Experimental study of inflammatory response and collagen morphometry with different types of meshes.

PURPOSE: To compare an inflammation score and collagen morphometry after incisional hernia repair with four different meshes at two time points. METHODS: Four types of mesh were used to repair an abdominal wall incisional defect in Wistar rats: high-density polypropylene (HW/PP); low-density polypropylene (LW/PP); polypropylene mesh encapsulated with polydioxanone coated with oxidized cellulose (PP/CE); and expanded polytetrafluoroethylene (ePTFE). An inflammation score based on histological analysis and collagen morphometry was performed after 7 and 28 days after operation (POD). RESULTS: Compared to LW/PP group at 7 POD, HW/PP group had lower (p = 0.014) and PP/CE group had higher inflammation scores (p = 0.001). At 28 POD, higher scores were seen in all the other groups compared to the LW/PP group (HW/PP, p = 0.046; PP/CE, p < 0.001; ePTFE, p = 0.027). Comparing groups individually at 7 and 28 PODs, all demonstrated lower inflammation score values at 28 POD (HW/PP, p < 0.001; LW/PP, p < 0.001; PP/CE, p = 0.002; ePTFE, p = 0.001). At 7 POD, higher amounts of collagen were detected in ePTFE compared to HW/PP (p < 0.001) and LW/PP (p = 0.004) and in PPCE group compared to HW/PP (p = 0.022). At 28 POD, no statistically significant difference was found. Comparing groups individually at 7 and 28 PODs, HW/PP and LW/PP showed larger amounts of collagen at the 28th POD, without any statistically significant differences for the PP/CE and ePTFE groups. CONCLUSIONS: Inflammation scores decreased in all groups at 28 POD. Collagen deposition was higher for non-composite meshes at 28 POD.

Clinical evaluation of hepatic transection on pediatric liver transplantation.

OBJECTIVES: Liver transplantation is an effective technique in the treatment of end-stage liver disease. The aim of this study was to evaluate the impact of hepatic transection, an advanced surgical technique able to tailor size to generate two grafts to from a single donor. MATERIALS AND METHODS: A retrospective study between January 2000 and September 2013, reviewing 91 pediatric patients who underwent 96 liver transplants from deceased donors. Patients were distributed into two groups: whole organ (WO, n = 39) and transected liver grafts (TLG, n = 57). The following were evaluated: etiology, anthrophometric parameters (age, weight, height, z score weight/age, and height/age), model for end-stage liver disease (MELD) or pediatric end-stage liver disease (PELD), previous surgeries, transfusion of blood components, 1-year survival rate, preoperative laboratory testing, from the second and seventh postoperative days, lactate during surgery, postoperative complications, duration of surgery, duration of cold and warm ischemia, types of biliary reconstruction, and laboratory testing of the donor. RESULTS: The anthropometric values showed significant differences (P < .05) between the groups. The average age was 124.7 months in the WO group and 33.6 months in the TLG group (P < .0001), while the weight was 28.0 kg and 7.4 kg, respectively (P < .0001). The analysis of z score weight/age showed that the TLG had greater acute and chronic malnutrition, probably due to the etiology of liver disease, present from birth in patients as young. Red blood transfusion was higher in the TLG group (P < .0006) due to the cut surface of the graft, emphasizing the use and improvement of hemostatic techniques. CONCLUSION: Despite differences between the groups, clinical and surgical complications were similar, showing that liver transection injury didn't change the results of transplantation. There was no impact on liver function, graft, or 1-year patient survival after liver transection. Second postoperative lactate is a predictive factor of death. Transection liver transplantation is an effective method as an alternative to pediatric liver transplantation.

Risk factors of pancreatic graft loss and death of receptor after simultaneous pancreas/kidney transplantation.

