Asunto(s)
Colestasis Extrahepática/cirugía , Conducto Hepático Común/cirugía , Hipertensión Portal/cirugía , Trasplante de Hígado , Derivación Portosistémica Intrahepática Transyugular/efectos adversos , Colestasis Extrahepática/diagnóstico por imagen , Colestasis Extrahepática/etiología , Conducto Hepático Común/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: Laparoscopic techniques have emerged as a suitable approach for colon resection. This study determined and compared the outcomes of patients undergoing laparoscopic or open colectomy at United States academic centers. METHODS: Using ICD-9-CM codes, we obtained data from the University HealthSystem Consortium database for 50,443 patients who underwent open (n = 47,090; 94%) or laparoscopic (n = 3,353; 6%) colectomy during a 5-year period (2002 to 2006). Outcomes studied included length of stay (LOS), costs, in-hospital morbidity and risk-adjusted mortality rates. RESULTS: Mean LOS (open = 11 days and laparoscopic = 7 days) was significantly shorter and mean costs (open = $23,000 and laparoscopic = $17,000) significantly fewer with the laparoscopic approach. The overall in-hospital morbidity rate was significantly lower with laparoscopic colectomy (open = 33% and laparoscopic = 24%). The risk-adjusted mortality ratio was comparable between groups (open = .9 and laparoscopic = .7). COMMENTS: Despite the major biases inherent in this retrospective review of the University Health System Consortium, which favors the use of laparoscopic colectomy by United States academic surgeons, laparoscopic colectomy offers the potential of significantly shorter LOS, fewer costs, lower in-hospital morbidity rates, and comparable risk-adjusted mortality rates compared with open colectomy. Laparoscopic colectomy is as safe as the open approach.
Asunto(s)
Centros Médicos Académicos/estadística & datos numéricos , Colectomía/métodos , Enfermedades del Colon/cirugía , Laparoscopía , Colectomía/estadística & datos numéricos , Femenino , Humanos , Laparoscopía/estadística & datos numéricos , Masculino , Estudios Retrospectivos , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: This study assessed whether preoperative weight loss resulted in favorable outcomes after open Roux-en Y gastric bypass (RYGB). METHODS: A retrospective review of all patients who underwent RYGB at the DVAMC was undertaken. Patients were divided into: patients who did not lose weight within 3 months preoperatively (n=25) and group II, those who did (n=15). RESULTS: Both groups had similar demographics, body mass index, comorbid conditions, and American Society of Anesthesiology class. Group II lost 28.2+/-6.5 lbs (8.3% of body weight) within 3 months before RYGB. Operative time was longer in group I compared to group II (180.0+/-0.0 vs 161.0+/-0.0 min; p=0.05). Both groups had the same rate of postoperative complications and the same long-term weight loss at a 2-year follow-up (n=6 both groups). CONCLUSIONS: An 8% reduction of body weight is associated with a decrease in operative time. These preliminary data suggest that preoperative weight loss results in a technically less challenging operation in the super-obese patient.
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Derivación Gástrica , Pérdida de Peso , Femenino , Hospitales de Veteranos , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Obesidad Mórbida/cirugía , Complicaciones Posoperatorias/prevención & control , Cuidados Preoperatorios , Estudios Retrospectivos , Grapado Quirúrgico , Resultado del TratamientoRESUMEN
Phytobezoars associated with diabetic gastroparesis are often sources of diminished quality of life for patients. Poor blood sugar control has been associated with increasing gastroparesis. For recipients of pancreas transplants to correct diabetes, phytobezoar treatment post-transplant can typically be limited to invasive procedures and prokinetic agents. We present the case of an alternative treatment to phytobezoar, cola libation, i.e., "cola-lysis."
