General Surgery

BACKGROUND: Hepatitis D virus is a small defective RNA virus that requires the presence of hepatitis B virus infection to infect a person. Hepatitis D is a difficult-to-treat infection. Several clinical trials have been published on the efficacy of interferon alpha for hepatitis D virus (HDV) infection. However, there are few randomised trials evaluating the effects of interferon alpha, and it is difficult to judge any benefit of this intervention from the individual trials.OBJECTIVES: To evaluate the beneficial and harmful effects of interferon alpha for patients with chronic hepatitis D.SEARCH METHODS: We identified relevant for the review randomised clinical trials by electronic searches in the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until May 2011. We also checked the bibliographic references of identified randomised trials, textbooks, and review articles in order to find randomised trials not identified by the electronic searches.SELECTION CRITERIA: Randomised clinical trials evaluating interferon alpha versus placebo or no intervention for patients with chronic hepatitis D infection.DATA COLLECTION AND ANALYSIS: Two authors assessed the trials and extracted data on mortality, virologic, biochemical, and histological response as well as adverse events at end of treatment and six months or more after completing treatment. The analyses were performed using the intention-to-treat principle including all randomised participants irrespective of follow-up. Drop-outs, withdrawals, and non-compliance were considered as treatment failures. Data were analysed with fixed- and random-effects models. Reported results were based on fixed-effect model except in cases where statistical significance varied between the two models.MAIN RESULTS: Six randomised trials fulfilled the inclusion criteria. Two hundred and one randomised participants (male = 174) were included. The risk of bias in all the included trials was high. Five trials compared interferon alpha with no treatment in the control group. One of these trials had two treatment arms with a higher dose and lower dose of interferon alpha and a no-treatment control group. We analysed both treatment regimens as a single group in a primary analysis and as separate groups in the subgroup analysis of different interferon dosages. The sixth trial compared only a higher dose of interferon alpha with a lower dose.Meta-analysis of five trials comparing interferon alpha with no-treatment control group included 169 participants. There were seven drop-outs in the treatment group and nine in the control group. One patient out of 92 (1.1%) died in the interferon alpha group compared with zero out of 77 (0.0%) in the no-intervention control group (risk ratio (RR)) 3.00; 95% confidence interval (CI) 0.14 to 66.5). Interferon alpha led to failure of end of treatment virological response in 62/92 (67.4%) of the patients compared with 71/77 (92.2%) in the untreated controls (RR 0.76, 95% CI 0.66 to 0.87, P = 0.0001 by fixed-effect model and RR 0.71, 95% CI 0.43 to 1.16, P = 0.17 by random-effects model). Failure of normalisation of alanine aminotransferase (ALT) at the end of treatment was seen in 60/92 (65.2%) patients treated with interferon alpha versus 76/77 (98.7%) in the control group (RR 0.69, 95% CI 0.59 to 0.80, P < 0.00001). Sustained virological response was not achieved in 76/92 (82.6%) of patients on interferon compared with 73/77 (94.8%) of controls (RR 0.89, 95% CI 0.80 to 0.98, P = 0.02). Serum alanine aminotransferase was abnormal in 81/92 (88.0%) treated with interferon alpha patients at six months post-treatment follow-up compared with 76/77 (98.7%) in controls (RR 0.92, 95% CI 0.84 to 0.99, P = 0.04). There was no significant histological improvement in 67/92 (72.8%) patients treated with interferon alpha compared with 65/77 (84.4%) in controls (RR 0.86, 95% CI 0.74 to 1.00, P = 0.06).Two trials comparing a higher dose of interferon alpha with the lower dose showed no significant difference in sustained virological response (76.7% compared with 90.0%) (RR 0.85, 95% CI 0.68 to 1.07, P = 0.16). Adverse events such as flu-like symptoms, asthenia, weight loss, alopecia, thrombocytopenia, and leukopenia were reported in all these trials and the adverse events were related to interferon alpha. These were common and sometimes severe. One patient in the treatment group was reported to have died by suicide towards the end of the study period.AUTHORS' CONCLUSIONS: Interferon alpha does not seem to cure hepatitis D in most patients. The agent seems effective in suppressing viral and liver disease activity in some patients, but this improvement is not sustained in the majority of patients. We cannot exclude overestimation of benefits and underestimation of harms due to high risk of bias (systematic errors) and high risk play of chance (random errors). Therefore, more randomised trials with large sample sizes and less risk of bias are needed before interferon can be recommended or refuted.

