Immunologic prognostic factors of renal allograft survival.

INTRODUCTION: Successful outcome of renal transplantation depends on various factors, of which immunologic is one of the most important. Accumulated experience of a single center, with the same surgical and immunological team contributes significantly to safe conclusions. Purpose of this study was the evaluation of potential factors, in particular immunologic, that influence renal allograft survival. PATIENTS AND METHODS: During the period 1991-2013, 20,784 surgical operations have been performed in our Department of Surgery - Transplant Unit, of which 575 were renal transplantations. We examined donor and recipient demographic factors, immunologic characteristics along with patient and graft survival. RESULTS: Renal allograft was retrieved from living-related donor in 103 cases and in 472 from cadaveric donor. Donor age was 46.7 ± 18.5 years old and 49.9% (287) were male. Recipient age was 48 ± 12.3 years old and 402 were male. HLA histocompatibility was carefully matched resulting in 85.5% renal transplants with 2-4 HLA mismatches and 93.8% renal transplants with at least one HLA-DR. Renal graft survival the first, fifth and tenth year was 89%, 76%, and 67% and patient survival was respectively 95%, 89% and 83%. Statistical analysis revealed that only donor age influenced renal graft survival (P < .05). HLA mismatches were not correlated with graft survival (log rank P = .495), but identification of panel reactive antibodies (PRA) class I and class II post transplantation had a statistically significant impact on long term renal graft survival (log rank P < .001 and P = .021, accordingly). CONCLUSIONS: Analysis of potential prognostic factor showed that only donor age was correlated with allograft survival. Development of PRA following renal transplantation influenced long term graft survival. Good HLA matching with at least one HLA DR resulted in excellent graft and patient survival.

Intestinal neurofibromatosis and small-bowel adenocarcinoma: a single case study.

OBJECTIVE: Patients with Von Recklinghausen's disease (neurofibromatosis type 1) are at increased risk of developing various tumours. However, the coexistence of neurofibromatosis with small-bowel adenocarcinoma is exceedingly rare. We present an uncommon case of neurofibromatosis type 1, involving the small bowel in a 73-year-old man, who was admitted to our department with signs of acute abdomen. At laparotomy, multiple mesenteric and intramural nodules were seen in the distal ileum. These nodules obstructed ileal lumen, while the intestine wall was perforated in one point. A wide resection of the affected ileum together with all visible nodules in the adjacent mesentery was performed. Histology revealed neurofibromatosis type 1 with malignant transformation to small-bowel adenocarcinoma. The patient had no additional therapy. In a follow-up of 2 years, the patient is very well and there was no recurrence of the disease. We suggest that adenocarcinoma of small bowel should be considered in the evaluation of acute abdominal pain in neurofibromatosis patients.

Thyroid microcarcinoma during thyroidectomy.

INTRODUCTION: We aimed to retrospectively assess the prevalence of microcarcinoma in thyroidectomy specimens from a Greek population and the role of histopathology in determining management of these patients. METHODS: We used histopathological reports of thyroidectomies performed in a Greek general district hospital. The samples consisted of 191 thyroidectomies performed between January 1997 and July 2001. The female:male ratio was approximately 2:1 and the follow-up period was 327 weeks. RESULTS: There were 29 microcarcinomas (15.2 percent) with a female:male ratio of 6:1. The prevalence rate in cases with Hashimoto's thyroiditis was significantly higher compared to cases with other benign thyroid pathology (26.8 percent versus 11.9 percent, p-value equals 0.02). Eight microcarcinomas (27.6 percent) were multifocal. The histological type was that of papillary tumour in ten cases (34.5 percent) and follicular in 18 cases (62.1 percent). There were no deaths, recurrences or metastases during the follow-up period. CONCLUSION: Our results suggest that incidental microcarcinomas are low-risk tumours that do not require routine further intervention. The latter may be necessary for tumours with poor differentiation or for non-incidental microcarcinomas.

Localisation and surgical treatment of insulinomas.

Most insulinomas are solitary, benign and functional neuroendocrine pancreatic tumours which give rise to manifold symptoms. Their preoperative localisation is often unclear, but the cure rate after their excision is very high. It was the aim of this study to analyse and evaluate our group of patients with regard to preoperative tumour localisation and overall surgical results. Twelve patients with a biochemical diagnosis of organic hyperinsulinism were surgically treated. Diagnosis was made with the combination of magnetic resonance imaging, computed tomography, selective angiography and intraoperative portal vein sampling. In five patients, the tumour was enucleated, in three patients Whipple procedure was performed; while three patients underwent left pancreatectomy with spleen preserving in two cases. The twelfth patient underwent total pancreatectomy following Whipple procedure performed elsewhere. There was no postoperative death. The complications were two pancreatic fistulas and two wound infections. The fasting pre- and postoperative plasma glucose mean value was 2.8 mm/l and 4.9 mm/l, respectively; while the pre- and postoperative plasma insulin mean value was 282 pm/l and 72 pm/l, respectively. Accurate diagnosis, preoperative localisation and diligent surgical exploration by experienced surgeons are the key to a successful outcome in patients with insulinomas.

Lichtenstein tension-free repair of inguinal hernia.

