Randomized clinical trial of continuous sutures or non-penetrating clips for radiocephalic arteriovenous fistula.

BACKGROUND: Despite several modifications to the original design, patency rates of radiocephalic arteriovenous fistulas have changed little since the first report in 1966. The use of non-penetrating clips for vascular anastomosis on the outcome of such fistulas was studied. METHODS: Between January 2000 and August 2003, 107 primary radiocephalic fistulas were constructed in 98 patients. The vascular anastomoses were performed at random with either sutures (n = 56) or clips (n = 51). RESULTS: Although there were trends for better primary and primary assisted patency of clipped fistulas, the differences were not statistically significant. The 6-month primary patency rate was 61 per cent with sutures and 69 per cent with clips (P = 0.393). The mean(s.d.) primary patency was 315(306) and 285(285) days for clipped and sutured fistulas respectively. With regard to secondary patency, clipped fistulas were better (P = 0.009). The mean(s.d.) secondary patency was 435(376) and 344(316) days for clipped and sutured fistulas, respectively. There were no significant differences in flow characteristics, number of revisions or other morbidity. CONCLUSION: This randomized clinical trial provided further evidence that the use of vascular clips may improve the patency rate of radiocephalic arteriovenous fistulas for haemodialysis.

Treatment of short-necked infrarenal aortic aneurysms with fenestrated stent-grafts: short-term results.

INTRODUCTION: A proximal neck of 15 mm length is usually required to allow endovascular repair of abdominal aortic aneurysms (EVAR). Many patients have been refused EVAR due to a short neck. By customising fenestrated grafts to the patients' anatomy, we can offer an endovascular solution, especially for patients who are unsuitable for open repair. METHODS: Eighteen patients were selected for fenestrated stent-grafting if they presented with an abdominal aneurysm of at least 55 mm in diameter, a short neck (less than 15 mm), plus contra-indications for open repair (cardiopulmonary impairment or a hostile abdomen). The stent-graft used was a customised fenestrated model based on the Cook Zenith composite system. We used additional stents to ensure apposition of the fenestrations with the side branches. RESULTS: All endovascular procedures were successful. Out of the 46 targeted side branches (10 superior mesenteric arteries, 36 renal arteries), 45 were patent at the end of the procedure. One accessory renal artery became occluded by the stent-graft. There was one possible proximal type I endoleak, which later proved to be a type II endoleak. There was no mortality, but complications occurred in six patients: two cardiac complications, three urinary complications and one occlusion of a renal artery. At follow-up (mean 9.4 months, range 1-18), there were no additional renal complications and all the remaining targeted vessels stayed patent. DISCUSSION: By customizing fenestrated stent-grafts, it is possible to position the first covered stent completely inside the proximal neck, thus achieving a more stable position. The additional side-stents may also contribute to a better fixation. This technique may become a valuable alternative for patients who are at high risk from open surgery.

Rat islet isolation yield and function are donor strain dependent.

Effective rat islet isolation is pertinent for successful islet transplantation and islet studies in vitro. To determine which rat strain yields the highest number of pure and functional islets, four commonly used rat strains were compared with regard to islet yield, islet purity and islet function. Secretory responses were assessed by stimulation with glucose, and by stimulation with glucose plus 3-isobutyl-1-methylxanthine (IBMX). We show that rat islet function and isolation yield are donor strain dependent. Albino Oxford (AO) rats donated twice as many islets than Wistar, Lewis and Sprague Dawley (SD) rats. Stimulation with glucose plus IBMX resulted in an average five-fold increase of the stimulation index of AO, Lewis, Wistar and SD rats compared to stimulation with glucose only. AO islets had improved secretory responses after a one-week culture period, but required the addition of IBMX to glucose to elicit a distinguished stimulated insulin secretion after 2 days of culture. Islets from SD rats showed inferior results with regard to purity immediately after isolation and with regard to function after short- and after long-time culture. Because Lewis islets possessed the highest secretory response to glucose (without IBMX) immediately after isolation, Lewis rats may be preferred as islet donors for immediate use. The addition of IBMX to glucose for in vitro functional testing is recommended because it elicits high insulin secretory responses of islets regardless of the rat strain. AO rats are preferred for culture experiments since the number of experimental animals is reduced two-fold compared to Lewis, Wistar and SD rats.