To determine the impact of prolonged cold ischemia time (CIT) on the outcome of acute kidney injury (AKI) renal grafts, we therefore performed a single-center retro- spective analysis in adult patients receiving kidney transplantation (KT) from AKI do- nors. Outcomes were stratified according to duration of CIT. A total of 118 patients receiving AKI grafts were enrolled. Based on CIT, patients were stratified as follows: (i) <20 hours, 27 patients; (ii) 20-30 hours, 52 patients; (iii) 30-40 hours, 30 patients; (iv) ≥40 hours, nine patients. The overall incidence of delayed graft function DGF was 41.5%. According to increasing CIT category, DGF rates were 30%, 42%, 40%, and 78%, respectively (P = .03). With a mean follow-up of 48 months, overall patient and graft survival rates were 91% and 81%. Death-censored graft survival (DCGS) rates were 84% and 88% for patients with and without DGF (P = NS). DCGS rates were 92% in patients with CIT <20 hours compared to 85% with CIT >20 hours (P = NS). In the nine patients with CIT >40 hours, the 4-year DCGS rate was 100%. We conclude that prolonged CIT in AKI grafts may not adversely influence outcomes and so discard of AKI kidneys because of projected long CIT is not warranted when donors are wisely triaged.

The value of importing expanded criteria donor (ECD) kidneys is uncertain. Methods: We retrospectively reviewed our single center experience with ECD kidney transplants (KT). Results: Over 12.8 years, we performed 497 ECD KTs including 247 local and 250 imported from other donor service areas. The import ECD group had more donors (16% vs 8.5%) ≥ age 70, more zero HLA-mismatches (14% vs 2%), more KTs with a cold ischemia time >30 hours (46% vs 19%), and fewer kidneys managed with pump preservation (78% vs 92%, all p ≤ 0.05) compared to the local ECD group. Mean KDPIs were 80% import vs 84% local. With a mean follow-up of 55 months, actual patient and graft survival rates were 71% and 57.6% in import vs 76% and 57.9% in local ECD KTs, respectively. Death-censored graft survival rates were 70% in import vs 69% in local ECD KTs. Delayed graft function occurred in 28% import vs local ECD KTs (p=NS) whereas the incidence of primary nonfunction was higher with import ECD kidneys (7.2% vs 2.8%, p=0.038).

Pancreas transplantation has become accepted as the only definitive long-term treatment that reliably restores euglycemia by restoring endogenous insulin production and improving glucose counterregulation in patients with type 1 diabetes mellitus and in carefully selected patients with insulin-dependent type 2 diabetes mellitus. Despite five decades of experience and with more than 41,000 pancreas transplants performed worldwide through 2011, a multitude of variations exist in operative technique, reflecting the lack of consensus regarding the best method for implanting a pancreas allograft into a recipient. These differences in technique are primarily related to the method of pancreatic exocrine secretion drainage and the site of portal-venous drainage. The surgical technique of pancreas transplantation has evolved over time in response to technical complications and physiologic derangements associated with earlier methods of implantation. This chapter reviews the historical development of the pancreas transplant technique and elaborates on the rationale for the different variations currently practiced. Detailed descriptions of the most common technical approaches to implantation are provided.
Keywords
Pancreas transplantation Technique Systemic-enteric drainage Systemic-bladder drainage Portal- enteric drainage

