Comparative efficacy of Belzer or Euro-Collins solutions for pancreatic preservation during cold ischemic storage in rats

PURPOSE:To compare the efficacy of different types of solutions (Belzer or Euro-Collins) for the preservation of rat pancreas during cold ischemia. METHODS:Thirty Wistar rats were divided into three groups according to the perfusion or storage solution: Group E (perfusion and storage in Euro-Collins solution); Group B (perfusion and storage in Belzer solution) and Group BE (Perfusion in Belzer solution and storage in Euro-Collins solution). After perfusion, the pancreas was excised and stored at 4˚C for 18 hours. Amylase was measured at 6, 12 and 18h, and histological analysis of the pancreas was performed after 18h of cold storage.RESULTS:Amylase was elevated and comparable in Groups E and BE after 12 and 18 hours of ischemia (p<0.05). In the exocrine pancreas, histological differences in the amount of necrosis (p=0.049), lymphocytic infiltrate (p<0.001) and neutrophilic infiltrate (p=0.004) were observed, with more favorable features present in Group B. In the endocrine pancreas, Group B showed less edema (p<0.001), but other parameters were similar among all groups. CONCLUSION:The Euro-Collins solution is inferior to the Belzer solution for the preservation of rat pancreas during cold ischemia.São Paulo Federal UniversityUNIFESP Paulista School of Medicine Department of SurgeryUNIFESP-EPM Department of SurgerySão Paulo Federal UniversityUNIFESP, Paulista School of Medicine Department of SurgeryUNIFESP, EPM Department of SurgerySciEL

Impact of delayed pancreatic graft function in simultaneous pancreas-kidney transplantation

OBJECTIVE: Simultaneous pancreas-kidney transplantation is an effective treatment for patients with type 1 diabetes melli>tus and end-stage chronic kidney disease. Delayed pancreatic graft function is a common and multifactor condition with significant impact in short-term outcome of simultaneous pancreas-kidney transplantations. The aim of this study was to analyze the impact of pancreatic delayed pancreatic graft function on simultaneous pancreas-kidney transplantation. METHODS: Donor and recipient's demographic data, percentage of panel reactivity, acute rejection incidence, and patient and grafts survivals were retrospectively analyzed in 180 SPKT performed between 2002 and 2007. RESULTS: The incidence of pancreatic delayed pancreatic graft function was 11%. Donors older than 45 years had significant risk of pancreatic delayed pancreatic graft function (OR 2.26; p < 0,05). Patients with pancreatic delayed pancreatic graft function had higher rates of acute renal rejection (47 versus 24%; p < 0.05), altered fasting plasma glucose (25 versus 5%; p < 0.05) and mean glycated hemoglobin (5.8 versus 5.4%; p < 0.05), than patients without pancreatic delayed pancreatic graft function at the end of the first year of follow up. There were no significant differences between patients with and without pancreatic delayed pancreatic graft function regarding patient survival (95 versus 88.7%; p = 0.38), pancreatic graft survival (90 versus 85.6%; p = 0.59) and renal graft survival (90 versus 87.2%; p = 0.70), respectively at the sample period of time. CONCLUSION: Pancreatic delayed pancreatic graft function had no significant impact in the short-term outcome of simultaneous pancreas-kidney transplantations. Although delayed pancreatic graft function had no impact on 1-year pancreas graft survival, it contributed to early pancreas graft dysfunction, as assessed by enhanced insulin and oral anti-diabetic drugs requirements.OBJETIVO: O transplante pâncreas-rim é efetivo para pacientes com doença renal crônica terminal e diabetes mellitus insulino-dependente. A função retardada do enxerto pancreático é condição frequente exercendo impacto significativo nos resultados em curto prazo dos transplantes pâncreas-rim. O objetivo foi analisar o impacto da função retardada do enxerto pancreático no transplante pâncreas-rim. MÉTODOS: Análise retrospectiva de 180 receptores de transplante pâncreas-rim, incluindo dados demográficos dos doadores e dos receptores, a reatividade contra painel, a incidência de rejeição aguda e as sobrevidas do paciente e dos enxertos pancreático e renal. RESULTADOS: A incidência de função retardada do enxerto pancreático foi 11%. A idade do receptor superior a 45 anos apresentou associação com o risco de desenvolvimento de função retardada do enxerto pancreático (Razão de chances 2,26; p < 0,05). Os pacientes com função retardada do enxerto pancreático apresentaram maior incidência de rejeição aguda renal (47 versus 24%; p < 0,05), glicemia de jejum alterada (25 versus 5%; p < 0,05) e média de hemoglobina glicada (5,8 versus 5,4%; p < 0,05) ao final do primeiro ano de acompanhamento em relação aos pacientes sem função retardada do enxerto pancreático. Não houve diferenças estatisticamente significativas entre os grupos de pacientes com e sem função retardada do enxerto pancreático quanto à sobrevida do paciente (95 versus 88,7%; p = 0,38), do enxerto pancreático (90 versus 85,6%; p = 0,59) e do enxerto renal (90 versus 87,2%; p = 0,70), respectivamente, nesse mesmo período. CONCLUSÃO: A função retardada do enxerto pancreático não exerceu impacto significativo nos resultados em curto prazo dos transplantes pâncreas-rim desta casuística. Embora a função retardada do enxerto pancreático não tenha influenciado a sobrevida do enxerto pancreático ao final do primeiro ano após o transplante, contribuiu para a disfunção pancreática precoce, indicando maior necessidade de uso de insulina e hipoglicemiantes orais.Universidade Federal de São Paulo (UNIFESP) Departamento de MedicinaUNIFESP Departamento de CirurgiaUNIFESP, Depto. de MedicinaUNIFESP, Depto. de CirurgiaSciEL