Non-suture methods of vascular anastomosis.

BACKGROUND: The main aim of performing a vascular anastomosis is to achieve maximal patency rates. An important factor to achieve that goal is to minimize damage to the vessel walls. Sutures inevitably induce vascular wall damage, which influences the healing of the anastomosis. Over time, several alternatives to sutures have become available. METHODS: A Medline literature search was performed to locate English, German and French language articles pertinent to non-suture methods of vascular anastomosis. Manual cross-referencing was also performed and many historical articles were included. RESULTS AND CONCLUSION: The non-suture techniques can be categorized into five groups based on the materials used: rings, clips, adhesives, stents and laser welding. With all these techniques a faster and less traumatic anastomosis can be made compared with sutures. However, each device is associated with technique-related complications. As a consequence, suturing continues to be the standard approach. The disadvantages of the non-suture techniques include: rigidity and a non-compliant anastomosis with rings; toxicity, leakage and aneurysm formation with adhesives; early occlusion with stents; cost, reduced strength in larger-sized vessels and demand for surgical skills with laser welding. Further refinement is needed before widespread adoption of these techniques can occur. Clips, however, may be particularly promising but long-term evaluation is required.

Response of Encapsulated Rat Pancreatic Islets to Hypoxia.

Hypoxia contributes to encapsulated pancreatic islet graft failure. To gain insight into the mechanisms that lead to hypoxia-induced graft failure, encapsulated islet function, vitality, and cell replication were assessed after 2 and 5 days of hypoxic (1% O2) and normoxic (20% O2) culture. The mRNA expression levels of Bcl-2, Bax, inducible nitric oxide synthase (iNOS), and monocyte chemoattractant protein 1 (MCP-1) were assessed, as well as the amount of nitrite and MCP-1 in the culture medium. Hypoxia was associated with loss of encapsulated islet function and vitality, but not with an increase in islet cell replication. Loss of vitality was due to necrosis, and only modestly due to apoptosis. Hypoxia was not associated with changes in the Bcl-2/Bax mRNA ratio, but it did increase the expression of iNOS and MCP-1 mRNA. The increased mRNA levels were, however, not associated with elevated concentrations of nitrite nor with elevated levels of MCP-1 protein. The increased iNOS mRNA levels imply a role for NO in the completion of cell death by hypoxia. The increased MCP-1 mRNA levels suggest that encapsulated islets in vivo contribute to their own graft failure by attracting cytokine-producing macrophages. The discrepancy between iNOS mRNA and nitrite is explained by the longer half-life of NO during hypoxia. MCP-1 protein levels are underestimated as a consequence of the lower number of vital cells in combination with a higher proteolytic activity due to necrosis. Thus, strategies to eliminate hypoxia may not only improve islet function and vitality, but may also reduce the attraction of macrophages by encapsulated islets.

Response of encapsulated rat pancreatic islets to hypoxia.

Hypoxia contributes to encapsulated pancreatic islet graft failure. To gain insight into the mechanisms that lead to hypoxia-induced graft failure, encapsulated islet function, vitality, and cell replication were assessed after 2 and 5 days of hypoxic (1% O2) and normoxic (20% O2) culture. The mRNA expression levels of Bcl-2, Bax, inducible nitric oxide synthase (iNOS), and monocyte chemoattractant protein 1 (MCP-1) were assessed, as well as the amount of nitrite and MCP-1 in the culture medium. Hypoxia was associated with loss of encapsulated islet function and vitality, but not with an increase in islet cell replication. Loss of vitality was due to necrosis, and only modestly due to apoptosis. Hypoxia was not associated with changes in the Bcl-2/Bax mRNA ratio, but it did increase the expression of iNOS and MCP-1 mRNA. The increased mRNA levels were, however, not associated with elevated concentrations of nitrite nor with elevated levels of MCP-1 protein. The increased iNOS mRNA levels imply a role for NO in the completion of cell death by hypoxia. The increased MCP-1 mRNA levels suggest that encapsulated islets in vivo contribute to their own graft failure by attracting cytokine-producing macrophages. The discrepancy between iNOS mRNA and nitrite is explained by the longer half-life of NO during hypoxia. MCP-1 protein levels are underestimated as a consequence of the lower number of vital cells in combination with a higher proteolytic activity due to necrosis. Thus, strategies to eliminate hypoxia may not only improve islet function and vitality, but may also reduce the attraction of macrophages by encapsulated islets.

