Severe acute pancreatitis can be complicated early in its course by life threatening conditions such as abdominal compartment syndrome. We report a patient who needed abdominal decompression three days after admission to the intensive care unit because of intra-abdominal hypertension and end stage organ dysfunction. The clinical course was protracted, but the patient survived and was discharged from the hospital.

INTRODUCTION:The use of desmopressin and vasopressors in cadaveric organ donors is considered a risk factor for graft dysfunction following pancreas transplantation by influencing the microcirculation. The aim of this study was to investigate the influence of these substances on early graft function.PATIENTS AND METHODS:This single-center retrospective trial included 59 patients who underwent simultaneous or solitary pancreas transplantation. The corresponding donor charts were reviewed for the use of vasopressors and desmopressin. Impaired graft function was determined as graft thrombosis or as insulin-dependence for more then 3 days posttransplant. Daily amylase and lipase concentrations from abdominal drains were measured to quantify reperfusion pancreatitis and fistula formation.RESULTS:Overall, pancreas thrombosis was observed in 4 of 59 (6.8%) recipients. There were no significant differences in thrombosis rate whether the donors received desmopressin (3/38 vs 1/21, P >.1) or the needed vasopressors (3/53 vs 1/9, P >.1). The number of patients who required insulin for more than 3 days posttransplant was comparable whether the donors received desmopressin (9/38 vs 4/21, P >.1), or vasopressors (9/46 vs 3/8, P >.1). At present all recipients with functioning pancreatic grafts (ie, 92.7%) are free of exogenous insulin therapy at 2 to 80 months posttransplant. The amylase/lipase concentrations of peritoneal fluid were independent of the administration of desmopressin or vasopressors in the donors.CONCLUSION:In this study donor desmopressin and vasopressor administration did not influence graft function after pancreas transplantation.

The influence of des mop ressin and vasopressors in the donor mana˜ement on ˜raft function followin˜ pancreas transplantation

Click to increase image sizeClick to decrease image size Additional informationNotes on contributorsU. J. HesseProfessor U. J. Hesse Dienst Heelkunde, universitair Ziekenhuis Ghent De Pintelaan 185 B-9000 Gent, Belgium Tel.: + 32-9-240.55.19 Fax: + 32-9-240.38.91 E-mail: uwe.hesse@rug.ac.beB. de HemptinneProfessor B. de Hemptinne Tel.: + 32-9-240.32.33 Fax: + 32-9-240.38.91 E-mail: bernard.dehemptinne@rug.ac.beF. DeromProfessor F. Derom Tel.: + 32-9-240.32.96 Fax: + 32-9-240.38.91 E-mail: fritz.derom@pandora.be

OBJECTIVE:To evaluate the clinical significance of modulating the recipient portal inflow (rPVF) through perioperative ligation of the splenic artery in adult living-donor liver transplantation (ALDLTx) by focusing on vascular complications, intractable ascites production, and the prevention of small-for-size syndrome (SFSS).SUMMARY BACKGROUND DATA:In ALDLTx, portal graft flow is enhanced to at least twice the donor value, raising the total liver inflow. Recipient hepatic arterial flow (rHAF) is lower than expected. Portal hyperperfusion of small grafts in larger recipients is thought to be one of the main causes of posttransplant graft dysfunction/SFSS.METHODS:Seventeen ALDLTx were reviewed for a minimum of 2 months. Patients were divided retrospectively into two groups: G1 (n = 7), without modulation of rPVF, and G2 (n = 10), with splenic artery ligation to decrease rPVF perioperatively. Donor and recipient hepatic hemodynamics were evaluated against graft function and outcome, including correlations between rPVF, graft weight, graft:recipient body weight ratio, and recipient weight.RESULTS:Following portal and arterial reperfusion, mean rPVF and rPVF/graft weight were much higher than in the donors, whereas mean rHAF and rHAF/graft weight were much lower. No differences were found between groups, except for rPVF and rHAF, which were much more higher and lower, respectively, before splenic artery ligation. In G1 patients, SFSS was seen in two patients and vascular complications occurred in two others. In G2 patients, splenic artery ligation permitted a significant decrease in rPVF, an improvement in rHAF, and the resolution of refractory ascites. Neither SFSS nor vascular complications were seen in G2 patients.CONCLUSIONS:When a suboptimal graft:recipient body weight ratio is accompanied by high rPVF in ALDLTx, the portal flow should be modulated perioperatively; splenic artery ligation is a simple and safe method that is sufficient to allow this modulation in most patients.