Simultaneous pancreas/kidney transplants require a long graft survival and the recipient to present with more benefits than risks. We evaluated the risk factors of receptor's death and pancreatic graft loss on 2 occasions (3 and 12 months' postoperatively) in 292 transplants in whom 22 variables were evaluated. Variables were selected, 9 receivers, 8 donors, and 5 variables related to the surgical procedure. All independent variables were compared with the dependent variables of pancreatic graft losses and patient deaths. Those considered significant according to univariate analysis were analyzed by using multiple logistic regression techniques in an attempt to develop a mathematical model capable of predicting both pancreatic graft and patient losses. Lastly, based on the resulting models with all significant variables, scores were created to determine the risk of patient death and pancreatic graft loss. In the adjusted multivariate analysis, the significant variables were donor age, receiver's body mass index, initial pancreas implant, iliac venous drainage, and use of induction therapy related to pancreatic loss within 3 months after transplantation. Independent risk factors regarding the loss of patients within 12 months were body mass index and receptor induction therapy. The variables related to pancreatic graft loss within 3 months were donor age, receiver body mass index, initial use of pancreatic graft, iliac venous drainage, and induction therapy; these variables can be used for creating a risk score. The donor body mass index and the induction therapy were independently related to patient loss within 12 months after the transplant.

Endovascular management of massive hemobilia as a late complication of percutaneous biliary drainage in a pediatric liver transplant recipient: a case report.

Development of biliary strictures after liver transplantation is not uncommon, and minimally invasive procedures are the first-line treatment of choice in most centers. Hemobilia is an infrequent, usually self-limited complication related to the initial biliary access procedure. Massive hemobilia with severe hemodynamic instability is a rare event, particularly as a delayed complication. The difficulty of obtaining surgical access makes management of this condition highly challenging. Endovascular embolization may represent an important treatment option in this setting.

Early and late postoperative inflammatory and collagen deposition responses in three different meshes: an experimental study in rats.

PURPOSE: Although meshes reduce abdominal hernia recurrence, they increase the risk of inflammatory complications. This study aimed to compare the early and late postoperative inflammation and collagen deposition responses induced by three meshes. METHODS: Rats were allocated into three groups. In group I, a polypropylene (PP) mesh was implanted in the abdominal wall. In groups II and III, PP + polyglactin (PP + PG) and PP + titanium (PP + TI) meshes were employed, respectively. On the seventh (7th) postoperative day, collagen deposition and inflammation were evaluated, and immunohistochemistry was performed on abdominal wall biopsies. These data were compared with those obtained on the fortieth (40th) postoperative day in a previous study. RESULTS: The early inflammatory responses were the same in all groups. With time, it decreased in group I (p = 0.047) and increased in group II (p = 0.003). Group I exhibited early elevated VEGF (p < 0.001), COX2 (p < 0.001), and collagen (p = 0.023) levels, and group II exhibited the most severe inflammatory tissue response. On the 40th postoperative day, the VEGF (p < 0.001) and collagen (p < 0.005) were reduced as compared with the 7th postoperative day in all groups. CONCLUSIONS: Belatedly, the inflammatory reaction decreased in PP mesh group and increased in PP + PG mesh group. The PP mesh induced early great elevations in VEGF, COX2 and collagen levels, whereas the PP + PG mesh caused severe tissue inflammation with small elevation in these levels. PP + TI mesh induced inflammatory response levels between the others. In conclusion, the inflammatory response depends on the mesh density and also the mesh material with clinical implications.

Delayed kidney allograft function after simultaneous pancreas-kidney transplantation.

BACKGROUND: Simultaneous pancreas-kidney transplantation (SPKT) is one of the treatments for insulin-dependent chronic renal failure patients. METHODS: One-year patient and kidney allograft survival rates of 150 patients undergoing SPKT were subjected to Cox regression and Kaplan-Meier analyses. Uni- and multivariate methods identified risk factors involved in allograft and patient survival. RESULTS: One-year patient and kidney allograft survival rates were 82% and 80%, respectively. Delayed graft function (DGF) (P = .001; hazard ratio [HR]5.41) and acute kidney rejection episodes (P = .016; HR 3.36) were related to 1 year patient survival as well as intra-abdominal infection (IAI) rates. (IAI). One-year kidney allograft survival was related to DGF (P = .013; odds ratio [OR] 3.39), acute rejection (P = .001; OR 4.74), and IAI (P = .003, OR 6.29). DGF was related to a time on dialysis >27 months (P = .046; OR 2.59), cold kidney ischemia time >14 hours (P = .027; OR 2.94), donor age >25 years (P = .03; OR 2.82), and donor serum sodium concentration >155 mEq/L (P < .0001; OR 1.09). Female kidney to male recipient in 17% of the cases did not increase the risk of DGF. We observed an important correlation between donor serum sodium and creatinine (P < .0001), which suggested undertreatment of diabetes insipidus secondary to brain death. CONCLUSIONS: DGF, acute rejection, and IAI were the main determinants of survival after SPKT. Improving the care of deceased donors may reduce DGF occurrence.