Recurrences have been a significant problem following hernia repair. The purpose of this study was to present our experience of Lichtenstein tension-free repair of inguinal hernia. In this retrospective study, 223 inguinal hernia repairs were performed between September 2000 and August 2003 in 203 patients, using a polypropylene mesh. The main outcome measure was early and late complications and especially recurrences. There were 189 males (93.1%) and 14 females (6.9%). Inguinal hernia was indirect in 70% of cases (n=156), direct in 25% (n=56), and of the mixed type in 5% (n=11). Bilateral inguinal hernia was found in 20 patients (9.8%). 210 (94.2%) of hernias were de novo, while 13 (5.8%) were recurrences. The mean patients age was 54.3 years (range, 32-71 years). The follow-up was completed in 160 patients (78.8%) by clinical examination. The median follow-up period was 3.0 years (range, 1-5 years). Seroma and postoperative neuralgia were observed in one and 5 patients respectively. There was only one recurrence (0.4%) four years later. Lichtenstein tension-free mesh repair of inguinal hernia is a simple and safe method, with no significant early and late morbidity and achieved a method with no recurrence during the follow-up period.

Transplantation of pediatric kidneys to adult recipients: an analysis of 13 cases.

INTRODUCTION: The shortage of cadaveric donors for kidney transplantation has prompted many centers to expand the criteria used for donor selection to increase the organ supply. The use of cadaveric pediatric kidneys has been suggested as a means to overcome the shortage. However, some studies indicate that kidneys from pediatric donors show inferior results to those from adult donors. In this retrospective study we examined the outcome of kidney transplantation using cadaveric pediatric donors. MATERIALS AND METHODS: From October 1990 to May 2002, 13 adult patients received pediatric renal transplants including two that were transplanted en bloc. The patients were divided into two groups based upon donor age: group I donors were 18 months to 6 years old; the seven recipients were of mean age 47.3 years. Group II donors were 7 to 15 years old; the six recipients were of mean age 43.6 years old. Cyclosporine-based immunosuppressive regimens were used in both groups. RESULTS: The patient survival rate was 85.7% in group I and 100% in group II. The graft survival rates at the first and third posttransplant year in group I were 71.4% (5/7) and 57.1% (4/7) and in group II, 66.7% and 50%, respectively. The frequency of urinary complications in group I was 28.5% (2/7) and in group II 33.3% (2/6). There was one case of venous thrombosis in group II. CONCLUSION: Pediatric renal grafts may be used with reasonable safety. However, surgical complications remain a significant problem especially with younger pediatric grafts.

Bleeding from the upper gastrointestinal tract after Mason's vertical banded gastroplasty.

BACKGROUND: Gastric bleeding is a rare complication after a vertical banded gastroplasty (VBG). Only a few cases of gastric bleeding after a VBG have been reported, and there is discussion about its etiology. We present two cases of gastric bleeding after a VBG, and discuss the etiology, diagnostic approach and management. METHODS: During the period 1989-98, we treated two cases of gastric bleeding out of 328 morbidly obese patients that underwent a VBG. The first patient was a 36-year-old woman with body mass index (BMI) 61.5. Gastric bleeding occurred on the 7th postoperative day, due possibly to the increased dose of Low Weight Molecular Heparin (LWMH) which was administrated as prophylactic anticoagulation. The second case concerns a 27-year-old man with 54.0 BMI. Gastric bleeding occurred on the 16th postoperative day and was attributed to a stress ulcer. RESULTS: Both patients were treated conservatively successfully. In the first patient, bleeding was stopped when LWMH was discontinued. In the second patient, bleeding was stopped by gastroscopic epinephrine injection in the bleeding spot. CONCLUSIONS: From our cases and review of the literature, gastric bleeding after a VBG is rare, may be treated easily with conservative measures. Tension of the mesh that surrounds the canal between the two compartments, gastric mucosal irritation from the nasogastric tube and postoperative stress ulcer formation are the most frequent causes of this complication.

Ulcerative colitis and acute stroke: two rare complications after Mason's vertical banded gastroplasty for treatment of morbid obesity.

The authors present a very rare case of ulcerative colitis and acute stroke appearing as complications after Mason's vertical banded gastroplasty for treatment of morbid obesity in a 46-year-old man. On the basis of recent studies, the authors attempt to find the correlation of these three diseases and the possible effect of each disease on the appearance of the others. The dilemmas in the treatment of this patient are also described.

Gastrointestinal complications after vertical banded gastroplasty.

BACKGROUND: Gastric surgical procedures for morbid obesity may have occasional serious complications. The vertical banded gastroplasty according to Mason's technique (VBG) is a common procedure for morbid obesity. The aim of this study is to present the complications in the gastrointestinal (GI) tract after VBG and to discuss their treatment. METHODS: In this study 260 morbidly obese patients (62 males and 198 females) underwent VBG. RESULTS: Complications in the GI tract were encountered as follows: narrowing of the communicating lumen of the two parts of the stomach in four patients, dehiscence of the vertical stomach staple line in three patients, cholelithiasis in 12 patients, gastric perforation in four patients, postoperative fistulas in three patients, serious hepatic failure in one patient, significant gastritis and esophagitis in 32 patients, intestinal obstruction in five patients and frequent prolonged vomiting in 23 patients. The authors attempted to treat all these complications conservatively. In 22 patients, however, a new procedure was necessary. In some cases a partial gastrectomy was necessary. CONCLUSION: VBG is considered to be a satisfactory procedure for weight loss in morbid obesity, but has occasional complications from the GI tract, besides the complications from the other systems. Thus, this procedure should be performed only when absolute indications exist.

Simultaneous liver-renal grafting for polycystic disease.

Our purpose was to describe the first in our country and fourth worldwide simultaneous liver and renal grafting for polycystic disease.