Technical aspects of biliary reconstruction correlated with biliary complications in 46 consecutive right lobe liver transplantations from living donors.

INTRODUCTION: Biliary complications contribute to a high morbidity rate in patients with right lobe liver transplant from a living donor. We retrospectively evaluated biliary reconstructions and complications in a number of recipients with liver transplant from a living donor, in a single center. PATIENTS AND METHODS: A number of 46 patients (23 males and 23 females aged 9-63) received a right lobe liver graft between 2009 and 2013, with the following types of biliary reconstruction:duct-to-duct choledochocholedochal anastomosis (n=24)or Roux-en-Y hepaticojejunoanastomosis, with or without an external transanastomotic biliary stent. RESULTS: The rate of biliary complications (leakage 15.21%,anastomotic stenosis 4.34%, overall 17.39%) was not statistically significantly influenced by the demographics of the studied lot, by the etiology of the liver disease or by the characteristics of the biliary reconstruction; the only risk factor which showed a statistically significant influence in terms of biliary complications was MELD. CONCLUSION: The type and technique of the biliary reconstruction in LDLT should be adapted depending on the anatomy of the biliary tree of both the donor and recipient, as well as the clinical and laboratory findings of the recipient.

Emergency pancreaticoduodenectomy in a patient with an ampullary adenocarcinoma associated with severe acute pancreatitis: a case report.

Emergency pancreatico-duodenectomy is an infrequent surgical procedure. Herein, it is reported the case of a 58-year old man with ampullary carcinoma revealed by acute necrotizing pancreatitis. Due to clinical features, an emergency two-step pancreatico-duodenectomy was performed, accomplished by pancreatic and peripancreatic necrosectomy. The distal remnant pancreas was drained as an external pancreatic fistula. A time later, after complete remittance of local inflammation, the pancreas was anastomosed to the jejunum. The postoperative outcome was uneventful, the patient being disease-free at more than 5 years after surgery. Thus, pancreatico-duodenectomy is a feasible and safe operation when performed in tertiary hepato-bilio-pancreatic centers, in selected cases.

Transplantation of mesenchymal stem cells cultured on biomatrix support induces repairing of digestive tract defects, in animal model.

Transplanted mesenchymal stem cells (MSCs) appear to play a significant role in adult tissue repair. The aim of this research was to obtain MSCs enriched, three dimensional (3D) patches for transplant, and to test their ability to induce repair of iatrogenic digestive tract defects in rats. MSCs were obtained from human and rat bone marrow, cultured in vitro, and seeded in a collagen-agarose scaffold, where they showed enhanced viability and proliferation. The phenotype of the cultured cells was representative for MSCs (CD105+, CD90+, and CD34-, CD45-, CD3-, CD14-). The 3D patch was obtained by laying the MSCs enriched collagen-agarose scaffold on a human or swine aortic fragment. After excision of small portions of the rat digestive tract, the 3D patches were sutured at the edge of the defect using micro-surgical techniques. The rats were sacrificed at time-points and the regeneration of the digestive wall was investigated by immunofluorescence, light and electron microscopy. The MSCs enriched 3D patches were biocompatible, biodegradable, and prompted the regeneration of the four layers of the stomach and intestine wall in rats. Human cells were identified in the rat regenerated digestive wall as a hallmark of the transplanted MSCs. For the first time we constructed 3D patches made of cultured bone marrow MSCs, embedded into a collagen-rich biomatrix, on vascular bio-material support, and transplanted them in order to repair iatrogenic digestive tract defects. The result was a complete repair with preservation of the four layered structure of the digestive wall.

[The periampullary carcinoma. Clinical and therapeutic alternatives]. / Carcinomul periampular. Alternative clinico-terapeutice.