Intestinal obstruction due to internal hernia following pancreas transplantation.

BACKGROUND: Simultaneous pancreas-kidney transplantation has evolved as the best treatment for type 1 diabetic patients at end-stage renal disease. The surgical complication rate is high, which is an important barrier to the success of this procedure. The frequent complications that require relaparotomies include fistulas, graft thromboses, and intra-abdominal abscesses. Intestinal obstructions after pancreas transplantation due to internal herniation are not common. PURPOSE: The objective of this article was to review the literature about this problem and describe our personal experience in pancreas transplantation. METHODS: We examined the cases of small bowel obstruction secondary to an internal hernia after following 292 pancreas transplantations in our center from 2000 to 2009 as well as performed a Medline literature review. RESULTS: Only 2 articles described the diagnosis and treatment of internal hernias after pancreas transplantation. However, both contribution were from the same center reporting the same 3 cases, with surgical versus radiologic perspectives. We have described our 2 cases of young pancreas-kidney transplant patients who presented with acute intestinal obstruction due to internal hernia. CONCLUSION: Although internal hernias are rare, they are potentially fatal and difficult to diagnose when they occur after pancreas transplantation. Detection with early surgery demands a high degree of clinical vigilance.

Impact of liver ex situ transection on pediatric liver transplantation.

UNLABELLED: Ex situ hepatic transection (ESHT) has allowed transplantation of younger and smaller patients than whole liver grafts. Liver transection is a technical challenge due to the prolonged back table time, possible graft lesions, and increased surgical bleeding from the cut surface. We compare the outcomes of whole versus transected liver grafts in pediatric liver transplantation. METHODS: We retrospectively studied 41 pediatric patients who underwent 42 consecutive liver transplants (1 retransplant) from cadaveric donors. The study included all patients <18 years old who were transplanted at our institution from December 2001 to September 2009. Patients were distributed into 2 groups: whole organ (WO; n = 20) and transected liver grafts (TLG; n = 21). The ESHT grafts included 17 splits and 5 reduced size livers. We evaluated the age, weight, blood component transfusions, 1-year survival, laboratory tests at 2nd and 7th days postoperatively, surgical complications, reoperations, rejection episodes, cold ischemia time, biliary reconstruction type, and donor laboratory tests. Data were analyzed using Fisher and Student's t-tests. RESULTS: The mean age was 115 months (range, 7 months to 17.6 years) in the WO group and 43.3 months (range, 5 months to 16.25 years) in the TLG group (P = .0003). Mean weight was 19.8 kg (range, 5.8-67) and 9.7 Kg (range, 5.2-57) in the WO and TLG groups, respectively (P = .0079). Red blood cell transfusion was higher in the TLG group (P = .0479). Laboratory tests showed no difference between the 2 groups considering hepatic lesions or function markers. One-year patient survivals were 90% and 85.8% among the WO and LTG, respectively (P = .588). The overall 1-year survival rate was 88.8%. CONCLUSION: ESHT allowed smaller and younger children to be transplanted. There was an increased necessity of red blood cell transfusions after hepatic transection. There was no impact on liver function or 1-year patient or graft survival after ESHT.

Multivariate analysis of risk factors for early loss of pancreas grafts among simultaneous pancreas-kidney transplants.

