Trasplante pancreático

Diabetes mellitus is a health concern of the first order, given the high level of associated morbidity and mortality. The objective, in order to slow down the advance of its complications before they become irreversible, is based on correct metabolic control. The high rate of morbidity associated with the surgery of the vascularized pancreas transplant and the high index of rejection have for three decades formed an obstacle to this being considered a valid alternative in the treatment of these patients. Nowadays the pancreas transplant has come to occupy a key position, thanks to the new regimes of immunosuppression and to the perfection of surgical techniques. In this article we review the evolution of the pancreas transplant from its beginnings to its present state

Polycystic kidney disease in patients on the renal transplant waiting list: trends in hematocrit and survival

BACKGROUND: The patient characteristics and mortality associated with autosomal dominant polycystic kidney disease (PKD) have not been characterized for a national sample of end stage renal disease (ESRD) patients on the renal transplant waiting list. METHODS: 40,493 patients in the United States Renal Data System who were initiated on ESRD therapy between 1 April 1995 and 29 June 1999 and later enrolled on the renal transplant waiting list were analyzed in an historical cohort study of the relationship between hematocrit at the time of presentation to ESRD and survival (using Cox Regression) in patients with PKD as a cause of ESRD. RESULTS: Hematocrit levels at presentation to ESRD increased significantly over more recent years of the study. Hematocrit rose in parallel in patients with and without PKD, but patients with PKD had consistently higher hemoglobin. PKD was independently associated with higher hematocrit in multiple linear regression analysis (p < 0.0001). In logistic regression, higher hematocrit was independently associated with PKD. In Cox Regression analysis, PKD was associated with statistically significant improved survival both in comparison with diabetic (hazard ratio, 0.64, 95% CI 0.53–0.77, p < 0.001) and non-diabetic (HR 0.68, 95% CI 0.56–0.82, p = 0.001) ESRD patients, adjusted for all other factors. CONCLUSIONS: Hematocrit at presentation to ESRD was significantly higher in patients with PKD compared with patients with other causes of ESRD. The survival advantage of PKD in ESRD persisted even adjusted for differences in hematocrit and in comparison with patients on the renal transplant waiting list

Cirugía laparoscópica hepática y pancreática

The development of laparoscopic surgery also includes the more complex procedures of abdominal surgery such as those that affect the liver and the pancreas. From diagnostic laparoscopy, accompanied by laparoscopic echography, to major hepatic or pancreatic resections, the laparoscopic approach has spread and today encompasses practically all of the surgical procedures in hepatopancreatic pathology. Without forgetting that the aim of minimally invasive surgery is not a better aesthetic result but the reduction of postoperative complications, it is undeniable that the laparoscopic approach has brought great benefits for the patient in every type of surgery except, for the time being, in the case of big resections such as left or right hepatectomy or resections of segments VII and VIII. Pancreatic surgery has undergone a great development with laparoscopy, especially in the field of distal pancreatectomy due to cystic and neuroendocrine tumours where the approach of choice is laparoscopic. Laparoscopy similarly plays an important role, together with echolaparoscopy, in staging pancreatic tumours, prior to open surgery or for indicating suitable treatment. In coming years, it is to be hoped that it will continue to undergo an exponential development and, together with the advances in robotics, it will be possible to witness a greater impact of the laparoscopic approach on the field of hepatic and pancreatic surgery

Cirugía bariátrica laparoscópica: bypass gástrico proximal

The spectacular increase in the prevalence of obesity in our society and the significant complications and comorbidities that it gives rise to have stimulated the interest of scientists and public in this pathology. Surgical treatment is at present the only efficient and lasting treatment for morbid obesity and in many cases it appreciably improves, and even definitively cures, associated complications such as the case of diabetes or hypertension. Amongst the different techniques of bariatric surgery, the gastric bypass (GBP) seems to be definitively establishing itself, since it offers an excellent balance between loss of weight (>70% of the excess), surgical risk and subsequent quality of life. The possibility of carrying out this technique employing a laparoscopic approach has improved its acceptance by doctors and patients while it has made it possible to reduce morbidity and mortality, length of hospital stay and costs. Proximal GBP is carried on those patients with an BMI 60 Kg/m2 the GBP employed is denominated distal. Between October 2003 and November 2005, our centre performed 55 laparoscopic proximal Roux-en-Y gastric bypasses via laparoscopy. These involved 42 women and 13 males with an average age of 44 years. The average BMI was 43.5 (35-55.8). The average basal weight was 116.15 Kg. There was no peroperative mortality, nor reinterventions. The BMI after 12 months was 28.4. The average basal weight was 74.2 Kg. Laparoscopic Roux-en-Y proximal gastric bypass is a safe and efficient technique for the treatment of morbid obesity