Asunto(s)
Bezoares/terapia , Bebidas Gaseosas , Cola , Complicaciones de la Diabetes , Gastroparesia/complicaciones , Adulto , Bezoares/etiología , Humanos , Masculino , Trasplante de Páncreas/rehabilitaciónRESUMEN
BACKGROUND: The purpose of this study was to compare risk factors for the development of incisional versus organ/space infections in patients undergoing colorectal surgery. METHODS: An institutional review board-approved retrospective review was performed examining a 4-year period (January 2002 to December 2005). Patients were included if they had undergone abdominal operations (open or laparoscopic) in which the colon/rectum was surgically manipulated. Patients were excluded if the surgical wound was not closed primarily. A standardized definition of incisional and organ/space infection was employed. RESULTS: A total of 428 operations were performed. Overall, 105 infections were identified (25%); 73 involved the incision and 32 were classified as organ/space. Multivariate analysis suggested that incisional infection was independently associated with body mass index (odds ratio [OR], 1.07; 95% confidence interval [CI], 1.02-1.11) and creation/revision/reversal of an ostomy (OR, 2.2; 95% CI, 1.3-3.9). Organ/space infection was independently associated with perioperative transfusion (OR, 2.3; 95% CI, 1.1-5.5) and with previous abdominal surgery (OR, 2.5; 95% CI, 1.2-5.3). CONCLUSIONS: Factors associated with infection differed based on the type of surgical site infection being considered. The lack of overlap between factors associated with incisional infection and organ/space infection suggests that separate risk models and treatment strategies should be developed.
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Procedimientos Quirúrgicos del Sistema Digestivo/estadística & datos numéricos , Laparoscopía/estadística & datos numéricos , Estomía/estadística & datos numéricos , Infección de la Herida Quirúrgica/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Transfusión Sanguínea/estadística & datos numéricos , Índice de Masa Corporal , Colon/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Morbilidad , Análisis Multivariante , Recto/cirugía , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Factores de RiesgoRESUMEN
NH is a rare disorder of iron storage in newborns resulting in rapid liver failure. Outcomes are dismal with 20-30% survival. We report our experience in eight children with NH. Assessment of liver function included admission PT and serum levels of FV and FVII. Medical treatment (antioxidant cocktail) was started in all patients, with chelation therapy in six. Of these six, three survived with medical treatment alone. The other three underwent liver transplant. One died 158 days after transplant to sepsis: two are well more than five yr after transplant. The two neonates who did not receive chelation therapy, died to multi-organ failure and sepsis. In summary, five children (62.5%) survived long-term. In the three transplanted, one- and five-yr-survival was 66%. Older children with compromised synthetic liver function (FVII levels < or = 15%) required liver replacement for survival. Early referral to a tertiary care center is essential to increase survival of these children with a rare and otherwise fatal disease. Single center experience of children with NH is here presented. Potentials for survival improvement with of medical and surgical treatment are examined.
Asunto(s)
Antioxidantes/uso terapéutico , Terapia por Quelación/métodos , Deferoxamina/uso terapéutico , Hemocromatosis/terapia , Trasplante de Hígado/métodos , Sideróforos/uso terapéutico , Progresión de la Enfermedad , Quimioterapia Combinada , Factor VII/metabolismo , Femenino , Estudios de Seguimiento , Rechazo de Injerto/diagnóstico , Rechazo de Injerto/epidemiología , Rechazo de Injerto/prevención & control , Hemocromatosis/sangre , Hemocromatosis/complicaciones , Humanos , Incidencia , Lactante , Recién Nacido , Fallo Hepático/epidemiología , Fallo Hepático/etiología , Fallo Hepático/prevención & control , Imagen por Resonancia Magnética , Masculino , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Tasa de Supervivencia , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
Advances in immunosuppression and surgical technique have greatly improved patient outcomes after intestinal transplantation. However, the procedure remains one of the most challenging among solid organ transplantation as a result of the high rate of acute rejection, sepsis, and posttransplantation lymphoproliferative disorder. Recently, clinical trials to explore tolerance protocols in humans have been initiated, including small bowel transplant recipients, with results not always reproducible. The concept of operational tolerance is more meaningful in the clinical setting when physiological stability of graft function is achieved in the absence of maintenance immunosuppression. We report the intriguing case of a living related small bowel transplant recipient who developed clinical "prope" tolerance to the graft after treatment of severe acute rejection despite continuous noncompliance with immunosuppressive therapy.