UNLABELLED: To evaluate the risk factors for pancreas graft loss within 3 months postoperatively among 170 simultaneous pancreas-kidney transplantation (SPKT) we examined 38 variables. METHODS: Twenty-two variables were related to recipients; 12 to donors and 4 to the surgical procedure. In addition the latest follow-up dates as well as the transplant and/or death dates. Independent variables were examined with reference to the dependent pancreatic loss variable, excluding losses owing to deaths. Variables with statistical significance were analyzed to predict early graft loss. RESULTS: Univariate analyses determined the following significant variables: kidney cold ischemia time, older donors, non-white donors, death cause related to vascular disease, wound infection, and length of extended hospitalization. However, multivariate analysis showed that only donor age and kidney cold ischemia time were significant predictors for early pancreatic graft loss. CONCLUSION: Donor age and kidney cold ischemia time were independently related to pancreatic loss after SPKT within 3 months posttransplantation.

Experimental study comparing meshes made of polypropylene, polypropylene + polyglactin and polypropylene + titanium: inflammatory cytokines, histological changes and morphometric analysis of collagen.

PURPOSE: Incisional hernia occurs in approximately 11% of all laparotomies. Changes in collagen have been closely implicated in its pathogenesis. The high recurrence rate (45-54%) after primary suture has stimulated the development of meshes. Currently, meshes are the biomaterials implant group most used in medicine. This study aims to compare the serum and tissue inflammatory responses and collagen deposition caused by meshes made of polypropylene, polypropylene + polyglactin and polypropylene + titanium. METHODS: Thirty Wistar rats were divided into three groups. In group I, a high-density polypropylene mesh was positioned on the abdominal wall. In groups II and III, low-density meshes were used in associations with polyglactin and titanium, respectively. Immediately before the operation and on the first, third and fortieth postoperative days, pro-inflammatory cytokines were assayed. On the 40th postoperative day, the region of the inserted prosthesis was biopsied. The tissue inflammatory reaction was evaluated using a scale for objective scoring. For collagen, picrosirius was used with data reading using the Image Tool computer software. RESULTS: Cytokines: there were no statistically significant differences between the groups. HISTOLOGY: on the 40th postoperative day in group I, there were fewer inflammatory tissue response and greater collagen deposition (P < 0.01). In group II, there were greater inflammatory tissue response and less collagen deposition (P < 0.01). Group III presented intermediate values between groups I and II. CONCLUSIONS: There were no significant differences in cytokine levels between the groups in the present study. In the animals with the polypropylene + polyglactin mesh implant there was the most intense inflammatory process with lower tissue maturation and collagen deposition on the 40th postoperative day. The polypropylene mesh presented a less severe late inflammatory process, with greater tissue maturation and collagen deposition. The polypropylene + titanium mesh presented intermediate values between the others.

Extreme subcutaneous, intramuscular and inhaled insulin resistance treated by pancreas transplantation alone.

Diabetes mellitus with resistance to insulin administered subcutaneously or intramuscularly (DRIASM) is a rare syndrome and is usually treated with continuous intravenous insulin infusion. We present here two cases of DRIASM in 16 and 18 years female patients that were submitted to pancreas transplantation alone (PTA). Both were diagnosed with type 1 diabetes as young children and had labile glycemic control with recurrent episodes of diabetic ketoacidosis. They had prolonged periods of hospitalization and complications related to their central venous access. Exocrine and endocrine drainages were in the bladder and systemic, respectively. Both presented immediate graft function. In patient 1, enteric conversion was necessary due to reflux pancreatitis. Patient 2 developed mild postoperative hyperglycemia in spite of having normal pancreas allograft biopsy and that was attributed to her immunosuppressive regimen. Patient 1 died 9 months after PTA from septic shock related to pneumonia. In 8 months of follow-up, Patient 2 presented optimal glycemic control without the use of antidiabetic agents. In conclusion, PTA may be an alternative treatment for DRIASM patients.

Mycophenolate mofetil versus enteric-coated mycophenolate sodium after simultaneous pancreas-kidney transplantation.