Keywords: Age factors, Donors, Graft survival, marginal, Outcome
Controversy exists regarding optimal use of kidneys from small pediatric donors (SPDs).
The study purpose was to compare outcomes between single and dual en bloc (EB) kidney
transplants (KT) from SPDs in the context of the Kidney Donor Profile index (KDPI).
METHODS: Single center retrospective review of KTs from SPDs ≤5 years of age. Recipient
selection included low BMI, middle-aged adults at low immunologic risk. All patients (pts)
received depleting antibody induction with FK/MMF/prednisone.
RESULTS: From 2002-2015, 59 KTs were performed from SPDs including 34 dual EB and
25 single KTs. Mean donor age (17 vs 38 months, p<0.001), mean weight (11.0 vs 17.4 kg,
p=0.046) and male donors (50% vs 84%, p=0.01) were lower in the EB compared to the
single KT group, respectively. Mean cold ischemia time (21 hours), KDPI (73% vs 62%) and
serum creatinine (SCr) levels (0.37 vs 0.49 mg/dl, all p=NS) were comparable in the EB
and single KT groups, respectively. Other than mean recipient age (38 EB vs 46 years single
KT, p=0.04), there were no significant differences in pt characteristics between groups.
With a mean follow-up of 5 years, actual pt (94% vs 80%, p=0.12) and graft survival (GS,
91% vs 68%, p=0.04) rates were slightly higher in EB compared to single KT, respectively
(Table 2). Death-censored kidney GS rates were 93.9% and 81% (p=0.19), respectively.
Delayed graft function incidence (12% EB vs 20% single KT, p=NS) was slightly lower in
EB KT pts. Mean 4-year SCr and GFR levels, which improved over time in both groups,
were 1.0 vs 1.17 mg/dl and 81 vs 64 ml/min/1.73 m2 (both p=NS) in the EB and single KT
groups. EB KT outcomes were comparable to concurrent living donor KTs and superior to
standard criteria donor (SCD) KTs at our center whereas outcomes following single KT
from SPDs were inferior to living donor KTs and similar to concurrent SCD KTs. Based on
actual 5-year GS, the projected KDPIs of EB and single KTs from SPDs were <1% and 65%.
CONCLUSION: With appropriate pt selection, excellent mid-term outcomes can be
achieved by KT from SPDs into adult recipients. KDPI is predictive of survival for single KT
but is not accurate for predicting EB KT outcomes from SPDs.

Background Celiac trunk agenesis is the recent and the rarest vascular variation reported. Reported cases in literature were identified either incidentally on imaging or while cadaveric dissections. This is a unique experience of hepatectomy in a patient without celiac artery ever reported. Case presentation This is a case of a patient who was scheduled to undergo donor hepatectomy. He was found to have a rare anatomical variation of agenesis of the celiac trunk during preoperative imaging done as a routine transplant surgery workup. He underwent live donor hepatectomy with no intra-operative or post-operative complications. This is the first case to be reported in the literature of a donor hepatectomy for liver transplantation in a patient with this rarest vascular variation of the celiac axis. Conclusion Pre-operative imaging to determine hepatic vascular anatomy improves the understanding of the surgeon intraoperatively while dissection and decreases the chance of any iatrogenic ...

To determine the impact of prolonged cold ischemia time (CIT) on the outcome of acute kidney injury (AKI) renal grafts, we therefore performed a single center retrospective analysis in adult patients receiving kidney transplantation (KT) from AKI donors. Outcomes were stratified according to duration of CIT. 118 patients receiving AKI grafts were enrolled. Based on CIT, patients were stratified as follows: a) &lt;20 hours, 27 patients; b) 20-30 hours, 52 patients; c) 30-40 hours, 30 patients; ≥40 hours, 9 patients. The overall incidence of DGF was 41.5%. According in increasing CIT category, DGF rates were 30%, 42%, 40%, and 78%, respectively (p=0.03). With a mean follow-up of 48 months, overall patient and graft survival rates were 91% and 81%. Death-censored graft survival (DCGS) rates were 84% and 88% for patients with and without DGF (p=NS). DCGS rates were 92% in patients with CIT &lt;20 hours compared to 85% with CIT &gt;20 hours (p=NS). In the 9 patients with CIT &gt;40 hours...

Imperforate anus is a rare anomaly associated with defects commonly referred to as vertebral defects, anal atresia, cardiac defects, tracheo-oesophageal fistula, renal anomalies and limb abnormalities (VACTERL). With modern surgical procedures the overall outcome is excellent. Permanent colostomy which is required in some cases of this disease can result in some rare complications such as enteroliths formation, as illustrated in the case we are presenting here related to a 28-year-old male who reported at urology emergency with features of urinary and acute large bowel obstruction. On investigation he was found to have two enteroliths in his distal loop of sigmoid colostomy. The more distal of the two enteroliths caused urinary retention and hence acute renal failure, and the proximal one caused large bowel obstruction by compressing the proximal loop of colostomy. This case demonstrates that the blind distal sigmoid colostomy loop can grow enteroliths secondary to stasis of its own...

We report a case of 40 years old female who was diagnosed to have gallbladder mass on radiological imaging and underwent radical cholecystectomy. Microscopic analysis of surgical specimen confirmed the diagnosis of multifocal intracholecystic papillary-tubular neoplasms (ICPNs) of the gallbladder with negative resection margin.