ObjectiveTo evaluate the use of a low-pressure gastric band in the treatment of severe obesity in a prospective study.Summary Background DataGastric banding for severe obesity has been associated with erosion and perforation of the stomach. The Swedish adjust able gastric band (SAGB) has been proposed as a low-pressure device.MethodsFrom January 1998 to October 2001, 625 patients underwent laparoscopic SAGB. Median age was 36 years, and 80.4% Of patients were female. Median preoperative body mass index (BMI) was 40. Previous upper abdominal surgery was reported in 36 (6%) patients. A five-trocar technique was used without a calibration balloon.ResultsMedian follow-up was 19.5 months. All patients were treated laparoscopically with a median operating time of 80 minutes. Conversion was necessary in two patients (0.3%): one trocar injury of the mesentery and one esophageal perforation. Median hospital stay was 3 days; there were no 30-day deaths. Early morbidity was present in 27 patients (4.3%). Late band reoperation was necessary in 49 patients (7.8%). Indications for reoperation were band slippage or pouch dilation, acute total dysphagia, and band leakage or malfunction. Median excess weight loss was 45.8%, 49.9%, and 47.4% after 1, 2, and 3 years, respectively, with a measurable beneficial effect on arterial hypertension, sleep apnea syndrome, and diabetes control.ConclusionsSAGB is a safe and effective new method in the management of severe obesity. Long-term follow-up (>3 years) is necessary to confirm its effectiveness and safety.

Verbeke, Stephen J. MD; De Waele, Jan J. MD; Hesse, Uwe J. MD; Vermassen, Frank E. MD; De Roose, Joseph MD Author Information

Somatostatin-14 and its analogue octreotide both exert inhibitory effects on gastrointestinal secretions and may therefore be beneficial in the treatment of gastrointestinal fistulae. There are no studies that have compared these two drugs directly and hence this paper aims to review studies that are available for each drug. There are only six controlled studies that have examined the effects of somatostatin-14 and octreotide on fistula output reduction, three for each drug. All studies compared conservative therapy and the drug in combination with conservative therapy. Of the somatostatin-14 studies, two showed a significant effect on output (p <0.05) and the other demonstrated an output reduction on day 1 that was twice that in the control group (NS). Of the octreotide studies, one showed a significant effect (p <0.01) and the other two showed no effect of the drug on output. No study with either drug has demonstrated an increase in the number of patients that have achieved closure. However, a positive effect on the time to achieve closure has been found. Of the five controlled studies with somatostatin-14, all showed a significant reduction in time to closure. Of the two controlled studies with octreotide, one showed a significant reduction (p=0.002) and the other showed no difference. Due to the limited number of trials, a definitive evaluation of the efficacies of somatostatin-14 and octreotide in the treatment of gastrointestinal fistulae is not possible. However, currently available information seems to suggest a considerable benefit of somatostatin-14 when administered in association with standard conservative treatment, but this needs to be confirmed in a large prospective controlled study.

INTRODUCTION:Two different adjustable silicone gastric bandings were laparoscopically applied and compared regarding per- and postoperative complications and successful weight loss.PATIENTS AND METHODS:A total of 120 consecutive patients received a laparoscopic adjustable gastric banding and were prospectively documented. In the learning phase (LP) 50 patients were treated with an Adjustable Silicone Gastric Banding (ASGB, Bioenterics) using an intragastric balloon calibration technique according to Belachew. Group I (n = 29) received the same band using a surgical technique with tunneling behind the oesophagus towards His' angle, while the second group (n = 41) received a Swedish Adjustable Gastric Banding (SAGB), using the same technique as in group I. A BMI of > 35, complications secondary to obesity and failed diets were the indication for the operation. Thirty patients were male, 90 female, with a mean age of 37 years (18-60).RESULTS:In the LP 8 patients had to be reoperated (16%) for band slippage and/or pouch dilatation, in group I 6 (19%) and in group II 1 (3%) (P = 0.02, II vs I). The mean hospital stay was 3.7 +/- 0.5, 3.4 +/- 0.8 and 3.3 +/- 0.4 days in LP, I und II, respectively. LONG-TERM RESULTS: After a mean of 24 months (19-42) the loss of body weight was 8.4 kg after 3, 13.9 kg after 6, 22.1 kg after 12 and 27.8 kg after 18 months in the LP. In group I after a mean of 14 months (12-19) 10.3 kg after 3, 18.7 kg after 6, 24.8 kg after 12 months. In group II after a mean of 10 months (6-16) the loss of body weight was 7.9 kg after 3 and 19.4 kg after 6 months.CONCLUSION:In our experience it appears that the SAGB is easy to handle and less prone to complications such as dysphagia and slipping, probably due to good fixation of the band due to its width. A prospective randomized trial is warranted.