[One hundred years of the Association of Surgeons in the Netherlands. VI. The training]. / Honderd jaar Nederlandse Vereniging voor Heelkunde. VI. De opleiding.

Over the last 25 years the organisation and content of the residency training program for general surgeons have been adapted to meet the needs of changing surgical practice. Recently more profound changes have been dictated by the Dutch Working Hours Act, which has strictly limited the working hours of resident physicians. With this the emphasis will be on improving theoretical and practical training methods. Because of the limiting working hours resident physicians will have a smaller role in patient care. These changes will require a huge effort from both the teaching surgeons and the resident physicians, as well as substantial financial investments from the government and healthcare providers.

Clinical experience with non-penetrating vascular clips in free-flap reconstructions.

To date, the gold standard for performing a microvascular anastomosis has been the penetrating suture with attached needle. During the last two decades, non-penetrating techniques have been introduced, including the Unilink system for end-to-end anastomoses, and the VCS clip-applier system for both end-to-end and end-to-side anastomoses. The aim of this study was to compare the results of different techniques used to create microvascular anastomoses in free-flap reconstructions. Between January 1995 and October 1999, we performed 474 microvascular anastomoses in 216 consecutive free-tissue transfers. The anastomosis techniques included manual sutures (42%), Unilink rings (34%) and VCS clips (24%). Seven combined sutured-clipped anastomoses were excluded from further analysis. The mean anastomotic time when rings were applied was significantly shorter than when using clips (P 0.0001) or sutures (P 0.0001). Venous anastomoses using clips took less time than those using sutures (P 0.05). There were 19 anastomotic failures, all of which lead to early flap failure. Ten flaps were salvaged by early reoperation; nine flaps were lost. Three more flaps were lost as a result of other causes, bringing the flap survival rate down to 94.4%. Early flap failure was caused by failure of the arterial anastomosis in eight cases; all of them were sutured (these represented 5% of all arterial anastomoses with sutures). None of the clipped arterial anastomoses failed. Early flap failure was caused by failure of the venous anastomosis in 11 patients. Three of these anastomoses were sutured (representing 6% of all venous anastomoses with sutures), seven were anastomosed with rings (representing 5% of all venous anastomoses with rings) and one was clipped (representing 2% of all venous anastomoses with clips). Both the VCS clip-applier system and the Unilink system are easy to handle and allow fast microvascular anastomoses without intraluminal penetration. The patency rate of clipped vessels is at least as good as the patency rates of vessels anastomosed using sutures or rings.

Donor brain death reduces survival after transplantation in rat livers preserved for 20 hr.

BACKGROUND: Eighty percent of donor organs come from donors who have suffered brain trauma (brain-dead donors). This unphysiological state alters the hemodynamic and hormonal status of the organ donor. This can cause organ injury, which has been suggested to alter the immunological or inflammatory status of the organ after transplantation, and may lead to increased sensitivity of the organ to preservation/transplantation injury. In this study we asked the question: does brain death cause injury to the liver that decreases successful liver preservation? METHODS: The rat liver transplant model was used to compare survival in rats receiving a liver from a brain-dead donor versus a non-brain-dead donor. Brain death was induced by inflation of a cranially placed balloon catheter. The rats were maintained normotensive with fluid infusion for 6 hr. The livers were flushed with University of Wisconsin (UW) solution and immediately transplanted or cold stored for 20 hr before transplantation. RESULTS: Recipient survival with immediately transplanted livers or those stored for 20 hr was 100% with livers from non-brain-dead donors. However, survival decreased when livers were procured from brain-dead donors. Survival was 75% (6/8) when storage time was 0 hr and 20% (2/10) when the liver was cold stored for 20 hr before transplantation. CONCLUSION: This study shows that brain death induces alterations in the donor liver that make it more sensitive to preservation/reperfusion injury than livers from donors without brain death. The mechanism of injury to the liver caused by brain death is not known. Because most livers used clinically for transplantation come from brain-dead donors, it is possible that poor function of these livers is due to the intrinsic condition of the donor organ, more than the quality of the preservation. Methods to treat the brain-dead donor to improve the quality of the liver may be needed to allow better preservation of the organ and to give better outcome after liver transplantation.