BACKGROUND AND STUDY AIMS: An analysis of the diagnosis difficulties in periampullary carcinoma (PAC) is done, the consequences being the possible therapeutically insufficiencies. PATIENTS AND METHODS: During 10 years (1990-1998) 54 patients have been operated on for a PAC. Sex ratio: 34 males (63%)/20 females (37%). The pick of frequency was in the decade 61-70 years (20 patients) with extremes ages between 20 and 80 years. The main symptom was the cholestatic progressive jaundice with or without neoplasic pain (39 patients--72%). The intermittent jaundice was present only to 7 patients (13%) and the clinical forms without jaundice were manifested to other 8 (15%); superaded colangitic syndrome was present to 17 patients (31%). Other concomitances manifestations of the neoplasic disease were record to 23 cases (43%). Historical evolution of the illness until the cholestatic jaundice appearance was under 2 month to 23 cases, between 2 and 4 months to 24 patients and not sure determined to other 8. The biological preoperative investigations confirmed the clinically evident biliary retention syndrome in 85% of the cases and not yet clinically visible to other 15% of the cases. The ultrasonography was the most conclusive method from the imaging examinations because it have suggested the diagnostic of PAC to 43.5% from the patients submitted to this exploration. Computed tomography was diagnosis relevant only for the in site-regional invasion of the tumors or for the nodes or systemic metastases. Endoscopy and the endobiopsy proved to be valuable especially associated with ERCP (our experience regarding ERCP is not conclusive yet). Therefore the real preoperative diagnostic was established to 11 patients (20%), and for the rest of the cases there have been another presumptive preoperative diagnosis: cancer of the pancreatic head (11 patients), retentive jaundice without determined origin (24 patients), others (8 patients). Intraoperative exploration detected the periampullary tumor through palpation in 30 (55%) cases, through palpation and exploratory duodenectomy in 8 (15%) cases and/or by accessory signs (hydropic gallbladder, dilatation of the main biliary duct etc.). Organic metastases or duodenal stenosis was present in nine cases (6 with nodes metastases). The practiced surgery was: Whipple operations (in one--the majority--or two steps)--35 cases (65%); palliative surgery for biliary drainage 16 (30%) cases; others 3 (6%) cases. The postoperative staging of pT parameter (in situ or ex situ dimensional determined) reveled: pT1-12 patients; pT2--9 patients; pT3--14 patients; pT4--19 patients. Histopathological examinations confirmed the diagnostic of periampullary adenocarcinoma (32 patients) or carcinoma (3 patients) for the 35 patients with resectional operations. The determination of the tissular origin of the periampullary tumor was initially possible only in 11 (31%) operative specimens. A secondary study with many repeated sections in the wax included blocks specified the histogenesis of the tumors to other 10 patients, therefore for a total of 21 cases. We think that this histogenetically diagnosis aspect is important only for some predictive appreciations regarding the outcome of the operated patients and not for the elected therapeutically surgical method. RESULTS: The globally perioperative mortality was 8 (15%) patients. Three from this deceased were a consequence of palliative surgery applied to patients with advanced stages of neoplasic disease. The medium outcome for patients submitted to Whipple operation--in course of evaluation--is between 32 and 41 months to the patients which we can followed. For the patients with palliative operations the same distant survival is between 12 and 24 months.

[Mechanical digestive system suturing devices]. / Suturile digestive mecanice.

Between 1994 (December)-1996 (May) 150 patients have been operated on using one or many stapling devices. The staplers disposable to us were the "Linear Cutter" or GIA (Gastrointestinal Anastomosis), "Linear Stapler" (TA) and "Intraluminal Circular Stapler" or EEA (end-to-end anastomosis) types, produced by ETHICON (Johnson and Johnson Ltd. Company). The principles operations performed were various digestive resections, intervisceralis anastomosis and interventions of reconstructions (in oesophagus surgery, ileal pouch etc.). The advantages of staplers applications are: a) the reduction of the time of operation, of the anesthesia, of the blood loss; b) a soft manipulation of the tissues; c) a smaller inflammatory reaction and the prevention of intraoperative septic contamination and d) a better and faster take back of the functionality of the anastomosis. There were only 4 intraoperative haemorrhages easy controllable. Postoperative complications: a) 3 haemorrhages medically treated; b) immediate leakage 1 patient after colorectoanastomosis, treated by Hartman colostomy; precocious, 7 patients and after 4-6 month, 2 patients. Corrective iterative interventions were necessary only in 5 patients. The operative mortality-1 patient, the cause of death being a bronhopneumonia after a radical oesophagectomy with oesophagoplasty (oesophageal cancer). There was not postoperative mortality depending of stapling application. We don't observed late postoperative complications like stenosis of various anastomosis, quoted in the literature, because the time of following of our 150 patients is too short (maximum 18 months). The conclusions are that the stapling devices are a real surgical progress with the conditions of a correct indication and adequate tactics and operative technique. The economical effort is justified and entirely compensated by the major benefits obtained for the patients.