Nefropatia brucel·lar

L'afectació renal en el curs de la Brucel·losi ha estat citada de fa anys per alguns autors. Però entre els parènquimes que es poden veure envoltats en el curs d'aquesta malaltia, la localització renal no era, sovint, descoberta. Fins fa pocs anys els informes sobre aquest aspecte procedien bé de peces de nefrectomia, bé de necròpsies. ..

Totally Laparoscopic Roux-en-Y Duct-to-Mucosa Pancreaticojejunostomy After Middle Pancreatectomy A Consecutive Nine-case Series at a Single Institution

To present the results of a series of laparoscopic middle pancreatectomies with roux-en-Y duct-to-mucosa pancreaticojejunostomy. SUMMARY OF BACKGROUND DATA: Middle pancreatectomy makes it possible to preserve pancreatic parenchyma in the resection of lesions that traditionally have been treated by distal splenopancreatectomy or cephalic duodenopancreatectomy. The laparoscopic approach could minimize the invasiveness of the procedure and enhance the benefits of middle pancreatectomy. METHODS: From March 2005 to October 2007, 9 consecutive patients with benign or low malignant potential lesions in the pancreatic neck or body underwent surgery. Laparoscopic middle pancreatectomy with a roux-en-Y duct-to-mucosa pancreaticojejunostomy was planned on all of them. In the first 2 patients, the pancreas was transected by endostapler; in the last 7, the staple line was reinforced with absorbable polymer membrane. RESULTS: The intervention was concluded laparoscopically in every case except 1 (laparoscopic-assisted) in which pancreaticojejunostomy was performed by means of minilaparotomy. Mortality was 0% and perioperative morbidity was 33%, (fistula of the cephalic stump in the first 2 patients (22%)). The pancreaticojejunostomy fistula rate was 0%. The median postoperative hospital stay was 5 days (range, 3-41). In the last 7 patients, in which pancreas was transected with staple line reinforcement material there were no stump fistulas; morbidity decreased to 14% and the median hospital stay was 4 days (range, 3-30). CONCLUSIONS: Laparoscopic middle pancreatectomy is feasible and safe. Duct-to-mucosa pancreaticojejunostomy can be performed safely using this approach. The method of pancreatic transection seems to be decisive in the incidence of cephalic stump fistulas

Liver Transplantation in Patients with Hepatocellular Carcinoma Across Milan Criteria

Milan criteria are the most frequently used limits for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC), but our previous experience with expanded criteria showed encouraging results. The aim of this study was to investigate whether our expanded Clinica Universitaria de Navarra (CUN) criteria (1 nodule up to 6 cm or 2-3 nodules up to 5 cm each) could be used to select patients with HCC for LT. Eighty-five patients with HCC fulfilling CUN criteria were included as candidates for LT. Survival of transplanted HCC patients was compared with survival of patients without HCC (n = 180). After the exclusion of 2 patients with tumor seeding of the chest wall due to pre-LT tumor biopsy, survival and recurrence rates were compared according to tumor staging. Twenty-six out of 85 (30%) patients exceeded Milan criteria. Twelve patients had tumor progression on the waiting list. Patients exceeding Milan criteria had a higher dropout rate due to tumoral progression. One-, 3-, 5-, 7-, and 10-year survival rates of the 73 transplanted HCC patients were 86%, 74%, 70%, 61%, and 50%, respectively. Survival of patients with HCC was significantly lower than that of patients without HCC, but by multivariate analysis, HCC was not associated with lower survival. Tumor recurrence and survival rates were similar for patients fulfilling Milan and CUN criteria. Pathological staging showed 55 patients within Milan criteria, 7 patients exceeding them but within CUN criteria, and 9 patients exceeding CUN criteria. Tumor recurrence rates were 2/55 (4%), 0/7 (0%), and 4/9 (44%) in each of these groups, respectively. In conclusion, following CUN criteria could increase the number of HCC patients who could benefit from LT, without worsening the results. Because of the short number of patients in this series, these data need external validation