Objective. The objective of this study was to determine the prevalence and radiologic features of postoperative complications after Swedish laparoscopic adjustable gastric banding surgery and to emphasize the role of the radiologist in the follow-up of those patients, especially in the treatment of complications.Materials and methods. We reviewed the radiologic findings in 218 consecutive morbidly obese patients after laparoscopic placement of the Swedish gastric banding system. Radiographic studies of the stomach (obtained with liquid barium sulfate suspension) were performed before surgery and 1 month after band placement in every patient. Additional studies in symptomatic patients were performed when needed.Results. Surgical complications found included misplacement of the band (five patients, 2.3%), slippage of the band (17 patients, 7.8%), and pouch enlargement (eight patients, 3.7%). Technical problems encountered were inversion of the access port (three patients, 1.4%), leakage of the device (two patients, 0.9%), and spontaneous decrease of the stoma size caused by gastritis (seven patients, 3.2%) or the hyperosmolar properties of the IV contrast material (12 patients, 5.5%). Intrinsic abnormalities of gastroesophageal tract seen included trapping of food in the stoma (four patients, 1.8%) and esophagitis (11 patients, 5%).Conclusion. Although, according to the available data, the gastric banding operation with the Swedish band meets the criteria of a low-risk laparoscopic alternative treatment of morbid obesity, the radiologic appearances of various complications may be seen on the images of patients who have undergone the procedure. The radiologist plays a key role in the early detection of those complications and treatment of specific abnormalities.

Einleitung: Zwei verschiedene Bänder zur laparoskopischen Anlage am Magen wurden an 2 Patientenkollektiven im Hinblick auf peri- und postoperative Komplikationen und den Erfolg der Gewichtsreduktion untersucht. Patienten und Methoden: 120 Patienten wurden behandelt und prospektiv dokumentiert. In der Lernphase (LP) handelte es sich um 50 Fälle des anpassbaren Silicon Gastric Bandings (ASGB, Bioenterics®). Das Band wurde nach der Technik von Belachew im Bereich der distalen Magenkardia angelegt. In Gruppe I (n = 29) wurde das gleiche Band in der Technik von Forsell angelegt. In Gruppe II (n = 41) wurde das Schwedische anpassbare Gastric Banding (SAGB, Obtech®) nach der Methode von Forsell angelegt. Als Indikation zur Operation wurde ein Body Mass Index (BMI) über 35 sowie sekundäre Komplikationen der Obesitas und gescheiterte konservative Gewichtsreduktionstherapien angesehen. 30 Patienten waren männlich, 90 weiblich mit einem gemittelten Alter von 37 Jahren (18–60). Resultate: In der LP mussten 8 Patienten wegen eines Bandslipping und/oder Pouchdilatation reoperiert werden (16 %), in Gruppe I 6 (19 %) und in Gruppe II 1 (3 %) (p = 0,02, II vs I). Der gemittelte Krankenhausaufenthalt betrug 3,7 ± 0,5, 3,4 ± 0,8 und 3,3 ± 0,4 Tage in der LP, I und II respektive. Langzeitresultate: Nach einer Beobachtungszeit von gemittelt 24 Monaten (19–42) betrug der Gewichtsverlust 8,4 kg nach 3, 13,9 kg nach 6, 22,1 kg nach 12 Monaten und 27,8 kg nach 18 Monaten in der LP. In Gruppe I nach gemittelt 14 Monaten (12–19) 10,3 kg nach 3, 18,7 kg nach 6, 24,8 kg nach 12 Monaten. In Gruppe II nach gemittelt 10 Monaten (6–16) betrug die Gewichtsreduktion 7,9 kg nach 3 und 19,4 kg nach 6 Monaten. Schlussfolgerung: In unserer Erfahrung erscheint die Anlage des SAGB leicht durchzuführen und weniger komplikationsanfällig zu sein im Hinblick auf Dysphagie und Slipping des Bandes vermutlich wegen der guten Fixation des Bandes auf Grund seiner Breite. Eine prospektiv randomisierte Studie ist erforderlich.

Indications for splenectomy (SP) during whole liver transplantation (LT) remain controversial and SP is often avoided because of common complications. We aimed to evaluate specific complications of these combined procedures.Data were retrospectively analysed. Splenectomy was performed in patients with splenorenal shunt and/or splenic artery aneurysms or hypersplenism. Patients undergoing simultaneous transplantation and splenectomy (LTSP group) were matched to a non-splenectomy group (LT group).Between 1994 and 2013, we included 47 and 94 patients in LTSP and LT groups, respectively. The LTSP patients had a higher rate of pre-LT portal vein thrombosis (PVT). The LTSP group had a longer operative time and greater blood loss. Mean follow-up was 101 months and 5-year survivals were identical (LTSP 85% vs LT 88%, p = 0.831). Hospital morbidity and rejection incidence were comparable, whereas de novo PVT (34% vs 2%, p < 0.0001) and infection (47% vs 25%, p = 0.014) rates were higher after SP.Splenectomy during LT is technically demanding and exposes recipients to a higher thrombosis rate, therefore portal vein patency must be specifically assessed postoperatively. In selected recipients, SP can be performed without increased mortality but at the price of worsening outcome as evidenced by greater risk of infection and PVT.