An unusual case of chest pain and cardiomegaly.

Thymolipoma is an uncommon benign tumour of the anterior mediastinum, consisting of fat and thymic tissue. The diagnosis is easily missed because the tumour may simulate multiple intrathoracic pathological entities. It was first described by Lange in 1916, and since then about 50 cases have been reported. We describe a patient who presented with recurrent episodes of central chest pain and abnormal cardiac silhouette due to a thymolipoma.

Management problems of coincident traumatic diaphragmatic hernia and myocardial infarction.

A 32 year old man suffered a traffic accident, and was admitted to the Emergency Department with closed left-sided chest injury. Subsequent standard procedures revealed a traumatic rupture of the diaphragm and resulting hernia. The surgical treatment of these lesions was without complications. Postoperative monitoring showed a persistent elevation of the ST segment, which was considered to be due to the original trauma. After 14 days the patient was discharged, but at a precautionary follow-up two months later coronary angiography revealed severe ischaemic disease and ventricular aneurysm. The diagnostic and management problems of cases such as this are discussed. It is concluded that one should not be tempted by the youth or apparent good health of the patient to take short-cuts at any stage.

Long-term results of DeVega tricuspid annuloplasty.

DeVega tricuspid annuloplasty was performed in 74 patients undergoing mitral or mitral and aortic valve replacement between January, 1972, and December, 1985. Sixty-two hospital survivors have been followed up for a mean of 85.3 +/- 6.6 months. Actuarial survival at 14 years was 71.5 +/- 8.2%. None of the late deaths was related to the tricuspid annuloplasty. Three patients required tricuspid valve replacement for recurrence of tricuspid regurgitation (0.68% per annum). Eleven asymptomatic patients studied hemodynamically at a mean period of 53 months after the operation showed maintenance of the hemodynamic improvement. We recommend DeVega annuloplasty as the method of choice for moderate to severe tricuspid regurgitation in the absence of an organically diseased or deformed valve.

Biatrial myxoma associated with mitral valve lesion.

Biatrial myxomas are extremely rare. By 1983, only eight successful removals of such tumors had been reported. We describe another such patient, who also had involvement of the mitral valve. Diagnostic aspects of echocardiography and a simple operative technique for the en bloc removal of both tumors are discussed.

Right ventricular outflow tract reconstruction with a bovine pericardial monocusp patch. Long-term clinical and hemodynamic evaluation.

A bovine pericardial monocusp patch was used in 21 patients with a variety of congenital heart defects for reconstruction of obstructed right ventricular outflow tract. Two early postoperative deaths and one late death occurred, and these were unrelated to monocusp patch function. Survivors have completed a mean follow-up of 113 months (range 29 to 141 months). They are all asymptomatic, and their physical activity is unrestricted. Seventeen patients have completed more than 5 years of follow-up and, of these, 11 patients have completed more than 10 years of follow-up. Eleven patients have been reinvestigated by sequential postoperative hemodynamic and angiographic studies at mean periods of 16, 48, and 100 months. The mean peak systolic pressure gradient across the right ventricular outflow tract under conditions of normal flow was 13 +/- 2.4 mm Hg at 16 months, and it has shown no significant change when measured at intervals of up to 124 months after the operation. This lack of change suggests effective long-term relief of the outflow tract obstruction. Serial radiographic screening of all patients and angiographic studies in 11 patients disclosed no evidence of graft calcification, stenosis, or dilatation. The monocusp valve remained functional and effectively abolished or reduced pulmonary valve incompetence. In 11 patients who had residual pulmonary regurgitation, the regurgitation was mild and, up to 12 years after operation, had not resulted in any adverse clinical sequelae.

Late outcome of patients with Braunwald-Cutter mitral valve replacement.