Preservation of endothelial integrity and function in experimental vascular anastomosis with non-penetrating clips.

BACKGROUND: Vascular repair with sutures is associated with disruption of the endothelial lining and subsequent thrombus formation on the intraluminal lesions. This experimental study was designed to determine whether the use of non-penetrating clips improved endothelial preservation. METHODS: In ten female pigs, 25-mm arteriotomies were made in both carotid arteries. The arteriotomies were repaired with jugular vein patches. On the left side, the repair was done with 1.4-mm titanium clips, and on the right side with two running 6/0 polypropylene sutures. Next, the aorta was divided and subsequently repaired with 2-mm clips in five of these pigs, and with two running 5/0 polypropylene sutures in the remaining five pigs. Endothelial function was studied at the anastomotic site in the carotid arteries by determination of endothelium-dependent and -independent relaxatory responses. Morphometric examination of the carotid arteries and inspection of the aortic endothelium were performed by means of scanning electron microscopy. RESULTS: Maximal endothelium-dependent relaxation to adenosine 5'-diphosphate was less in sutured than in clipped carotid arteries (P < 0.05), while there was no difference in maximal endothelium-independent relaxation to sodium nitrite. This result in clipped carotid arteries was not accompanied by less intimal hyperplasia. Screening of the aortic anastomotic line showed better preservation of endothelial architecture after clip anastomosis. Mean cross-clamp time for carotid patch repair was significantly less when using clips than with sutures. CONCLUSION: The use of non-penetrating clips for vascular anastomoses preserved endothelial function and structural integrity better than running sutures, although the degree of intimal hyperplasia was similar.

C-peptide responses after meal challenge in mice transplanted with microencapsulated rat islets.

AIMS/HYPOTHESIS: This study aimed to assess a response of microencapsulated rat islets to a meal challenge after being transplanted intraperitoneally into diabetic mice. METHODS: Microencapsulated rat islets or control naked syngeneic mouse islets were transplanted intraperitoneally into mice with streptozotocin-induced diabetes. Meal challenges were done 3, 6 and 9 weeks after transplantation. Glucose-induced insulin secretion from microencapsulated islets before and after transplantation was assessed in vitro. RESULTS: Within the first week, all animals transplanted with either microencapsulated rat islets or with syngeneic murine islets became normoglycaemic (< 11 mmol/l). At 4 and 6 weeks, body weight was less than normal in the non-diabetic control mice. Mice with the encapsulated rat islets had lower fasting glucose concentrations and more rapid glucose clearance after a meal challenge than the control mice. The group of mice with transplanted syngeneic islets had similar glucose profiles to control mice, except for slightly accelerated glucose clearance. The C peptide responses of mice with either microencapsulated or naked islets were clearly lower than the controls. An increase of C peptide appeared as early as 20 min in the plasma of the group with encapsulated islets, but this was considerably slower than in the other two groups. Microencapsulated rat islets retrieved 9 weeks after transplantation did not lose their ability to respond to glucose, but their output was less than half of the pretransplant control islets. CONCLUSION/INTERPRETATION: The delivery of C peptide and presumably the accompanying insulin are delayed by restrictions of the capsules and the peritoneal location. However, this delay in reaching peripheral target organs does not prevent microencapsulated grafts from efficiently clearing glucose after a meal.

Effects of brain death and hemodynamic status on function and immunologic activation of the potential donor liver in the rat.