Asunto(s)
Rechazo de Injerto/inmunología , Íleon/trasplante , Tolerancia al Trasplante/inmunología , Trasplante Homólogo/inmunología , Negativa del Paciente al Tratamiento , Adulto , Biopsia , Humanos , Inmunosupresores/uso terapéutico , Donadores Vivos , Masculino , Trasplante Homólogo/patologíaRESUMEN
BACKGROUND: Transmetatarsal amputation (TMA) is an operation designed to remove a limited area of irremediable tissue ischemia and/or infection and preserve limb function. Patients are selected for TMA based on degree of tissue loss/infection, adequacy of tissue perfusion at the transmetatarsal level, current ambulatory status, and estimation of the likelihood of postprocedure ambulation. The purpose of this study was to assess the validity of these selection criteria. METHODS: An institutional review board-approved retrospective review was conducted of all patients undergoing TMA from January 1, 1997, until January 1, 2006. Information was collected on patient demographics, medical comorbidity, and clinical and surgical variables. Outcome measures included the proportion of patients requiring amputation revision to a more proximal level and ambulatory status at last follow-up. RESULTS: Fifty-two TMAs were performed. In 35 procedures, the skin was left open, and in 17 TMA was closed primarily. Primary indications for the procedure were vascular insufficiency or infection in 50 of 52 patients, whereas 2 patients required amputation for malignancy. The majority (46/52, 89%) of patients were diabetic. After the index TMA, 85 additional operations were required. Only 9 patients (18%) underwent a single operation. Revision of the TMA to a more proximal level was required in 29 of 52 (56%) patients, resulting in 4 Syme, 20 transtibial, and 5 transfemoral amputations. Non-insulin-dependent diabetes was associated with an increased likelihood of revision to a more proximal amputation (odds ratio [OR] = 5.4; 95% confidence interval [CI], 1.2-24). At the time of last follow-up (median 18 months), 37 of 50 (74%) patients were ambulatory (83% for TMAs and 67% for more proximal amputations, P = 0.18). Prior vascular procedures were associated with a significantly decreased likelihood of ambulation (OR = 14; 95% CI, 1.9-103). CONCLUSIONS: Although most patients retain the ability to ambulate after TMA, multiple operations should be anticipated in the majority of patients and revision of a TMA to a more proximal level may be required. These data suggest that current selection criteria for TMA may be inadequate.
Asunto(s)
Amputación Quirúrgica , Angiopatías Diabéticas/cirugía , Pie/irrigación sanguínea , Isquemia/cirugía , Metatarso/cirugía , Selección de Paciente , Comorbilidad , Enfermedad Coronaria/epidemiología , Angiopatías Diabéticas/epidemiología , Femenino , Humanos , Isquemia/epidemiología , Tiempo de Internación , Modelos Logísticos , Masculino , Persona de Mediana Edad , Enfermedades Vasculares Periféricas/epidemiología , Pletismografía , Reoperación , Estudios RetrospectivosRESUMEN
BACKGROUND: Different medical and social conditions have been associated with primary and recurrent hernias. Possible predictors of recurrence after elective umbilical hernia repair have not been defined clearly. The aim of this study was to determine factors that predict recurrence in patients after elective repair of umbilical hernias. METHODS: A 6-year retrospective review of patients with elective umbilical hernia repair at the Dallas VA Medical Center was performed. Clinical and pathologic data were evaluated by univariate analysis to identify predictive factors for recurrence. RESULTS: A total of 244 patients underwent elective hernia repair within the study period (male, 96%; mean age, 56 y; Caucasian, 74%; African American, 14%; Hispanic, 8%). Because 15 patients were not compliant with follow-up requirements, 229 were eligible for the study. Ninety-seven underwent suture repair (42.4%) and 132 underwent mesh repair (57.3%). Eleven recurrences were identified (4.8%): 7 in the suture repair group (7.7%) and 4 in the mesh repair group (3%). Univariate analysis showed that patients likely to develop recurrences were as follows: African American (15.6% vs. 3.5%; P = .017), type II diabetics (14.2% vs. 2.6%; P = .002), patients with hyperlipidemia (9.2% vs. 2.6%; P = .028), and human immunodeficiency virus-positive patients (66.6% vs. 3.9%; P = .000). CONCLUSIONS: Smoking, obesity, size of hernia, type of repair, or chronic obstructive pulmonary disease do not seem to predict recurrence of hernias in our VA population. African Americans, patients with type II diabetes, hyperlipidemia, and positive for human immunodeficiency virus, may have a higher risk for recurrence after elective umbilical hernia repair.