Eighty patients who underwent mitral valve replacement (MVR) with Braunwald-Cutter prostheses (54, single valve replacement; 26, multiple valve replacement) between December, 1972, and September, 1975, are discussed. The period of follow-up ranged from 72 to 120 months with a mean of 84.6 months. For the hospital survivors, actuarial survival at ten years was 73 +/- 6.7% for patients with MVR alone and 30 +/- 17.5% for those with multiple valve replacement. The linearized rate of embolic complications in patients with MVR was 3.2% per year and in patients with multiple valve replacement, 1.5% per year. These low rates of embolism allow a favorable comparison of the Braunwald-Cutter valve with other mechanical prostheses. There was no evidence of serious poppet wear or poppet escape after ten years of the valve in the mitral and tricuspid positions. Thus, elective replacement of the Braunwald-Cutter valve from the atrioventricular position because of this potential problem is not considered necessary. In the aortic position, escape of the poppet from the valve has occurred as late as 101 months. The overall morbidity for the group was high. Only 34% of the patients having MVR and 12% of those with multiple valve replacement are expected to be alive and to remain free from any major complication ten years after operation.

Durability of the pericardial valve.

The fate of 1001 pericardial xenograft valves was analysed during a maximum follow-up period of 13 years. Two basic types of pericardial valves have been implanted. Between 1971 and 1975, 213 patients received 'hospital made' valves (single replacement). Between 1976 and 1983, 601 patients received 788 pericardial valves manufactured by Shiley Inc. (474 Standard and 314 Low profile valves) for both single and multiple replacement. There were 27 instances of valve dysfunction between 13 and 92 months after operation, 20 with 'hospital made' and 7 with Shiley valves. The actuarial freedom from valve failure at 8 years is 94.0 +/- 4.6% for aortic and 98.8 +/- 1.2% for mitral replacement in patients with Shiley valves. In patients with 'hospital made' valves the actuarial freedom from valve failure at 12 years of follow-up is 86.7 +/- 7.6% for aortic and 84.7 +/- 14.1% for mitral replacement. The linearised rate of valve dysfunction was 0.31% per annum for Shiley valves and 1.27% per annum for 'hospital made' valves. This analysis demonstrates that the pericardial xenograft has a low risk of valve failure and a predictable behaviour over a period of 13 years. The Shiley made valves have shown improved durability when compared with the 'hospital made' valves.

Embolism, thrombosis and anticoagulant haemorrhage in mitral valve disease. A prospective study of patients having valve replacement with the pericardial xenograft.

The incidence of systemic embolism has been assessed in 461 patients having mitral valve replacement with the pericardial xenograft. No patient received long-term anticoagulant therapy. The bulk of the patients received six weeks' postoperative treatment with warfarin (322 patients) or dipyridamole (71 patients). No case of valve thrombosis has been encountered. Embolism was recognised in 9 patients of whom 7 had chronic atrial arrhythmias. No patient has died from the effects of embolism and only 2 patients have any residual clinical deficit. The majority of the episodes occurred within the first 6 postoperative weeks. The linearised rate of embolism is 0.55% per annum and is very similar to the rates reported after closed mitral valvotomy, open mitral commissurotomy and mitral valve repair. This rate of embolism is significantly lower than that reported after mitral valve replacement with porcine heterografts (2.9-5.3% per annum) even in patients having long-term anticoagulation where there is an additional haemorrhagic risk associated with the anticoagulant treatment.

Reconstruction of the pericardial sac with glutaraldehyde-preserved bovine pericardium.

Complete closure of the pericardial sac after open-heart surgery is thought to be a help in avoiding some postoperative complications and in facilitating reoperation. Since 1977, sixty-six patients who were subjected to open-heart surgery had glutaraldehyde stabilized xenogeneic bovine pericardial patches inserted to achieve closure of their own pericardial sacs. There were no hemodynamic problems related to the implantation of these patches. All 60 surviving patients were clinically well during a follow-up of 145 patient-years. Reoperation was undertaken in three patients 2(1/2), 3, and 7 years after the initial operation. The presence of the pericardial patch greatly facilitated the reopening of the chest because it prevented the formation of adhesions between the patch and the epicardium. Histologically, the implanted pericardium consisted of laminae of collagen fibrils containing evenly dispersed fibrocyte nuclei and parallel runs of fairly wide, separated elastic fibrils. There was no evidence of immune reaction. On the basis of our findings that there was no host reaction or complications after its use, glutaraldehyde stabilized xenogeneic bovine pericardium appears to be the material of choice for patch closure of the pericardium when primary closure alone is not feasible.

Implications of late morphology of Braunwald-Cutter mitral heart valve prostheses.