OBJECTIVE: To assess the effect on the function and immunologic status of potential donor livers of the duration of brain death combined with the presence and absence of hemodynamic instability in the donor. SUMMARY BACKGROUND DATA: Brain death, regarded as a given condition in organ transplantation, could have significant effects on the donor organ quality. METHODS: Brain death was induced in Wistar rats. Short or long periods of brain death in the presence or absence of hemodynamic instability were applied. Sham-operated rats served as controls. Organ function was studied by monitoring standard serum parameters. The inflammatory status of the liver was assessed by determining the immediate early gene products, the expression of cell adhesion molecules, and the influx of leukocytes in the liver. RESULTS: Progressive organ dysfunction was most pronounced in hemodynamically unstable brain-dead donors. Irrespective of hemodynamic status, a progressive inflammatory activation could be observed in brain-dead rats compared with controls. CONCLUSIONS: Brain death causes progressive liver dysfunction, which is made worse by the coexistence of hemodynamic instability. Further, brain death activates the inflammatory status of the potential donor liver, irrespective of the presence of hypotension. The changes observed may predispose the graft to additional damage from ischemia and reperfusion in the transplant procedure.

Nonpenetrating vascular clips for small-caliber anastomosis.

In the search for better anastomosing techniques, an improved vascular stapler device (VCS clip applier system(R)) has been introduced. The system uses nonpenetrating clips to approximate everted vessel walls. The objective of this study was to determine the effects of nonpenetrating vascular clips on endothelial wound healing. Aortic end-to-end anastomoses were performed in male Wistar rats. A comparison was made between clipped (n = 12) and conventional hand-sewn (n = 6) anastomoses. Patency rates were verified at different time intervals (after 1, 4, and 8 weeks), after which the anastomotic sites were removed. Morphological evaluation was carried out using scanning electron microscopy. All rats survived the procedure. Closure with clips took less time than closure with conventional sutures, with decreasing aortic clamping times for the clipped procedures during the course of the experiments. Patency rates were 100% in both the "clipped" and "sutured" groups. Microscopic examination showed favorable endothelial healing at the clipped anastomotic sites, with less inflammatory reaction at 1 week, and a more complete endothelial regeneration at 4 and 8 weeks follow-up, as compared with the sutured anastomoses. The clip applier holds the promise of a useful device in anastomosing small-caliber vessels, since clip closure takes less time than suturing, while patency rates are identical, and morphological results are favorable. Training is mandatory to obtain technical skills and to achieve optimal results.

[Gastrointestinal surgery and gastroenterology. II. Transplantation of pancreas]. / Gastro-intestinale chirurgie en gastro-enterologie. II. Pancreastransplantatie.

In patients with type I diabetes mellitus, adequate blood glucose control prevents the development or aggravation of late complications. Apart from administration of insulin, transplantation of insulin-producing tissue is also a possibility. Transplantation of Langerhans islets which contain the insulin-producing beta cells is still in its initial phase. Transplantation of the entire pancreas received a boost in the mid-eighties when it became possible to drain the secretion of the exocrine part of the pancreas to the bladder using the duodenum. Other important steps forward were prevention and treatment of rejection and improvement of the preservation fluid. Because pancreas transplantation makes lifelong immunosuppression necessary, it is performed mainly in patients subjected to kidney transplantation because of terminal renal failure. The one-year survival of the patients after simultaneous pancreas and kidney transplantation increased to over 90%, that of the grafted pancreas to 82% and that of the grafted kidney to 86-90%. The one-year survival after transplantation of the pancreas alone increased to 62%. A successful pancreas transplantation leads to independence from insulin treatment and to normal glucose and HbA1c values. Pancreas transplantation also reduces diabetes nephropathy and progression of coronary sclerosis.

Why do microencapsulated islet grafts fail in the absence of fibrotic overgrowth?

The survival of microencapsulated islet grafts is limited, even if capsular overgrowth is restricted to a small percentage of the capsules. In search of processes other than overgrowth contributing to graft failure, we have studied the islets in non-overgrown capsules at several time points after allotransplantation in the rat. All recipients of islet allografts became normoglycemic. Grafts were retrieved at 4 and 8 weeks after implantation and at 15.3 +/- 2.3 weeks postimplant, 2 weeks after the mean time period at which graft failure occurred. Overgrowth of capsules was complete within 4 weeks postimplant, and it was usually restricted to <10% of the capsules. During the first 4 weeks of implantation, 40% of the initial number of islets was lost. Thereafter, we observed a decrease in function rather than in numbers of islets, as illustrated by a decline in the ex vivo glucose-induced insulin response. At 4 and 8 weeks postimplant, beta-cell replication was 10-fold higher in encapsulated islets than in islets in the normal pancreas, but these high replication rates were insufficient to prevent a progressive increase in the percentage of nonviable tissue in the islets. Necrosis and not apoptosis proved to be the major cause of cell death in the islets. The necrosis mainly occurred in the center of the islets, which indicates insufficient nutrition as a major causative factor. Our study demonstrates that not only capsular overgrowth but also an imbalance between beta-cell birth and beta-cell death contributes to the failure of encapsulated islet grafts. Our observations indicate that we should focus on finding or creating a transplantation site that, more than the unmodified peritoneal cavity, permits for close contact between the blood and the encapsulated islet tissue.

