Radiofrequency-assisted transection of the pancreas versus stapler in distal pancreatectomy: study protocol for a multicentric randomised clinical trial (TRANSPAIRE)

INTRODUCTION

To date, no pancreatic stump closure technique has been shown to be superior to any other in distal pancreatectomy. Although several studies have shown a trend towards better results in transection using a radiofrequency device (radiofrequency-assisted transection (RFT)), no randomised trial for this purpose has been performed to date. Therefore, we designed a randomised clinical trial, with the hypothesis that this technique used in distal pancreatectomies is superior in reducing clinically relevant postoperative pancreatic fistula (CR-POPF) than mechanical closures.

METHODS AND ANALYSIS

TRANSPAIRE is a multicentre randomised controlled trial conducted in seven Spanish pancreatic centres that includes 112 patients undergoing elective distal pancreatectomy for any indication who will be randomly assigned to RFT or classic stapler transections (control group) in a ratio of 1:1. The primary outcome is the CR-POPF percentage. Sample size is calculated with the following assumptions: 5% one-sided significance level (α), 80% power (1-β), expected POPF in control group of 32%, expected POPF in RFT group of 10% and a clinically relevant difference of 22%. Secondary outcomes include postoperative results, complications, radiological evaluation of the pancreatic stump, metabolomic profile of postoperative peritoneal fluid, survival and quality of life. Follow-ups will be carried out in the external consultation at 1, 6 and 12 months postoperatively.

ETHICS AND DISSEMINATION

TRANSPAIRE has been approved by the CEIM-PSMAR Ethics Committee. This project is being carried out in accordance with national and international guidelines, the basic principles of protection of human rights and dignity established in the Declaration of Helsinki (64th General Assembly, Fortaleza, Brazil, October 2013), and in accordance with regulations in studies with biological samples, Law 14/2007 on Biomedical Research will be followed. We have defined a dissemination strategy, whose main objective is the participation of stakeholders and the transfer of knowledge to support the exploitation of activities.

REGISTRATION DETAILS

ClinicalTrials.gov Registry (NCT04402346).

Shuttle Walking Test and 6-Minute Walking Test Induce a Similar Cardiorespiratory Performance in Patients Recovering from an Acute Exacerbation of Chronic Obstructive Pulmonary Disease

BACKGROUND

The incremental shuttle walking test (SWT) has recently been proposed as a more valid and reproducible alternative to the conventional 6-min walking test (6MWT) in the evaluation of exercise tolerance in patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVE

To compare the cardiorespiratory performance obtained during two sessions of SWT with that obtained during two sessions of 6MWT.

METHODS

We examined 18 patients (forced expiratory volume in 1 s: 48 +/- 14%) recovering from an acute exacerbation of COPD that had required hospitalization. In the same afternoon, each patient performed two SWT and two 6MWT, with an interval of at least 30 min between each test; the sequence of the tests was randomized.

RESULTS

Mean walking distance was greater in the second SWT test than in the first SWT. The changes from baseline in systolic blood pressure, heart rate, respiratory rate, oxygen saturation and dyspnea Borg index at the end of the test were similar between the two 6MWT and the two SWT. There was a highly significant correlation between walking distances measured during SWT and during 6MWT (rho: 0.85, p < 0.0005). Neither SWT nor 6MWT correlated with functional data of COPD.

CONCLUSIONS

SWT, though being considered to be closer to a submaximal exercise test than 6MWT, does not induce a greater cardiorespiratory performance than 6MWT in patients recovering from acute exacerbation of COPD.