Asunto(s)
Hernia Umbilical/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Comorbilidad , Procedimientos Quirúrgicos Electivos , Hernia Umbilical/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Obesidad/epidemiología , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Fumar/epidemiología , Mallas Quirúrgicas , Técnicas de Sutura , Estados Unidos , VeteranosRESUMEN
INTRODUCTION: Living donor bowel transplantation has recently emerged as a valuable alternative to cadaver bowel transplant. We herein present our single-center experience with this procedure. MATERIALS AND METHODS: From April 1998 to October 2004, 12 living donor intestinal transplants were performed in 11 patients (7 males, 4 females; average age, 26 years). Four of the patients were children under 5 years. A segment of distal ileum 150 to 180 cm long in pediatric recipients and 200 cm long in adult was used. The immunosuppressive protocol consisted of induction with thymoglobulin and maintenance with tacrolimus with or without mycophenolate mofetil and steroids. RESULTS: All donors recovered well and did not experience any early or late complications. The overall 1- and 3-year patient survival was 82% with a graft survival of 75%. In the last 8 patients, transplanted after January 2000, the 1-year patient and graft survival has been 100% and 88%, respectively. The median hospital stay was 36 days (range, 13-290 days). During the first year after transplant only, the patient who received a totally mismatched graft experienced one episode of rejection (8%). All the surviving patients are currently supported by enteral diet without fluid requirements. CONCLUSIONS: Living donor bowel transplantation is a valuable strategy in the treatment of irreversible intestinal failure. The results have improved over the years thanks to increased experience of the team.
Asunto(s)
Íleon/trasplante , Enfermedades Intestinales/cirugía , Donadores Vivos , Adulto , Preescolar , Femenino , Estudios de Seguimiento , Supervivencia de Injerto , Humanos , Lactante , Enfermedades Intestinales/mortalidad , Masculino , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
Bilateral pulmonary agenesis (PA) is a rare embryological defect incompatible with life. Unilateral PA has a wide range of clinical presentations: its prognosis depends on the presence and severity of other associated anomalies. Fetal biliary atresia has been associated with a number of congenital anomalies, but the etiology is still not understood. An unusual case of a child with right PA, right diaphragmatic hernia, and delayed diagnosed biliary atresia leading to liver failure is presented herein. At the age of 4 months the patient was referred to the Transplant Department at Children Healthcare of Atlanta at Egleston with cholestasis and failure to thrive. With a rapidly progressive liver insufficiency, this child was evaluated for liver transplantation. In the absence of any respiratory symptom, the patient received a deceased donor size-matched left lateral segment liver transplant, which covered the diaphragmatic defect, with no further repair required. Twenty-seven months post-transplant, the patient has good graft function, a normal Z-score and is thriving. In spite of the increased physiological and surgical challenges (absence of right lung tissue, hemi-diaphragm, and ectopic position of the liver in the right chest), liver transplantation was performed with positive outcome in this high-risk child. Whether PA, may have developmentally contributed to expression of biliary atresia will need further investigation.