INTRODUCTION: Adverse gastrointestinal events are frequent after mycophenolate use. The objectives of the present study were to report the incidence of acute noninfectious diarrhea, to determine the risk factors, and to compare the severity of reactions between mycophenolate mofetil (MMF) and enteric-coated mycophenolate sodium (EC-MPS) after simultaneous pancreas kidney transplantation (SPKT). METHODS: We included 165 SPKT patients from December 2000 to May 2007. Uni- and multivariate analyses were performed, using acute noninfectious diarrhea as the dependent variable. P < .05 was considered significant. RESULTS: Mean age and duration of dialysis and of diabetes were 34.9 +/- 8.2 years, 27.3 +/- 18.3 months, and 21.9 +/- 16.2 years, respectively. Sixty-three percent used MMF, 36.4% used EC-MPS, and 0.6% used azathioprine. Multivariate analysis showed that the duration of diabetes (P = .049, confidence interval [CI] 1.0- 1.13) and MMF use (P = .013, 95% CI 0.2-0.82) were the main determinants of acute diarrhea after SPKT. MMF dose reduction (79.2% vs 62.3%, P = .024) and severity of diarrhea associated with orthostatic hypotension were more pronounced among MMF than EC-MPS patients (42.4% vs 15.1%, P = .001). There was no difference between MMF and EC-MPS after dose reduction in relation to the occurrence of acute kidney rejection (30.8% vs 26.7%, P = .53). CONCLUSIONS: Acute noninfectious diarrhea after SPKT was related to the duration of diabetes and to prescription of MMF. Preferential use of EC-MPS was associated with a lower necessity of dose reduction and less severe episodes of acute diarrhea compared with MMF, although dose reduction was equally associated with acute episodes of kidney rejection.

Incidence and risk factors for surgical site infection after simultaneous pancreas-kidney transplantation.

A simultaneous pancreas-kidney transplantation (SPKT) is the best treatment option for type I diabetic patients with advanced chronic renal failure. Infectious complications affect 7-50% of the patients receiving this procedure. We conducted a nested case-control study to assess the risk factors for surgical site infection (SSI) in patients receiving SPKT at our centre between 2000 and 2006. Of the 119 evaluated transplant recipients, 55 (46.2%) developed SSIs and the 30 day mortality was 11.8%. Gram-negative organisms were the predominant organisms isolated from SSIs. After multivariate logistic regression, the variables independently associated with SSI were: acute tubular necrosis, post-transplant fistula and graft rejection. This study demonstrated a high incidence of SSI in this patient cohort and variables related to the surgical procedure were closely associated with the development of SSI.

Asynchronous kidney allograft loss after simultaneous pancreas-kidney transplantation: impact on pancreas allograft outcome at a single center.

OBJECTIVE: We analyzed the clinical evolution of pancreas allografts in simultaneous pancreas-kidney transplantation (SPKT) cases after asynchronous kidney allograft loss and kidney retransplantation at a single non-United States center. PATIENTS AND METHODS: We performed a retrospective analysis of 168 SPKT from December 2000 to June 2007. RESULTS: The 5-year kidney allograft survival rate was 71%. Excluding cases of death with a functioning graft after SPKT (n = 35; 74.4%), 12 kidney allografts were lost due to acute rejection (n = 7; 15%) or chronic allograft nephropathy (n = 5; 10.6%). Delayed graft function contributed to kidney allograft loss. Five of 12 patients underwent kidney retransplantation. Sixty percent of pancreas allografts were lost after this procedure, which was attributed to either the diabetogenic effects of the immunosuppressive regimen or to the perioperative stress. Oral glucose tolerance tests performed before kidney retransplantation identified patients with good pancreas allograft function versus those with intolerance on glucose tests who received reduced glucocorticoid doses. CONCLUSIONS: In SPKT, pancreas allograft function was seriously affected by kidney retransplantation. Oral glucose tolerance tests performed before kidney retransplantation were helpful to assess beta-cell function and suggest prescription of lower steroid doses to decrease the pancreas allograft dysfunction.

Carcinosarcoma of the liver: a case report.

Primary hepatic carcinosarcoma is a rare malignant hepatic tumor containing both carcinomatous and sarcomatous elements. A 40-year-old man referred to our liver transplant team because of hepatic cirrhosis was on the waiting list, having undergone all liver tests, ultrasonography, and with normal serum alpha fetoprotein markers every 6 months to search for a tumor. He underwent a liver transplantation without complication. The pathologic findings of the original liver indicated carcinosarcoma. We have reviewed the literature on this subject.