Comparative immunohistochemical analysis of the expression of cytokeratins, vimentin and alpha-smooth muscle actin in human foetal mesonephros and metanephros

The human mesonephros is currently regarded as a simplified version of the foetal metanephros, primarily due to the close morphological resemblance between these two structures. The aim of the present study was to define whether human mesonephric and foetal metanephric nephrons share immunophenotypical traits in their corresponding structures (glomeruli, proximal and distal tubules). For this purpose we first investigated immunohistochemically the overall expression and topographical distribution of cytokeratins 7, 8, 18, 19, and 20, vimentin and alpha-smooth muscle actin in mature mesonephric nephrons and compared the results with those obtained in maturing-stage foetal metanephric nephrons. No expression of cytokeratins 7 and 20 was found. Cytokeratins 8, 18, and 19 and vimentin showed a restricted and basically coincident expression along the different components of both mesonephric and metanephric nephrons. These findings indicate that the intermediate filament protein profile of human mature mesonephric nephrons closely recapitulates that observed in developing metanephros and thereby strengthens the concept that human mesonephros, a transient ontogenic structure, is largely similar to the foetal metanephros. The sole difference between human mesonephros and foetal metanephros was the divergent expression of alpha-smooth muscle actin. This protein exhibited an increasingly accentuated mesangial expression paralleling the morphological maturation of metanephric glomerulus, whereas it was absent from the mesonephric one. This would suggest that the mesangial cells in these two renal structures have a different function during the foetal life.

Reuse of liver grafts after early death of the first recipient

Three cases are reported of reuse of a transplanted liver graft after early death of the first recipient due to cerebral hemorrhage. The good condition of the donors; the excellent biochemical evolution of the graft in the first recipients; total ABO compatibility and donor-recipient crossmatch; the absence of positivity to hepatitis B virus (HBV), hepatitis C virus (HCV), and bacteriologic cultures; and early death made reuse possible. The shortage of donors in relation to patients on the waiting list and the poor clinical condition of the second recipients made it necessary to adopt the decision to reuse the graft in an attempt to save their lives. The evolution of the patients and the reused grafts was satisfactory, and there were no complications that could be attributed to the fact that the graft had been transplanted before.

Alterations in renal endothelin production in rats with reduced renal mass

Renal endothelin-1 (ET-1) production is diminished in spontaneously hypertensive rats. An increase has been reported of renal ET-1 production associated with progression of renal disease in rats with reduced renal mass. The purpose of the present study was to investigate the evolution over time of the urinary ET-1 excretion in an experimental model of renal mass reduction not caused by renal infarction. Rats were subjected to 2/3 nephrectomy (right nephrectomy and resection of the lower left renal pole) and thereafter randomly assigned to a no-treatment control group or to treatment with recombinant erythropoietin, recombinant erythropoietin plus verapamil, or recombinant erythropoietin plus enalapril. The urinary ET-1 excretion was decreased by week 16 after nephrectomy as compared with healthy animals and with the levels 6 weeks after nephrectomy. The temporal evolution of urinary ET-1 excretion in the various groups of rats showed a trend toward decrease in all groups except the one receiving enalapril. The urinary ET-1 excretion correlated directly with creatinine clearance and inversely with tubulointerstitial damage. We observed an inverse correlation between urinary ET-1 excretion and arterial blood pressure 16 weeks after nephrectomy. These results indicate that renal ET-1 production decreases with the progression of renal disease and in relation with the severity of tubulointerstitial damage. The decrease in renal ET-1 production might contribute to the development and perpetuation of renal disease-associated arterial hypertension; this situation may be favorably modified by the use of enalapril.

[Liver transplantation using grafts from donors over 65]

OBJECTIVE

Donors age 50 years was an exclusion criteria in past decades. The increase of patients in the waiting list has determined the acceptance of older donors (over 65 years old). We analyze our results in liver transplantation using donors over 65 years.

PATIENTS

From 1986 to may 1994, we performed 381 OLT. In five cases (1.3%) the OLT was performed using donors over 65 years of age (66, 67, 68, 70 and 71). The selection criteria for donors and recipients were similar to the other transplanted patients. Immunosuppression included cyclosporine or FK-506, prednisone and azathioprine.

RESULTS

There were no primary graft failures and preservation damage, biochemical and clinical evolution were not different to the procedures using younger donors. Three grafts presented non-corticoresistant acute rejection. After a follow-up of 11.6 mo (range 4-37 mo) only one graft was lost (Kaposi's sarcoma in the liver). Four grafts and four patients are in excellent biochemical and clinical condition.