Asunto(s)
Atresia Biliar/complicaciones , Atresia Biliar/cirugía , Hernias Diafragmáticas Congénitas , Trasplante de Hígado , Pulmón/anomalías , Femenino , Estudios de Seguimiento , Supervivencia de Injerto , Hernia Diafragmática/diagnóstico , Hernia Diafragmática/diagnóstico por imagen , Hernia Diafragmática/cirugía , Humanos , Lactante , Radiografía , Factores de Tiempo , Resultado del TratamientoRESUMEN
Transplanting blood group A, B, or O (ABO)-incompatible (ABO-I) liver grafts has resulted in lower patient and graft survival with an increased incidence of vascular and biliary complications and rejection. We report that, without modification of our standard immunosuppression protocol, crossing blood groups is an acceptable option for children requiring liver transplantation. In our study, ABO-I liver grafts -- regardless of recipient age -- have comparable long-term survival (mean follow-up of 3.25 yr) with ABO-compatible grafts without any difference in rejection, vascular or biliary complications. From January 1, 1999 to October 1, 2005, we studied 138 liver transplants in 121 children: 16 (13.2%) received an ABO incompatible liver allograft. One-year actuarial patient survival for ABO-matched grafts vs. ABO-I grafts was 93.0% and 100%, respectively, whereas graft survival was 83.4% and 92.3%. Additionally, 6 of 16 (37.5%) ABO-I transplanted children had 8 rejection episodes, whereas 47 patients (44.8%) had 121 rejection episodes in the ABO-compatible group. There were no vascular complications and 2 biliary strictures in the ABO-I group. Plasmapheresis was not used for pretransplantation desensitization and was only required in 1 posttransplantation recipient. No child was splenectomized. Six of the 16 children were older than 13 yr of age, suggesting the possibility of successfully expanding this technique to an older population. In conclusion, our outcomes may support the concept of using ABO-I grafts in a more elective setting associated with split and living donor liver transplants.
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Sistema del Grupo Sanguíneo ABO , Incompatibilidad de Grupos Sanguíneos , Terapia de Inmunosupresión , Trasplante de Hígado , Plasmaféresis , Adolescente , Niño , Preescolar , Femenino , Rechazo de Injerto/inmunología , Rechazo de Injerto/prevención & control , Humanos , Lactante , MasculinoRESUMEN
BACKGROUND: The incidence of complications after reversal of Hartmann's procedure is unknown. This study compares the morbidity of Hartmann's reversal versus loop ileostomy reversal. METHODS: Two groups of 20 patients were studied retrospectively over a 5-year period. One group underwent Hartmann's takedown, and the other underwent loop ileostomy takedown. Postoperative complications were compared between the 2 groups. RESULTS: Similar demographics were noted between each group. The most common initial indications for Hartmann's procedure were diverticulosis (11 patients, 55%) and colon cancer (4 patients, 20%). For patients who had undergone colectomy with primary anastomosis and ileostomy, colon cancer was the most common indication (12 patients, 60%) followed by diverticulosis (3 patients, 15%). Complications were more common after Hartmann reversal than loop ileostomy reversal (16 complications/11 patients versus 6 complications/4 patients, P = .047). CONCLUSION: Segmental colonic excision with anastomosis and loop ileostomy may be an attractive alternative to minimize morbidity with stoma reversal.
