[show abstract][hide abstract] ABSTRACT: Poor vascular access due to previous surgery can be a major obstacle in pancreas transplantation for which new exocrine and vascular outflow techniques might be useful. A 34-year-old female with early onset type 1 diabetes who underwent living donor kidney transplantation 20 years ago and a failed pancreas transplantation 2 years ago presented for pancreas retransplantation.
The inferior vena cava was used in the previous deceased donor pancreas transplantation and both iliac arteries had intense perivascular fibrosis, making arterial anastomosis impossible. The only remaining option for the implant was the infrarenal aorta, with venous drainage to the superior mesenteric vein and exocrine drainage to the gastric antrum.
The patient had an uneventful recovery and graft function appeared normal. This report shows that when the recipient's abdominal cavity does not provide clear access for the usual surgical techniques regarding exocrine drainage, the stomach drainage procedure is an option.
Duodenum-stomach anastomosis might be an alternative to portal enteric drainage because there is easy access for graft biopsies and even for procedures involving the papilla major.
Journal of Gastrointestinal Surgery 01/2012; 16(5):1072-5. · 2.36 Impact Factor
[show abstract][hide abstract] ABSTRACT: Simultaneous pancreas-kidney transplantation (SPKT) has been accepted as treatment for type I diabetic patients with end-stage renal disease. Its success depends largely on the surgical technique. This study sought to compare groups of SPKT with initial pancreas implantation versus initial kidney implantation. From December 2000 to September 2006, 151 SPKT were performed by a single center. In 85 cases, the pancreas was implanted first (group 1), and in 66 cases the order was inverted (group 2). Variables were implantation sequence, pancreas and kidney ischemia time, donor age, venous drainage, previous donor peritoneal dialysis, and recipient age and gender. Outcome variables included pancreas vascular thrombosis, 3-month graft survival, 3-month patient survival, pancreas rejection episodes, intra-abdominal infection, diabetes control and reoperations. We observed a 10.6% incidence of vascular thrombosis in group 1 but none in group 2 (P = .005). In groups 1 and 2, the 3-month pancreas survivals were 74.1% and 89.4% (P = .022), and the mean hospital stays were 24.3 and 15.8 days, respectively (P = .002). Our results suggested that, when 2 different teams are involved in SPKT, with >1 exposure and the need for retractor replacement, the kidney should be transplanted first, because the pancreas may be damaged during the surgical procedure.
[show abstract][hide abstract] ABSTRACT: Pancreas transplantation is an invasive procedure that can restore and maintain normoglycemic level very successfully and for a prolonged period in DM1 patients. The procedure elevates the morbimortality rates in the first few months following the surgery if compared to kidney transplants with living donors, but it offers a better quality of life to patients.Although controversial, several studies have shown the stabilization or the improvement of some of the chronic complications related to diabetes, as well as the extra number of years of life that patients submitted to a double pancreas-kidney transplantation may gain.Recent studies have demonstrated clashing outcomes regarding isolated pancreas transplantations, a fact which reinforces the need for a more discerning selection of patients for this procedure.
Diabetology and Metabolic Syndrome 09/2009; 1(1):11. · 1.92 Impact Factor
[show abstract][hide abstract] ABSTRACT: Pancreas transplantation (PT) is a relatively uncommon therapy for non-uremic type 1 diabetes, as the severity of diabetes must warrant the risk of immunosuppression. In pediatric diabetic patients, who are less likely to display uremia because of the duration of diabetes, there is very little experience with pancreas transplantation alone (PTA). This report describes a 13-yr-old male PTA recipient. This patient was initially diagnosed with type 1 diabetes mellitus at the age of four yr. Following a multidisciplinary evaluation, PTA was found to be indicated based on a history of severe labile diabetes and hypoglycemic unawareness resulting in frequent episodes of hypoglycemia and hospital admissions. Because of the failure of medical management of the patient's diabetes, a whole organ bladder and systemic drained PTA was performed. Immunosuppression included thymoglobulin, tacrolimus, mycophenolate mofetil, and steroids. Early outcome was uneventful and patient was discharged 12 d after surgery normoglycemic and insulin-free. An episode of acute rejection (Maryland grade II) 20-d post-transplant was successfully treated with corticosteroids. A second and more severe episode of rejection (Maryland grade IV) occurred 13 months post-transplant, requiring treatment with thymoglobulin and conversion from steroid to sirolimus. On tacrolimus, sirolimus, and mycophenolic acid, he remains euglycemic and insulin-free 38 months after PTA. His quality-of-life is judged to be superior to his insulin dependent state prior to transplantation. According to the medical literature, this is the youngest patient ever to undergo PTA.