Financial cost of the admissions for simultaneous pancreas-kidney transplant in a Brazilian Hospital

PURPOSE:To perform a cost analysis of simultaneous pancreas-kidney transplantation (SPKT) in a Brazilian hospital.METHODS:Between January 2008 and December 2011, 105 consecutive SPKTs at the Hospital of Kidney and Hypertension in São Paulo were evaluated. We evaluated the patient demographics, payment source (public health system or supplementary system), and the impact of each hospital cost component. The evaluated costs were corrected to December 2011 values and converted to US dollars.RESULTS:Of the 105 SPKT patients, 61.9% were men, and 38.1% were women. Eight patients died, and 97 were discharged (92.4%). Eighty-nine procedures were funded by the public health system. The cost for the patients who were discharged was $18.352.27; the cost for the deceased patients was$18.449.96 (p = 0.79). The FOR for SPKT during this period was positive at $5,620.65. The costs were distributed as follows: supplies, 36%; administrative costs, 20%; physician fees, 15%; intensive care unit, 10%; surgical center, 10%; ward, 9%.CONCLUSION:Mortality did not affect costs, and supplies were the largest cost component.Federal University of São Paulo Department of SurgeryUniversidade Federal de São Paulo (UNIFESP) Department of SurgeryHypertension and Kidney HospitalUniversidade Federal de São Paulo (UNIFESP) Department of Internal MedicineUniversidade Federal de São Paulo (UNIFESP) Department of PediatricUNIFESP, Department of SurgeryUNIFESP, Department of SurgeryUNIFESP, Department of Internal MedicineUNIFESP, Department of PediatricSciEL

Acompanhamento de longo prazo após a ressecção de metástases na tiroide de carcinoma hepatocelular em fígado cirrótico