Asunto(s)
Enfermedades del Colon/cirugía , Colostomía/efectos adversos , Ileostomía/efectos adversos , Complicaciones Posoperatorias , Adulto , Anciano , Colostomía/métodos , Femenino , Estudios de Seguimiento , Humanos , Ileostomía/métodos , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Renal autotransplantation is an acceptable treatment for a variety of renal pathology. Indications for autotransplantation include renal artery diseases, loin pain hematuria syndrome, repair of ureteral pathology, ex vivo tumor resection, and repair of traumatic injury. Long-term results confirm that autotransplantation is a safe and effective procedure. Renal allograft autotransplantation has also been described for repair of vascular disease, and relocation of an allograft. We describe the first case, to our knowledge of an emergent autotransplant of a renal allograft. The patient had undergone a simultaneous kidney-pancreas transplant 7 yr prior. During attempted stenting of a common iliac artery occlusion, the stent migrated, thus jeopardizing the renal allograft. The patient was taken emergently to the operating room for open repair. This included autotransplantation of the entire kidney. The patient recovered to baseline renal function. This article reviews the indications for renal autotransplantation and autotransplantation of a renal allograft. A case of emergent autotransplant of a renal allograft is described.
Asunto(s)
Trasplante de Riñón/métodos , Trasplante Autólogo/métodos , Adulto , Urgencias Médicas , Migración de Cuerpo Extraño/cirugía , Humanos , Arteria Ilíaca , Masculino , Trasplante de Páncreas , Reoperación , Stents , Trasplante Homólogo , Enfermedades Vasculares/cirugíaRESUMEN
Prednisone-minimization protocols have been successful in low-risk recipients. We report on the use of a protocol incorporating rapid discontinuation of prednisone in a cohort of kidney transplant recipients (n = 79) at increased immunologic risk. Our data suggests that such recipients should not be excluded from prednisone-minimization protocols.
Asunto(s)
Terapia de Inmunosupresión , Trasplante de Riñón , Prednisona/administración & dosificación , Humanos , Trasplante de Riñón/inmunología , Trasplante de Riñón/mortalidad , Riesgo , Tasa de SupervivenciaRESUMEN
Historically, late steroid withdrawal after kidney transplants has been associated with an increased rejection rate. Recently, low rejection rates have been reported for recipients treated with complete avoidance or rapid elimination of steroids. However, follow-up has been short. We herein report on 3-year outcome in recipients whose prednisone was rapidly eliminated and who were maintained on a steroid-free regimen. From 10/1/1999 through 5/1/2003, 349 recipients (254 LD, 95 CAD; 319 in first 30 s) were immunosuppressed with polyclonal antibody (Thymoglobulin), a calcineurin inhibitor, either mycophenolate mofetil or sirolimus, and rapid discontinuation of prednisone. Actuarial 3-year patient survival was 95%; graft survival, 93%. Acute rejection-free graft survival at 1 year was 94%; at 3 years, 92%. There was no difference between LD and CAD. At 2 years, the mean (+/- SE) serum creatinine level for LDs was 1.6 +/- 0.5 mg/dL; for CAD, 1.6 +/- 0.4 mg/dL. We have no new cases of PTLD or avascular necrosis; 22 recipients (6%) developed CMV. Currently, 84% of recipients remain prednisone-free. We conclude that excellent 3-year patient and graft survival can be achieved without maintenance prednisone. With such a protocol, steroid-related side-effects are minimal.