[show abstract][hide abstract] ABSTRACT: In patients with type 1 diabetes mellitus, atherosclerosis occurs earlier in life and coronary artery disease (CAD) constitutes the major cause of death.
Evaluate the prevalence and anatomic characteristics of coronary artery disease (CAD) in type 1 diabetic patients with chronic renal failure undergoing hemodialysis.
This is a descriptive study of 20 patients with type 1 diabetes mellitus undergoing hemodialysis without known CAD. CAD was assessed by quantitative coronary angiography (QCA) and intravascular ultrasound (IVUS). QCA was performed in all lesions >30%, visually. All proximal 18-mm segments of the coronary arteries were analyzed by IVUS. All other coronary segments with stenosis >30% were also analyzed.
Angiography detected 29 lesions >30% in 15 patients (75%). Eleven (55%) of the lesions were >50% and 10 (50%) >70%. Thirteen patients had all 3 major arteries interrogated by IVUS. Atherosclerosis was present in all patients and in all 51 proximal 18-mm segments analyzed. The mean vessel diameter of these segments was significantly larger at the IVUS than at the QCA, for all vessels. IVUS images of 25 (86.2%) of the 29 lesions >30% were obtained. Fibrotic plaques were common (48%) and 60% had intermediate vessel remodeling.
CAD was present in all vessels of all type 1 diabetic patients undergoing hemodialysis. These findings are in agreement with other autopsy, angiography and IVUS studies. Additionally, they indicate the need for additional epidemiological and imaging studies to better understand and treat such a complex and serious clinical condition affecting young people.
Arquivos brasileiros de cardiologia 07/2009; 93(1):15-21. · 1.32 Impact Factor
[show abstract][hide abstract] ABSTRACT: The medical context recognizes the efficiency of working with groups of patients. Group interventions can intensify the understanding, ability, and notion of recognizing the patient's own condition, increasing the responsibility for him- or herself. This survey sought to evaluate the efficacy of an interdisciplinary orientation group for hepatic transplantation preoperatively.
The opinions of all patients on a waiting list for liver transplantation and their accompanying persons were evaluated from August to December 2005 through a questionnaire with 17 relevant items concerning the transplantation process. The group efficacy was evaluated according to the percentage of correct answers from the subjects before and after attending the group.
The results showed a 59% increase in correct answers for the evaluated items after group attendance. The items which showed significant improvement were: what should I do after being called for transplantation; average time of admission to hospital and ICU; use of immunosuppressive drugs; clinical conditions for transplantation; frequency of appointments with the surgeon within the first month; physical activities; diet; blood transfusion; and forgetting medication. A ceiling effect was observed upon reevaluation of the previous conditions for transplantation item.
The percentage of health improvement after attending the group demonstrated an impact of the interdisciplinary orientation intervention on the instruction of patients and their accompanying persons, thus representing an important step in their training process.
[show abstract][hide abstract] ABSTRACT: There is evidence of benefits from psycho-educational groups in the compliance of patients undergoing complex procedures. Psycho-educational groups provide information, elucidate doubts and realities, fade out fantasies, and help lessen patients' anxieties, thus minimizing the chances of complications or irregular behavior. The objective of this study was to evaluate the efficacy of an interdisciplinary orientation group for pretransplantation preparation for pancreas/pancreas-kidney grafting.
All patients and their accompanying persons who attended information groups from February to August 2005 completed a questionnaire with 15 relevant items about the transplantation process. The efficiency of the orientation group was evaluated according to the percentage of correct answers before and after attending the group.
Twenty-seven subjects were evaluated demonstrating an increased number of right answers in 78% of the evaluated items after group attendance. An important improvement was observed in the following items: function of serum sent to the Central Laboratory; serum replacement period; kind of renal donor; blood transfusion; using medicaments; and how often should the patient return for an appointment with the surgeon within the first month. Further items such as surgery risks, using immunosuppressive drugs, and forgetting the medication showed 100% correct answers before and after attending the group.