The obestatin receptor (GPR39) is expressed in human adipose tissue and is down-regulated in obesity-associated type 2 diabetes mellitus

The G protein-coupled receptor 39 (GPR39) has recently been identified as the receptor for obestatin, a peptidic hormone involved in energy homeostasis. However, the expression levels of this receptor in human adipose tissue in obesity and obesity-associated type 2 diabetes mellitus (T2DM) remain unknown. Therefore, we evaluated the actual presence of GPR39 mRNA in human adipose tissue and whether GPR39 expression levels are altered in obesity and obesity-associated T2DM. DESIGN: Omental adipose tissue biopsies obtained from 15 women were used in the study. Patients were classified as lean (body mass index 20.8 +/- 1.0 kg/m(2)), obese normoglycaemic (body mass index 48.4 +/- 2.1 kg/m(2)) and obese T2DM patients (body mass index 52.6 +/- 4.9 kg/m(2)). Anthropometric measurements and biochemical profiles were assessed for each subject. Real-time RT-PCR analyses were performed to quantify transcript levels of GPR39 and adiponectin. RESULTS: Obese T2DM patients exhibited significantly lower GPR39 expression levels compared to lean (P = 0.016) and obese normoglycaemic subjects (P = 0.008), while no differences between lean and obese normoglycaemic patients were observed. The mRNA expression levels of GPR39 were negatively correlated to fasting glucose concentrations (r = -0.581, P = 0.023), while exhibiting a positive correlation to adiponectin mRNA expression levels (r = 0.674, P = 0.006). CONCLUSION: GPR39 is expressed in human adipose tissue. The reduced expression levels of GPR39 in omental adipose tissue observed in obese patients with T2DM suggest an involvement of obestatin signalling in glucose homeostasis and T2DM development

Association of increased Visfatin/PBEF/NAMPT circulating concentrations and gene expression levels in peripheral blood cells with lipid metabolism and fatty liver in human morbid obesity

BACKGROUND AND AIMS: Nicotinamide phosphoribosyltransferase (NAMPT) is an adipokine with physiological effects on the control of glucose homeostasis as well as potentially involved in inflammation. The association of circulating NAMPT concentrations with obesity has not been clearly established. The aim of the present work was to evaluate the effect of obesity on circulating concentrations and gene expression levels of NAMPT in human peripheral blood cells (PBCs) as well as its involvement in inflammation, glucose and lipid metabolism. METHODS AND RESULTS: Forty-four serum samples obtained from 14 lean and 30 obese volunteers were used to analyse the circulating concentrations of NAMPT. In addition, PBC, omental adipose tissue (OM) and liver biopsy samples obtained from a subgroup of subjects were used to determine transcript levels of NAMPT by Real-time PCR. Glucose and lipid profile as well as several inflammatory factors and hepatic enzymes were analysed. NAMPT circulating concentrations (P<0.01) and gene expression levels in PBC (P<0.05) were significantly increased in obese patients as compared to lean subjects. Total-cholesterol (P=0.016), HDL-cholesterol (P=0.036) and triglycerides (P=0.050) were significant and independent determinants of circulating concentrations of NAMPT (P<0.01). Moreover, a positive correlation (P<0.01) was found with the hepatic enzymes alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyltransferase after BMI adjustment. CONCLUSION: Our work shows that NAMPT circulating concentrations and mRNA expression levels in PBC are increased in obese patients and that plasma NAMPT levels are related to inflammation, lipid metabolism and hepatic enzymes suggesting a potential involvement in fatty liver disease and in the obesity-associated inflammatory stat

Pancreatectomía central en tumores benignos del cuello del páncreas

The surgical treatment of benign tumors of the neck of the pancreas usually consists of enucleation or formal pancreatectomy. Central pancreatectomy has been put forward because it has fewer major complications and can preserve endocrine and exocrine function. Between January 1999 and march 2003, three patients with benign tumors of the neck of the pancreas underwent central pancreatectomy. all patients underwent computed tomography scans, intraoperative ultrasound and frozen-section analysis. pathologic examination showed two mucinous cystadenomas and one serous cystadenoma. after a mean follow-up of 34 months, none of the patients has shown major complications or local recurrence, or has developed diabetes. In conclusion, central pancreatectomy is a useful technique for selected benign or low-grade malignant pancreatic tumors of the neck of the pancreas