CONCLUSIONS

Donor age should not be an exclusion criteria. Grafts from older donors (over 65 years old) may be considered safe and will permit to increase the number of OLT.

Crystallographic studies on complexes between retinoids and plasma retinol-binding protein

The three-dimensional structures of complexes between bovine plasma retinol-binding protein (RBP) and three retinol analogs with different end groups (fenretinide, all-trans retinoic acid, and axerophthene) have been determined to 1.8-1.9-A resolution. Their models are very similar to that of the bovine retinol.RBP complex: the root mean square deviations between equivalent alpha-carbons in the two proteins range from 0.17 to 0.24 A. The retinoid molecules fit in the beta-barrel cavity assuming the same conformation of the vitamin, and the substitutions have no consequences on the overall protein structure. While confirming that an intact hydroxyl end group is not an absolute requirement for a correct retinoid binding to RBP, this study has shown the occurrence of conformational changes, although limited, in the rather flexible loop region at the entrance of the beta-barrel upon fenretinide and retinoic acid binding. These changes are suitable for accommodating the end groups of the above retinoids. Instead, no such changes have been revealed in RBP complexed with axerophthene, a retinol analog bearing a hydrogen atom in place of the hydroxyl end group. The protein conformational changes in the above loop region, the steric hindrance of bulky end groups of bound retinoids, and the lack of the retinol hydroxyl group appear to be responsible for the possible reduced affinity of retinoids for RBP relative to retinol and, at the same time, for the abolished or reduced affinity of retinoid.RBP complexes for transthyretin relative to retinol-RBP.

[Incidence and surgical treatment of extrahepatic abdominal hydatidosis]

From 1974 to May 1991, 417 patients with abdominal hydatid cyst disease were surgically treated. Twenty-eight patients had extrahepatic abdominal cyst disease (6.7%). Six patients had only extrahepatic disease where as 22 had associated hepatic and extrahepatic cysts. Most frequent sites were the peritoneum (52.7%), the spleen (22%) and pelvis (11%). Fourteen out of the 14 CT scans performed, detected the extrahepatic cysts. The preferred surgical technique was total closed cystectomy (in hepatic and extrahepatic cysts). Resection of the organ affected (8 splenectomies, 1 nephrectomy, 1 partial vertebral resection, 1 orchiectomy and 1 salpingo-oophorectomy) was also performed. There was no mortality and morbidity was 32.1%: 3 intraabdominal abscesses, 1 intraabdominal haemorrhage, 4 biliary fistulae and 1 partial necrosis of the large bowel. Only 3 patients (neither were treated with mebendazole) were reoperated on for recurrent peritoneal hydatic cyst.

[Manometric changes induced by antireflux surgery (Nissen) and its relation to pH measurement and clinical findings. An analysis 6 months after the intervention]

We analyzed the preoperative ambulatory 24 hour ph-metric and manometric characteristics in a group of 20 patients treated surgically for gastroesophageal reflux (PGER) by Nissen fundoplication. At 6 months post-surgery they were reevaluated instrumentally (manometric and 24 hour ph-metry) and clinically. All ph-metric parameters of PGER (total reflux time, clearance, number of episodes, number of episodes greater than 5 minutes duration and duration of longest episode) were significantly improved (p less than 0.01-0.05) post-operatively (as globally as by position supine and upright) and this improvement was associated with resolution of symptoms in 19 (95%) patients. Of the manometric parameters evaluated (lower esophageal sphincter pressure--LESP--and length--LESL, peristaltic, triphasic, biphasic, absent and simultaneous waves and relaxation of LES) surgery only produced improvement in the lower esophageal sphincter pressure (LESP) and length (LESL) (p less than 0.001). We conclude that antireflux surgery (Nissen) by improving the pressure and length of the LES is capable of producing clinical and ph-metric remission in almost all (95%) of patients studied six months after.