The surgical risk of pancreas transplantation in the cyclosporine era: an overview

BACKGROUND: Pancreas transplants are still associated with the highest surgical complication rate of all routinely performed solid organ transplants. To date, the impact of serious surgical complications in the cyclosporine era on perioperative patient morbidity, graft and patient survival, and hospital costs has not been analyzed in detail. STUDY DESIGN: We retrospectively studied surgical complications after 445 consecutive pancreas transplants (45% simultaneous pancreas-kidney [SPK], 24% pancreas after kidney [PAK], and 31% pancreas transplant alone [PTA]). Of these, 80% were primary transplants, 20% were retransplants. Cadaver donors were used in 92%, living related donors in 8%. To develop guidelines for their prevention and management, we studied the impact of significant surgical complications (intra-abdominal infections, vascular graft thrombosis, and anastomotic leak) requiring relaparotomy on graft and patient survival. RESULTS: Relaparotomy was required after 32% of all pancreas transplants (SPK: 36%, PAK: 25%, PTA: 16% [p = 0.04]). Perioperative mortality was 9%. Graft and patient survival rates were significantly lower for recipients with (versus without) relaparotomy. The most common procedures were drainage of intra-abdominal abscess with graft necrosectomy (50% of all relaparotomies) and transplant pancreatectomy (34%). The most common causes of relaparotomy were intra-abdominal infection, vascular graft thrombosis, and anastomotic leak. Intra-abdominal infection occurred in 20% (SPK: 18%, PAK: 24%, PTA: 20% [p = NS]). The rate was significantly higher for living related donor (42%) versus cadaver donor (18%) recipients and for those with enteric-drained (39%) versus bladder-drained (18%) transplants. Graft and patient survival rates were significantly lower for recipients with (versus without) intra-abdominal infection. Outcome was better after bacterial (versus fungal) infections. For SPK recipients, those not on dialysis before the transplant had significantly higher graft survival than those on dialysis. Vascular graft thrombosis occurred in 12% of all recipients. The rate was significantly higher for PAK (21%) than for PTA (10%) and SPK (9%) recipients. It was significantly lower for recipients of grafts with donor iliac Y-graft reconstruction (versus all other types of arterial reconstruction) and with right-sided (versus left-sided) graft placement. Of note, patient survival was not different for recipients with versus without vascular graft thrombosis. The incidence of anastomotic or duodenal stump leaks was 10%; of these recipients, 70% required relaparotomy. Patient and graft survival rates were no different for recipients with versus without leaks. CONCLUSIONS: Serious surgical complications occurred in 35% of pancreas recipients and had a significant impact on patient and graft survival. Based on multivariate risk factor analyses, we recommend the following: donors over 45 years and those dying of cerebrocardiovascular disease should not be used; recipients over 45 years and those with a history of cardiac disease should be considered for a kidney transplant alone (KTA); surgical technique for graft procurement, preparation, and implantation should be meticulous; right-sided implantation and arterial Y-graft reconstruction should be performed when possible, since they had the highest success rates; when complications require relaparotomy, the focus must switch from graft salvage to life preservation; and the threshold for pancreatectomy should be low. Diagnosis should be timely, and treatment and relaparotomy expeditious. These cornerstones of success should help decrease the risk of surgical complications and mortality after pancreas transplants.     

Reduced performance of male and female athletes at 580 m altitude

Patients with craniocervical mandibular (TMD) disorders can present with tinnitus as a primary or secondary complaint. The embryology and functional anatomy of the middle ear, temporomandibular joint, muscles of mastication and associated tendons, ligaments, blood vessels, nerves and lymphatics was found to be helpful in establishing etiologic concepts which relate tinnitus to these temporomandibular disorders. In addition to etiologic concepts, treatment modalities are described. The authors relate their experiences as well as those of others with different patient populations.     

High-gain free electron lasers using induction linear accelerators

High-power free electron lasers (FEL's) can be realized using induction linear accelerators as the source of the electron beam. These accelerators are currently capable of producing intense currents (10²-10⁴A) at moderately high energy (1-50 MeV). Experiments using a 500 A, 3.3 MeV beam have produced 80 MW of radiation at 34.6 GHz and are in good agreement with theoretical analysis. Future experiments include a high-gain, high-efficiency FEL operating at 10.6 μm using a 50 MeV beam.     

Neuroanatomical localization of the motor hand area with magnetic resonance imaging: The left hemisphere is larger in great apes.