Factors influencing the properties and performance of microcapsules for immunoprotection of pancreatic islets.

There are several approaches of immunoprotection of pancreatic islets for the purpose of successful allo- or xenotransplantation in the absence of immunosuppressive medication. Extravascular approaches are either macroencapsulation (large numbers of islets together in one device) or microencapsulation. The latter approach is to envelop each individual islet in a semipermeable immunoprotective capsule. Quite promising results have been achieved with polylysine-alginate microencapsulated islet grafts in rodents, but clinical application is still restricted to a very small number of cases. Relevant considerations regard the following aspects. The biocompatibility of the microcapsules is influenced by the chemical composition of the materials applied and by mechanical factors related to the production process. With purified instead of crude alginates, the percentage of capsules with fibrotic overgrowth is reduced to approximately ten percent, and the remaining overgrowth is mainly explained by mechanical factors, i.e. inadequate encapsulation of individual islets. Even with purified alginates, however, the duration of encapsulated graft function is limited to a period of six to twenty weeks. Obviously, other factors than bioincompatibility play a role, which factors have to be identified. The limited duration of graft survival cannot be explained by rejection since, in rats, survival times of encapsulated isografts are similar, if not identical, to those of encapsulated allografts. An important factor is probably insufficient nutrition as a consequence of insufficient blood supply of the encapsulated and thus isolated islet. This also influences the functional performance of encapsulated islet grafts. Although normoglycemia can be readily obtained in streptozotocin diabetic rat recipients, glucose tolerance remains severely impaired, as a consequence of an insufficient increase of insulin levels in response to intravenous or oral glucose challenge. Important factors are the characteristics of the capsules applied in view of optimal diffusion kinetics, and the fact that an encapsulated islet graft can only be implanted in the peritoneal cavity because of its volume. Further studies should focus on finding a practically applicable method to reduce the barrier between encapsulated islets and the bloodstream, in order to improve both the functional performance and the survival of encapsulated islet grafts.

Induction of organ dysfunction and up-regulation of inflammatory markers in the liver and kidneys of hypotensive brain dead rats: a model to study marginal organ donors.

BACKGROUND: Marginal donors exposed to the full array of effects induced by brain death are characterized by low success rates after transplantation. This study examined whether organs from marginal brain dead animals show any change in organ function or tissue activation making them eventually more susceptible for additional damage during preservation and transplantation. METHODS: To study this hypothesis we first focused on effects of brain death on donor organ quality by using a brain death model in the rat. After induction of brain death, Wistar rats were ventilated for 1 and 6 hr and then killed. Sham-operated rats served as controls. Organ function was studied using standard serum parameters. Tissue activation of liver and kidney was assessed by staining of immediate early gene products (IEG: FOS, JUN), and inflammatory markers; cell adhesion molecules (Intercellular adhesion molecule-1, vascular cell adhesion molecule-1), leukocyte infiltrates (CD45, T cell receptor, CD8, CD4), and MHC class II. RESULTS: During brain death progressive organ dysfunction was observed that coincided with a significant increase in activation of immediate early genes, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, CD45, and MHC class II versus nonbrain dead controls. In liver tissue also the markers for T cell receptor and CD8 significantly increased. CONCLUSIONS: These findings suggest that an immune activation with increased endothelial cell activation and immediate early gene expression occurs in marginal donors after brain death induction. We suggest that brain death should not longer be regarded as a given nondeleterious condition but as a dynamic process with potential detrimental effects on donor organs that could predispose grafts for increased alloreactivity after transplantation.