Results suggest that the pretransplantation orientation group is an efficient way to provide information. Applying a knowledge verification questionnaire before and after the group helps to understand the difficulties of participants, thereby guiding the team and elucidating questions that need more consideration.
[show abstract][hide abstract] ABSTRACT: Livers from marginal donors are increasingly used for transplantation due to the shortage of donor organs. The definition of a marginal donor remains unclear; prediction of organ function is a challenge. In the literature the use of steatotic livers has been associated with poor liver function or even primary dysfunction of the allograft. Tekin et al created a scoring system that classifies a donor as marginal or nonmarginal, using a mathematical model based on donor age and steatosis degree. The aims of this study were to apply the Tekin method to identify marginal and nonmarginal donors and evaluate the influence of the cold ischemia time (CIT) on allograft evolution. We retrospectively reviewed deceased donor liver transplantations performed from October 1995 to March 2006, namely, 177 adult liver transplantations in 163 patients. Fifty-five were excluded due to retransplantation (14) or insufficient data (41). Donor age and macrovesicular steatosis were evaluated according to the mathematical formula proposed by Tekin et al, classifying the donors as marginal versus nonmarginal. The authors also analyzed the CIT, 3-month mortality, and development of primary nonfunction or primary dysfunction. The median donor age was 38.9 years (range, 6-71). The postreperfusion biopsy specimen showed moderate to intense steatosis (>30%) in 14.75% of specimens, with no steatosis or mild steatosis in 85.25%. Sixty-one grafts (50%) developed primary graft dysfunction (PGD): 10 grafts, with primary nonfunction (PNF); and 51 with initial poor function (IPF). Using the criteria provided by Tekin et al, we obtained 41 marginal and 81 nonmarginal allografts. The marginal group showed 61.9% PGD, compared with 59.2% of PGD by the nonmarginal group. The CIT was greater than 12 hours in 5 marginal group transplants and 4 PGD cases (80%). Of the nonmarginal allografts, the CIT was greater than 12 hours in 29.6%, with 75% PGD. The 3-month graft survival rate was 80% in the marginal group with ischemia time more than 12 hours: 86.1% of the same group when CIT was less than 12 hours, and 82.7% in the nonmarginal group. In contrast, when we analyzed the occurrence of allograft dysfunction, the 3-month mortality rate was 34% among, grafts with dysfunction, whereas, in those without initial dysfunction, it was 4.1%. In conclusion, the score suggested by Tekin et al that classifies the donors as ideal (nonmarginal) or marginal was not able to predict initial primary dysfunction.
[show abstract][hide abstract] ABSTRACT: Psychological and psychiatric alterations are common in patients submit a transplant, particularly, states of anxiety, depression, delirium and adjustment problems. The importance of therapeutic interventions during transplant has been known; however, the nature of the patients needs during their hospital stay are ignored or little described in medical literature. Objective: To evaluate the nature of the needs for psychological care to patients submit a organ transplant, in order to better prepare a treatment plan for this population. Results: All the records of patients who went through liver, pancreas or double transplant (pancreas and liver) were revised. A nine month period sample adding up to 73 patients. 24 submitted to a pancreas or double transplant and 49 patients who underwent liver transplant. Overall, transplant patients are younger and have lower education degrees when compared to others in a General Hospital. They also come from very different places, whereas the majority of patients in this General Hospital are from São Paulo. It was observed that liver transplant patients were older than pancreas or double transplant patients. They needed more psychology sessions and more psychiatric assessments. Psychological service was characterized by a lower frequency in managing care for the patient and a higher frequency of family sessions. Those being statistically significant when compared to other services in a General Hospital. The same repercussion happened when comparing patients of liver transplant and patients of pancreas or double transplant. The prevalence of consultation-liaison was due to the presence of symptoms as anxiety or apathy in liver transplant patients. In contrast, pancreas or double transplant patients had their needs aimed to behavioral alterations. Conclusion: In spite of the motivation to request the service being similar for both groups assessed, the amount of assistance offered to liver patients showed to be bigger. The comparison between the profiles of in-patients who underwent transplant in this General Hospital can help in the shaping of consultation-liaison services.
Revista de Psiquiatria Consiliar e de Ligação. 01/2005; 12:51-57.