Magnetic resonance images of the brain were obtained from 2 gorillas (Gorilla gorilla gorilla), 4 orangutans (Pongo pygmaeus), 14 chimpanzees (Pan troglodytes), and 4 bonobos (Pan paniscus), The region on the motor cortex of humans identified as responsible for motor skill of the hand (the "knob") was identified in this sample on consecutive 1-mm axial scans. The shape of the knob area was traced on each scan from both hemispheres, and the area from all scans was summed to calculate the knob volume. The width of the knob was also measured and correlated highly with knob volume. A significant population-level leftward asymmetry in the volume and width of the knob was revealed (p?     

The effect of aluminium coating on elemental standards in X-ray microanalysis

The standardisation of frozen hydrated bulk biological specimens using gelatin standards is described. The relationship between corrected elemental X-ray counts and ionic concentration was found to be linear, and minimum detectable limits for each element are stated. Variations in uncorrected standard curves were found to be due to changes in aluminium coating thickness. There was an inverse relationship between coating thickness and elemental X-ray counts. The factors causing this are discussed. To avoid errors arising from inconsistent aluminium thickness, experimental material should only be compared with standards of similar aluminium net counts. This can be achieved most easily by mounting and analysing specimen and standard together.     

A comparative laboratory study of liquid nitrogen and argon gas cryosurgery systems

Impaired adrenal function during perioperative stress carries the risk of acute cortisol (Cs) deficiency (Addisonian crisis), which may be critical without Cs supplementation. Thus, with evidence of dysfunction of the adrenal glands perioperative substitution is indicated. However, it is unclear whether unilateral adrenalectomy may attenuate the adrenocorticoid response. Glucocorticosteroids are potent agents with several well-known side effects. The purpose of the present study was to evaluate if routine Cs supplementation is justified and necessary in patients undergoing adrenalectomy during nephrectomy for renal-cell cancer. METHODS: Ten consecutive patients with renal-cell cancer (5 male, 5 female; age 58 +/- 10 years; ASA class I-II) who underwent adrenalectomy with radical nephrectomy were included in this study. None of them had received steroids for at least 5 years prior to the current surgery. Anaesthesia was induced with propofol, fentanyl, and vecuronium and maintained with isoflurane (PetIso: 0.8 +/- 0.3 vol.%) in nitrous oxide (66%) and oxygen. The patients did not receive any Cs treatment perioperatively. Monitoring included heart rate (beats/min), mean arterial pressure (mm Hg), central venous pressure (mm Hg), O2 saturation (%), and body temperature (degrees C, rectal). Plasma analyses included Cs (Cs radioimmunoassay IBL; normal 120-250 ng/ml), adrenocorticotropic hormone (ACTH) (ACTH-II IRMA; normal (10-50 pg/ml), glucose, and electrolytes determined as follows: preoperatively (8 a.m.); 1-6 h (60-min intervals) after surgery; pre-corticotropin-releasing hormone (CRH) (Corticobiss: 2 micrograms/kg i.v.) administration (1st postop. day at 8 a.m. and after 30, 60, 90, and 120 min. The study was completed with plasma analyses on postoperative days 2 and 3 (8 a.m.). RESULTS: None of the patients showed any clinical signs of plasma parameter of adrenal insufficiency due to the unilateral adrenalectomy. Serum levels (median: 25%/75% percentiles) of Cs (maximum [max.]:253 [217/288] ng/ml) and ACTH (max.:347 ([68/405] pg/ml) were elevated above the normal range postoperatively). After intravenous stimulation with CRH (1st postoperative day), Cs (max.:273 [248/310] ng/ml) and ACTH (max.: 107 ([75/275] pg/ml) were also increased above normal. During postoperative days 2 and 3 (8 a.m.) Cs and ACTH remained in the high-normal range. CONCLUSIONS: Data from this study indicate that unilateral adrenalectomy was associated with adequate spontaneous Cs secretion by the remaining adrenal gland. Moreover, stimulation with CRH demonstrated adequate reactivity of the pituitary-adrenal axis. None of the patients showed any signs of Cs deficiency by clinical or serum parameters. Therefore, we do not recommend routine Cs supplementation in patients undergoing adrenalectomy during tumor nephrectomy, nevertheless, Cs supplementation remains necessary for patients with primary hypothalamic-pituitary-adrenal dysfunction (Addison's disease) or hyperfunction (Cushing's disease).