Asunto(s)
Rechazo de Injerto/tratamiento farmacológico , Supervivencia de Injerto , Inmunosupresores/uso terapéutico , Trasplante de Riñón/mortalidad , Ácido Micofenólico/análogos & derivados , Prednisona/administración & dosificación , Suero Antilinfocítico/uso terapéutico , Estudios de Casos y Controles , Creatinina/sangre , Femenino , Humanos , Terapia de Inmunosupresión , Masculino , Persona de Mediana Edad , Ácido Micofenólico/uso terapéutico , Necrosis , Sirolimus/uso terapéutico , Factores de TiempoRESUMEN
On August 21, 1999, Region 7 of the United Network for Organ Sharing (UNOS) adopted a policy of regionwide sharing of cadaver livers for UNOS Status 1 recipients. We examined what impact this policy had at our center on their waiting times, waiting list mortality, and outcomes. From January 1, 1995, through December 31, 2002, our center listed 39 patients for an emergent (Status 1) transplant, according to the current criteria for Status 1 listing: patients (adult and pediatric) with fulminant hepatic failure (FHF), hepatic artery thrombosis, or primary nonfunction early after a liver transplant, or critically ill pediatric patients with chronic liver disease. These 39 candidates were analyzed in 2 groups: those listed before regionwide sharing (Group I, n = 19) and those listed after (Group II, n = 20). Patient characteristics did not differ significantly between the 2 groups, including mean donor and recipient age, proportion of pediatric patients, and type of graft used (i.e., living or deceased donor, segmental or whole-organ). FHF was the most common cause of liver failure in both groups-74% versus 70% (P = ns). The next most common cause in both groups was hepatic artery thrombosis, followed by primary nonfunction. Most transplants used deceased donors; however, 2 of the transplants in Group I versus only 1 in Group II used living donors. Waiting list mortality (the patient death rate before a transplant could take place) was 32% in Group I versus only 5% in Group II (P =.03). The mean number of days on the waiting list was also substantially lower in Group II (2.9 days) than in Group I, (5.8 days) (P =.04). For patients who underwent a transplant, graft and patient survival rates at 6 months posttransplant were 69.2% in Group I versus 89.5% in Group II (P =.03). In conclusion, the introduction of regionwide sharing seems to have been of benefit for Status 1 patients at our center. They have a significantly lower risk of dying while waiting for a transplant and undergo one in a much shorter period of time.
Asunto(s)
Trasplante de Hígado/mortalidad , Selección de Paciente , Obtención de Tejidos y Órganos/organización & administración , Listas de Espera , Adulto , Niño , Progresión de la Enfermedad , Hospitales Universitarios , Humanos , Fallo Hepático/cirugía , Minnesota/epidemiología , Estados UnidosRESUMEN
OBJECTIVE: With newer immunosuppressive agents, acute rejection and graft loss resulting from acute rejection have become less common for pancreas transplant recipients. As long-term graft survival rates have improved, an increasing number of grafts are being lost to chronic rejection (CR). We studied the incidence of CR and identified risk factors. METHODS: We retrospectively analyzed all cadaver pancreas transplants performed at the University of Minnesota between June 19, 1994, and December 31, 2002. We determined the causes of graft loss, the incidence of graft loss to CR and, using multivariate techniques, the major risk factors for CR. RESULTS: A total of 914 cadaver pancreas transplants were performed in the following three categories: simultaneous pancreas-kidney (SPK) (n=321), pancreas after kidney (PAK) (n=389), and pancreas transplant alone (PTA) (n=204). The mean recipient age was 41.3 years and the mean donor age was 30.1 years. Of the 914 pancreas grafts, 643 (70.3%) continue to function (mean length of follow-up, 39 months). The most common cause of graft loss was technical failure, accounting for 118 (12.9%) of the failed grafts. The second most common cause was CR, accounting for 80 (8.8%) of the failed grafts. The incidence of graft loss to CR was highest for PTA (n=23 [11.3%]) and PAK (n=45 [11.6%]) recipients and lowest for SPK recipients (n=12 [3.7%]) (P=0.002). By multivariate analysis, the most significant risk factors for graft loss to CR were a previous episode of acute rejection (relative risk [RR]=4.41, P<0.0001), an isolated (vs. simultaneous) transplant (PAK or PTA [vs. SPK], RR=3.02, P=0.002), cytomegalovirus infection posttransplant (RR=2.41, P=0.001), a retransplant (versus primary transplant) (RR=2.27, P=0.004), and one or two (vs. zero) antigen mismatches at the B loci (RR=1.68, P=0.04). CONCLUSIONS: As short-term pancreas transplant results improve and as isolated (PAK or PTA) pancreas transplants gain in popularity, CR will become increasingly common as a cause of pancreas graft loss.