was performed using four ports with patients in the half-lateral position. Laparoscopic ultrasonography (LapUS) was used in all cases. Laparoscopic enucleation (LapE) was planned in five patients and performed in four (one conversion for tumor not found during laparoscopy). Laparoscopic pancreatic resection (LapPR) with spleen salvage was planned in 13 patients and performed in 12 (one conversion for metastatic VIPoma), with splenic vessel preservation in 11 patients and short gastric vessel preservation in 1. The average operating time was 3.5 hours after enucleation, 4.0 hours after distal pancreatectomy, and 5.0 hours after subtotal pancreatectomy. Pancreatic fistula was observed in two patients after LapE and in three patients after LapPR. Splenectomy for splenic abscess was performed 1 week after surgery in a patient with short gastric vessel splenic preservation. The average hospital stay was 5 days. We concluded that LapPS is a safe method for removing EPTs and CyNPs, although the incidence of pancreatic fistulas remains high. In selected patients LapPS offers significant benefit to patients: reduced trauma to the abdominal wall, short hospital stay, and a quick postoperative recovery.