Interrelationships among silicone poppet wear, cloth wear, and tissue ingrowth were investigated in 14 retrieved Braunwald-Cutter heart valve prostheses following implantation of 37 to 118 (mean 83) months. Six aortic valves (mean 81 months) had severe cloth and poppet wear. In three the poppet had escaped. The lesser wear of the strut covering on the eight mitral valves (mean 84, range 37 to 108 months) was generally functionally insignificant. Mean decrease in mitral poppet diameter was 0.4% (range 0% to 1.5%), in contrast to a mean of 5.8% for aortic poppets. Histologic examination of the cloth/tissue complex demonstrated well-collagenized tissue ingrowth in areas of intact fabric with focal endothelial lining. Functionally trivial calcific deposits were often noted deep in the tissue coating, adjacent to cloth fibers or the strut metal. These results suggest that the mitral Braunwald-Cutter prosthesis need not be electively replaced without specific indication. A model is presented which explains the favorable clinical course demonstrated for mitral recipients and provides a rationale for the disparate clinicopathological behavior of mitral and aortic Braunwald-Cutter prostheses. Although inconsequential in this setting, the focal microcalcification noted in all mitral prostheses implanted for more than 72 months may have implications for the development of clinical cardiac assist devices for long-term application.

Use of the exercise maximal ST segment/heart rate slope in assessing the results of coronary angioplasty.

A new exercise test was used to assess the effects of coronary angioplasty in 22 patients. Twenty five angioplasty procedures were performed and the exercise maximal ST segment/heart rate slope was measured before and after operation on 23 occasions; in two patients treated for unstable angina the slope was measured only after the two procedures. Successful angioplasty (23 of the 25 procedures) resulted in a significant reduction of the maximal ST/HR slope, usually falling by the equivalent of single vessel disease according to previously published criteria. When angioplasty produced little angiographic change (two of the 25 procedures) the maximal ST/HR slope was not significantly altered. A second, and successful, angioplasty for these two patients led to a significant reduction of the maximal ST/HR slope. Twelve patients were restudied by coronary angiography and exercise testing approximately six months after angioplasty. Of these, six had experienced recurrent chest pain, and the exercise test successfully identified the three who had restenoses and the three who did not. Thus the maximal ST/HR slope was useful as a non-invasive and accurate method for following the progress of individual patients after coronary angioplasty.

Clinical durability of the pericardial xenograft valve: ten years experience with mitral replacement.

Data from 366 patients with mitral valve replacement (250 single and 116 multiple) who received pericardial xenografts between 1971 and 1981 were analyzed. Cumulative duration of follow-up was 1,151 patient-years, with a maximum duration of 10.7 years. Actuarial survival at 11 years is 71.6 +/- 14.2%. Pericardial valve failure occurred in 7 patients (0.6 episodes per 100 patient-years). Actuarial freedom from valve failure at 11 years is 90.4 +/- 9.1% for the entire series. Although 275 (75.1%) patients were in chronic atrial fibrillation, anticoagulants were not used in any patient beyond the first 6 postoperative weeks. The incidence of emboli was 0.6% per year. Six episodes occurred following single mitral valve replacement and 1 after multiple valve replacement (5 early and 2 late). The actuarial freedom from embolism in 96.4 +/- 1.5% at 6 and 11 years postoperatively. Valve thrombosis has not been encountered. This analysis has shown a low incidence of valve dysfunction and a very low risk of embolic complications without long-term anticoagulation. The pericardial xenograft is a safe substitute for the mitral valve, with predictable behavior during the first decade of follow-up.

Serial C-reactive protein measurements in infective complications following cardiac operation: evaluation and use in monitoring response to therapy.

Serum C-reactive protein (CRP) was studied serially in 100 patients who underwent cardiac operation and in another 17 patients in whom serious infections including prosthetic valve endocarditis developed in the early postoperative period. Eleven patients with late onset of prosthetic valve endocarditis and infective endocarditis were also investigated. The assay method used was radial immunodiffusion. Patients without postoperative infective complications showed a rapid increase in CRP levels, which reached a peak within 72 hours after operation followed by a progressive decline. The differences between the CRP levels in infected and uninfected patients were significant (p less than 0.01). Serial measurements were of prognostic value in evaluating the response to chemotherapy and in predicting the outcome of the disease.