Passenger lymphocyte syndrome in ABO and Rhesus D minor mismatched liver and kidney transplantation: A prospective analysis.

The increasing demand for solid organs has necessitated the use of ABO and Rhesus (Rh) D minor mismatched transplants. The passenger lymphocyte syndrome (PLS) occurs when donor lymphocytes produce antibodies that react with host red blood cell (RBC) antigens and result in hemolysis. Our aim was to evaluate prospectively the role of PLS in post transplant anemia and hemolysis in ABO and RhD minor mismatched recipients of liver and kidney grafts and to study the association of PLS with donor lymphocyte microchimerism. We examined 11 liver and 10 kidney recipients at Day +15 for anemia, markers of hemolysis, direct antiglobulin test and eluates, and serum RBC antibodies. Microchimerism was determined in peripheral blood lymphocytes by genotyping of simple sequence length polymorphisms encoding short tandem repeats. Immune hemolytic anemia and anti-recipient RBC antibodies were observed in 2 out of 11 liver (18.2%) and 2 out of 10 kidney (20%) transplants. RBC antibody specificity reflected the donor to recipient transplant, with anti-blood group B antibodies identified in 2 cases of O to B and 1 case of A to AB transplants while anti-D antibodies were detected in 1 case of RhD-negative to RhD-positive transplant. Donor microchimerism was found in only 1 patient. In conclusion, passenger lymphocyte mediated hemolysis is frequent in minor mismatched liver and kidney transplantation. Recognizing PLS as a potential cause of post transplant anemia may allow for early diagnosis and management to decrease the morbidity and mortality in some patients.

Pancreaticoduodenectomy in a tertiary referral center in Saudi Arabia: a retrospective case series.

CONTEXT: Perioperative outcome of pancreaticoduodenectomy is related to work load volume and to whether the procedure is carried out in a tertiary specialized hepato-pancreatico-biliary (HPB) unit. OBJECTIVE: To evaluate the perioperative outcome associated with pancreaticoduodenectomy in a newly established HPB unit. PATIENTS: Analysis of 32 patients who underwent pancreaticoduodenectomy (PD) for benign and malignant indications. DESIGN: Retrospective collection of data on preoperative, intraoperative and postoperative care of all patients undergoing PD. RESULTS: Thirty-two patients (16 male and 16 female) with a mean age of 59.5±12.7years were analyzed. The overall morbidity rate was high at 53%. The most common complication was wound infection (n=11; 34.4%). Pancreatic and biliary leaks were seen in 5 (15.6%) and 2 (6.2%) cases, respectively, while delayed gastric emptying was recorded in 7 (21.9%). The female sex was not associated with increased morbidity. Presence of co-morbid illness, pylorus-preserving PD, intra-operative blood loss ⩾1L, and perioperative blood transfusion were not associated with significantly increased morbidity. The overall hospital mortality was 3.1% and the cumulative overall (OS) and disease free survival (DFS) at 1year were 80% and 82.3%, respectively. The cumulative overall survival for pancreatic cancer vs ampullary tumor at 1year were 52% vs 80%, respectively. CONCLUSION: PD is associated with a low risk of operative death when performed by specialized HPB surgeons even in a tertiary referral hospital. However, the postoperative morbidity rate remains high, mostly due to wound infection. Further improvement by reducing postoperative infection may help curtail the high postoperative morbidity.

Blood transfusion in patients with sickle cell disease requiring laparoscopic cholecystectomy.

BACKGROUND: Surgery in patients with sickle cell disease is associated with high morbidity. To reduce this high morbidity, different preoperative transfusion regimens were introduced. However, blood transfusion is associated with problems. This prospective study aims to establish the safety of conducting laparoscopic cholecystectomy without transfusion in sickle cell disease patients. METHODS: Forty patients (16 males and 24 females; mean age 26.6 years) undergoing laparoscopic cholecystectomy for cholelithiasis were divided into 2 matched groups: Group I "no transfusion" (n=24 patients; 60%) and Group II "transfusion" (n=16; 40%). In Group II, 9 patients (22.5%) received a simple transfusion and 7 (17.5%) a partial exchange transfusion. RESULTS: Group II patients had significantly higher levels of Hb-S prior to transfusion. They developed a significantly higher complication rate (25% vs. 0%) and subsequently longer hospital stay (3.9±2 vs. 2.1±1.4). Moreover, there was no significant difference in the complications between the simple transfusion and partial exchange transfusion subgroups. CONCLUSION: Surgery in SCD patients is safe without a preoperative blood transfusion. Moreover, preoperative blood transfusion is associated with significantly higher postoperative complications and longer hospital stay. Hence, a "no transfusion" policy is recommended.

Using Multidetector CT in Predicting Resectability of Pancreatic Head Tumors: Surgical and Pathologic Correlation.

BACKGROUND: Computed tomography (CT) is widely used to pre-operatively evaluate patients with pancreatic tumors. AIM: The purpose of this study is to evaluate retrospectively, the ability of multi-detector computed tomography (MDCT) to predict resectability of pancreatic cancer on the basis of surgical outcome and pathologic correlation. PATIENTS AND METHODS: Sixty nine consecutive patients presenting between January 2007 and June 2010 with pancreatic head tumors were included in the study. The study group comprised patients with pancreatic head tumors from the local catchment area and others referred to our tertiary care center from surrounding hospitals. Sixty nine examinations were performed with the same 64 slice CT scan (Brillinat Philips). All patients were imaged using a standardized MDCT protocol. Patients with disease that was clearly inoperable were excluded from the study. The remaining patients (32) had their CT studies double-reported using a standard method. Images were scored for vascular involvement, tumor size and the presence of distant metastases. Surgical and pathologic reports were reviewed and compared to CT results. Frequencies, mean and range were used as descriptive statistics, positive predictive value (PPV) and negative predictive value (NPV) and sensitivity, specificity and accuracy were done using SPSS version 18 program. RESULTS: Of the 32 patients evaluated, 65.6% had successful resection of pancreatic head tumors; while 34.4% had a palliative procedure. When compared to surgical outcome, the positive predictive value of multidetector computed tomography for resectability was 100%. On the basis of pathologic results (considering the surgical technique and the positive surgical margin as a microscopic picture), the negative predictive value of multi-detector computed tomography for resectability fell to 65.5%, Three patients deemed resectable following multi-detector computed tomography had positive margins at pathology. CONCLUSION: There is improved prediction of resectability ÷ unresectability with the introduction of MDCT. When compared to Helical computed tomography (HCT) studies, there is a rise in the rate of successful surgical resection with a concomitant decrease in the rate of palliative surgery. The positive predictive value of multidetector computed tomography for resectable disease is lower when pathologic correlation, as opposed to surgical correlation, is used as the gold standard. KEY WORDS: Multidetector computed tomography (MDCT)- Resectability÷unresectability prediction- Pancreatic head tumors.