Magnetic resonance cholangiography in the diagnosis of biliary complications after orthotopic liver transplantation.

OBJECTIVE: The aim of our study was to evaluate the role of magnetic resonance cholangiography (MRC) in the diagnosis of biliary tract complications (BC) after orthotopic liver transplantation (OLT). MATERIALS AND METHODS: Among 21 OLT patients who underwent routine follow-up MRC using a breath-hold T2-weighted turbo spin-echo sequence with half-Fourier acquisition (HASTE), 5 had an elevated serum alkaline phosphatase level. Diagnostic confirmation was obtained with endoscopic retrograde cholangiography (ERC) (n = 11), surgery (n = 3), or clinical and laboratory follow-up of at least 1 year (n = 8). RESULTS: In 13 patients, no abnormality of the biliary tract was detected using MRC. In 8 patients, anastomotic strictures were diagnosed, 7 of which were confirmed at surgery or using ERC. One patient with normal findings at MRC and abnormal liver function test results was found to have a stricture at ERC. All patients with normal MRC and liver function tests had 1 year of uneventful follow-up and were considered true-negative cases. We found that MRC had 87.5% sensitivity, 92.3% specificity, 87.5% positive predictive value, 92.3% negative predictive value, and 90.4% accuracy for the diagnosis of BC. CONCLUSION: MRC is a valuable examination to detect BC after OLT. It provides useful information for planning interventional procedures.

Simultaneous pancreas-kidney transplantation: infectious complications and microbiological aspects.

OBJECTIVE: The purpose of this study was to describe the clinical and microbiological characteristics of the infectious complications among simultaneous pancreas-kidney transplantations (SPKT). MATERIALS AND METHODS: Among the first 45 SPKT the mean age was 34 years (range, 21 to 49) and the mean duration of follow-up 13 months (range, 2 to 27 months). RESULTS: Twenty-three patients (51%) presented at least one to three episodes (1.7 mean) of infectious complications that needed hospitalization. The etiology of the infections included 71% bacterial (44% gram-negative rods and 27% gram-positive cocci), 16% viral (12% from CMV and 4% from Herpes sp) and 13% fungal (8% by Candida sp and 4% by others fungus). Wound and urinary infections were most frequent, occurring in 22% and 28% of the patients, respectively. All patients who were submitted to vesical drainage developed infections in contrast a rate of only 44% among patients undergoing enteric drainage. CONCLUSION: Infectious complications are the main cause of morbidity and mortality following simultaneous pancreas-kidney transplantation, especially with vesical drainage. The use of enteric drainage combined with administration of broad spectrum prophylactic antibiotics is recommended.

Risk factors for the development of posttransplantation diabetes mellitus in simultaneous pancreas and kidney recipients.

We sought to determine the risk factors involved in the development of posttransplantation diabetes mellitus (PTDM) following simultaneous pancreas and kidney transplantation. Correlations were sought between tacrolimus (FK-506) levels/dose 2-hour capillary glucose (CG) and glycosylated hemoglobin (HbA(1c)), cyclosporine (CSA) levels/dose with HbA1c, 2-hour CG with prednisone dose and body mass index (BMI) and PTDM. Four patients (9.3%) developed PTDM. Three treated with FK-506 had altered 2-hour CG at 3 months after transplantation; 1 prescribed CSA displayed diabetes diagnosed after 1 year. There was no statistically significant difference among HbA(1c) values and FK-506 (P =.18) or CSA (P =.81) doses or FK-506 (P =.53) and CSA (P =.54) levels. In contrast, there was a statistically significant relationship between elevated 2-hour CG (> or =200 mg/dL) and daily prednisone dose (9.7 mg vs. 16.2 mg; P =.003). There was no correlation between 2-hour CG and FK-506 dose (P =.084) or FK-506 levels (P =.075). The greater BMI correlated with an increased risk of PTDM (21.25 +/- 3.13 kg/m(2) vs 24.67 +/- 2.38 kg/m(2); P =.034). Two-hour CG may be a useful tool to screen the diabetogenic effects of corticosteroids. A BMI increase should be discouraged due to the risk of PTDM.