Thyroid metastasis from hepatocellular carcinoma (HCC) is rare, and has poor prognosis. We report the case of a 62-year-old woman seen at our clinic because of the occurrence of a slightly painful abdominal mass. At that time, alpha-fetoprotein concentration was very high, reaching 49,831.7 ng/mL. Abdominal ultrasound showed a heterogeneous mass in segment IV of the liver, which was diagnosed as HCC upon MRI. The patient underwent surgical resection and histological analysis of the specimen confirmed HCC. Metastases to the thyroid were detected 17 months after liver resection. Although the presence of metastases indicates advanced disease, thyroidectomy was performed, since no other distant metastases were detected. In fact, the patient is doing well 3 years after thyroidectomy and regular imaging exams showed no tumor recurrence. Current alpha-fetoprotein concentration is 8 ng/mL. In conclusion, thyroid metastasis from HCC is uncommon and short-term survival is expected. However, surgical resection should be encouraged, especially in the case of solitary metastases.As metástases de carcinoma hepatocelular (CHC) em tiroide são raras e o prognóstico é ruim. Relatamos o caso de uma paciente de 62 anos de idade atendida em nossa clínica devido a uma massa abdominal levemente dolorida. Naquele momento, a concentração de alta-fetoproteína era muito alta, chegando a 49.831,7 ng/mL. O ultrassom de abdômen mostrou uma massa heterogênea no segmento IV do fígado, que foi diagnosticada como CHC por meio de ressonância magnética. A paciente foi submetida a uma ressecção cirúrgica, e a análise histológica do espécime confirmou o CHC. As metástases na tiroide foram detectadas 17 meses após a ressecção do fígado. Embora a presença de metástases indique doença avançada, a tiroidectomia foi feita porque não foram detectadas outras metástases distantes. De fato, três anos após a tiroidectomia, a paciente está bem e os exames de rotina mostraram não haver recorrência do tumor. A concentração atual de alfa-fetoproteína é de 8 ng/mL. Concluiu-se que as metástases de CHC em tiroide não são comuns e espera-se uma sobrevida curta. Entretanto, deve-se encorajar a ressecção cirúrgica, especialmente no caso de metástases solitárias.Universidade Federal de São Paulo (UNIFESP) Hepatology Unit Department of GastroenterologyUNIFESP Liver Transplant Unit Department of SurgeryUniversidade Federal de São Paulo (UNIFESP) Department of Pediatric SurgeryUniversidade Federal de São Paulo (UNIFESP) Department of Diagnostic RadiologyUniversidade Federal de São Paulo (UNIFESP) Department of PathologyUNIFESP, Hepatology Unit Department of GastroenterologyUNIFESP, Liver Transplant Unit Department of SurgeryUNIFESP, Department of Pediatric SurgeryUNIFESP, Department of Diagnostic RadiologyUNIFESP, Department of PathologySciEL

Estudo da eficácia e da reprodutibilidade da colangiopancreatografia por ressonância magnética na detecção das complicações biliares pós-transplantes hepáticos

PURPOSE: To evaluate the accuracy and reproducibility of magnetic resonance cholangiopancreatography (MRCP) in the detection of biliary complications in liver transplanted patients. METHODS: A study was conducted, with blinded review of 28 MRCP exams of 24 patients submitted to liver transplantation. The images were reviewed by two independent observers, at two different moments, regarding the degree of biliary tree visualization and the presence or absence of biliary complications. The MRCP results were compared, when negative, to at least 3 months of clinical and biochemical follow-up, and when positive, to the findings at surgery or endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: The degree of intrahepatic biliary tree visualization was considered good or excellent in 78.6% and 82.1% of the exams by the two observers and visualization of the donor duct, recipient duct and biliary anastomosis was considered good or excellent in 100% of the exams, by both observers. Six biliary complications were detected (21.4%), all of them anastomotic strictures. Intra and interobserver agreement were substantial or almost perfect (kappa k values of 0.611 to 0.804) for the visualization of the biliary tree and almost perfect (k values of 0.900 to 1.000) for the detection of biliary complications. MRCP achieved 100% sensitivity, 95.45% specificity, 85.7% positive predictive value and 100% negative predictive value for the detection of biliary complications. CONCLUSIONS: MRCP is an accurate examination for the detection of biliary complications after orthotopic liver transplantation and it is a highly reproducible method in the evaluation of the biliary tree of liver transplanted patients.OBJETIVO: Medir a acurácia e reprodutibilidade da colangiopancreatografia por ressonância magnética (CPRM) na avaliação da visibilização de complicações biliares em pacientes submetidos a transplantes hepáticos ortotópicos. MÉTODOS: Realizado estudo retrospectivo de 28 exames de CPRM de 24 pacientes submetidos a transplantes hepáticos. Os exames foram interpretados por dois observadores independentes, em dois momentos distintos, quanto ao grau de visibilização das estruturas estudadas e quanto à presença ou ausência de alterações nas vias biliares. Os resultados da CPRM foram comparados, nos casos de CPRM negativa, à evolução clínico-laboratorial por pelo menos 3 meses e, nos casos de CPRM alterada, aos achados de colangiopancreatografia retrógrada endoscópica (CPRE) e cirurgia, quando indicados. RESULTADOS: A visibilização das vias biliares intra-hepáticas foi considerada boa ou excelente em 78,6% e 82,1% dos exames pelos dois observadores. A visibilização da via biliar extra-hepática do doador e do receptor, bem como da anastomose biliar, foi considerada boa ou excelente em 100% dos casos por ambos os observadores. Foram detectadas seis complicações biliares (21,4% dos casos), todas elas estenoses anastomóticas. A concordância intra e intra-observador foi substancial ou quase perfeita (índices de kappa- k de 0,611 a 0,804) para a visualização das estruturas estudadas e quase perfeita (k de 0,900 a 1,000) para a detecção das complicações biliares. A CPRM apresentou sensibilidade de 100%, especificidade de 95,45%, valor preditivo positivo de 85,7% e valor preditivo negativo de 100% para a detecção de complicações biliares. CONCLUSÕES: A colangiopancreatografia por ressonância magnética (CPRM) é um exame acurado para a detecção de complicações biliares em pacientes submetidos a transplantes hepáticos ortotópicos por CPRM. Este exame configura-se como um método eficiente e altamente reprodutível para detecção de complicações biliares pós-transplantes hepáticos ortotópicos.Universidade Federal de São Paulo (UNIFESP) Department of SurgeryUniversidade Federal de São Paulo (UNIFESP) Department of Image DiagnosticUniversidade Federal de São Paulo (UNIFESP) Department of MedicineUniversidade Federal de São Paulo (UNIFESP) Department of Surgery Division of Liver TransplantationUniversidade Federal de São Paulo (UNIFESP) Department of Surgery Division of Surgical GastroenterologyUNIFESP, Department of SurgeryUNIFESP, Department of Image DiagnosticUNIFESP, Department of MedicineUNIFESP, Department of Surgery Division of Liver TransplantationUNIFESP, Department of Surgery Division of Surgical GastroenterologySciEL

