Effects of portal versus systemic venous drainage in kidney-pancreas recipients.

A randomized study of combined kidney-pancreas transplantation was performed on 30 insulin-dependent diabetic patients with end-stage renal disease to compare the consequences of pancreas transplantation with portal venous (PV) and systemic venous (SV) drainage. Fourteen patients (SV) group) received systemically drained and sixteen (PV group) portally drained pancreas allografts. Enteric drainage was performed in both groups. The routine follow-up included documentation of the clinical course and detailed endocrine studies. At 1 year after transplantation, the patient survival rate was 92% for the SV group and 96% for the PV group; the graft survival rate was 78% and 82%, respectively. Endocrine studies indicated no difference in fasting and stimulated glucose or in glycosylated hemoglobin between the two groups. In addition, no hyperinsulinemia and lipidic abnormalities were evidenced in either group Long-term studies are required to conclude whether PV and SV drainage in pancreas transplantation are equivalent in terms of patient and graft survival as well as metabolic consequences.

[Hazards of lumbar ureteroscopy: apropos of 4 cases of avulsion of the ureter]. / Des dangers de l'urétéroscopie à l'étage lombaire: à propos de 4 cas d'avulsion de l'uretère.

Ureteroscopy is frequently indicated in the treatment of stones of the pelvic ureter. Access to the lumbar ureter is associated with a higher complication rate: wounds, ureteric rupture, haemorrhage, or more serious lesions such as avulsions of the ureter. We present 4 cases of avulsion of the ureter seen in our department, corresponding to 4 men with stones of the lumbar ureter treated by ureteroscopy, 2 of them after failure of in situ extracorporeal lithotripsy (ESWL) and an attempt to "flush" the stone and the other two because ESWL was not available. The ureteric lesion was related to a Dormia catheter in 2 cases and the ureteroscope in 2 cases. The lesion was diagnosed and treated immediately in 2 patients and after a delay in the other 2 cases. Repair consisted of ureteric reimplantation on a Boari flap (1 case), implantation onto a psoas bladder (1 case), ureteroileoplasty (1 case) and autologous transplantation (1 case). Ureteric lesions prevented uretero-ureterostomy. Ureteric reimplantation on psoas bladder and/or Boari flap appears to be the simplest method, but it cannot always be performed. In the case of avulsion of the ureteropelvic junction with a large defect, autologous transplantation is a method of choice in young subjects. Ureteroileoplasty appears to be reserved for elderly patients.

Effect of the surgical technique on long-term outcome of pancreas transplantation.

To date there is no general consensus as to the best surgical technique for pancreas transplantation. Patients with a pancreas transplant functioning for 3 years or more were retrospectively investigated to compare three surgical techniques: segmental graft with duct obstruction (DO), whole graft with bladder drainage (BD), and whole graft with enteric drainage (ED). Several parameters were studied: patient and graft survival, rejection, long-term surgical and medical complications, and endocrine function. The best results in terms of graft survival and quality of metabolic control were obtained in the group that underwent whole graft transplantation with ED. At 3 years, overall pancreas graft survival was 65% for ED, 60% for BD, and 47% for DO. This surgical method has become the preferred technique in our unit.

[Simultaneous allotransplantation of the adrenal gland and the kidney]. / Allotransplantation simultanée de la surrénale et du rein.

Thirteen months after a bilateral nephrectomy for a synchronous bilateral renal cell carcinoma involving both adrenal glands, a 46 years-old man underwent a simultaneous adrenal and kidney allotransplantation. The left renal allograft was harvested together with a ipsilateral adrenal gland using a common aortic patch. Maintenance immunosuppression was based on azathioprine, antilymphocyte globulin cyclosporine and prednisolone. Kidney allograft function remained stable for 5 years until the patient died from multifocal pancreatic metastases. Clinical, biochemical, radiological and histological arguments demonstrated the function of adrenal allograft. To our knowledge, it is the first report of a simultaneous kidney and adrenal gland allotransplantation in a therapeutic intent. An adrenal gland allotransplantation is only justified when the adrenal insufficiency exists with an end stage organ failure requiring transplantation and therefore immunosuppressive drugs.