State Britain and the art of (Im)proper democratic protest

The installation of Mark Wallinger’s State Britain in the Duveen Galleries of Tate Britain recreated Brian Haw’s protest opposite the Houses of Parliament, which had largely been dismantled by the police under the Serious Organised Crime and Police Act 2005. Wallinger’s work bisected a boundary created by the Act inside which the police could be given greater than usual powers to control demonstrations. The intersection exemplified how, when understood in terms of the performative after Jacques Derrida, art may unsettle the ways in which both the law and aesthetics work to protect the political establishment. aesthetics work to protect the political establishment

Pancreas and islet transplantation in patients with diabetes mellitus

Pancreas and kidney transplants have specific indications, benefits and risks. The procedure has become more common and more often as long-term success has improved and risks have decreased. Compared with a patient being on dialysis, simultaneous pancreas-kidney transplant offers a distinct advantage when it comes to mortality, quality of life and diabetic complications. Since there can be a living-donor kidney transplant,, a possibly similar patient and graft survival by 10 years follow-up, this procedure should be considered. Pancreas after kidney transplants, when successful, can improve microvascular complications compared with kidney transplant alone, but immediate mortality may be higher. Solitary pancreas transplantation can improve the quality of life in selected patients, but it may also increase the immediate risk of mortality due to the complexity of the surgery and the risks of immunosupression. The results of Islet transplantation differ from the higher metabolic performance achieved by whole pancreas allotransplantation and its applicability is limited to selected adult diabetic patients.O transplante simultâneo de pâncreas/rim tem indicações específicas, riscos e benefícios. O procedimento, cada vez mais realizado, traz vantagens se comparado ao paciente em diálise, em relação à qualidade de vida, anos de vida ganhos e evolução das complicações crônicas. Se o paciente tiver a opção de realizar o transplante de rim com doador vivo, que apresenta sobrevida semelhante do enxerto e do paciente aos dez anos, o procedimento deverá ser considerado. O transplante de pâncreas após rim, quando efetivo, pode melhorar a evolução das complicações cardiovasculares, mas em contrapartida provoca maior mortalidade nos primeiros meses após a cirurgia. O transplante isolado de pâncreas também ocasiona a maior mortalidade pós-operatória, resultado da complexidade do procedimento e da imunossupressão. O transplante de ilhotas tem sua indicação para um seleto grupo de diabéticos com instabilidade glicêmica.Universidade Federal de São Paulo (UNIFESP) Departamento de Medicina Departamento de CirurgiaPontifícia Universidade Católica do Rio Grande do Sul Hospital São Lucas Serviço de NefrologiaUniversidade de São Paulo Núcleo de Terapia Celular e MolecularSistema de Saúde Centro de Pesquisa Médica Notre-Dame IntermédicaUSP Faculdade de Medicina Departamento de Clínica MédicaUniversidade Federal do Rio Grande do Sul Departamento de Medicina InternaHospital Israelita Albert Einstein Serviço de Transplante de PâncreasUNIFESP, Depto. de Medicina Depto. de CirurgiaSciEL