OBJECTIVES Early thrombosis (ET) contributes to autogenous arteriovenous fistula (AVF) failure. We studied patients undergoing AVF placement in the Hemodialysis Fistula Maturation (HFM) Study, a prospective, observational cohort study, using a nested case-control analysis to identify pre-operative and intra-operative predictors of ET. METHODS ET cases were compared to controls who were matched on gender, age, diabetes, dialysis status, and surgeon fistula volume. ET was defined as thrombosis diagnosed by physical exam or ultrasound within 18 days of AVF creation. Conditional logistic regression models were fit to identify risk factors for ET. RESULTS Thirty-two ET cases (5.3%) occurred among 602 study participants; 198 controls were matched. ET was associated with female gender (OR=2.75, CI 1.19–6.38, P=0.018), fistula location (forearm vs. upper arm) (OR=2.76, CI 1.05–7.23, P=0.039), feeding artery (radial vs. brachial) (OR=2.64, CI 1.03–6.77, P=0.043) and arterial diameter (OR=1.52, CI 1.02–2.26, P=0.039, per mm smaller). Draining vein diameter was nonlinearly associated with ET, with highest risk in 2–3 mm veins. Surprisingly, ET risk was lower in diabetics (OR=0.19, CI 0.07–0.47, P=0.0004), lower with less nitroglycerin-mediated brachial artery dilatation (NMD%) (OR=0.42, CI 0.20–1.92, P=0.029 for each 10% lower) and higher with lower carotid-femoral pulse wave velocity (OR=1.49, CI 1.02–2.20, P=0.041, for each m/sec lower). Intraoperative protamine use was associated with a higher ET risk (OR 3.26, CI 1.28-∞, P=0.038). Surgeon’s intraoperative perceptions were associated with ET: surgeons’ greater concern about maturation success (likely, marginal, unlikely) was associated with higher thrombosis risk (OR 8.09, CI 4.03-∞, p<0.0001, per category change), as were absence vs. presence of intraoperative thrill (OR 21.0, CI 5.07-∞, P=0.0002) and surgeons’ reported frustration during surgery (OR 6.85, CI 2.70-∞, P=0.0004). Reduced extent of intraoperative thrill (proximal, mid or distal third of the forearm or upper arm, based on AVF placement) was also associated with ET (OR 2.91, CI 1.31-∞, P=0.014, per diminished level). Oral antithrombotic medication use was not significantly associated with ET. CONCLUSIONS ET was found to be associated with female gender, forearm AVF, smaller arterial size, draining vein diameter of 2–3 mm, and protamine use. Paradoxically, diabetes and stiff, noncompliant feeding arteries were associated with lower frequency of ET. Absent or attenuated intraoperative thrill, and both surgeon frustration and concern about successful maturation during surgery, were strongly correlated with ET.

Multiple processes of care and complications are associated with AVF maturation outcomes.

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Objective: Recently, pancreaticogastrostomy (PG) has attracted renewed interest as a reconstruction technique after pancreaticoduodenectomy (PD), as it may imply a lower risk of clinical pancreatic fistula than reconstruction by pancreaticojejunostomy (PJ). We hypothesise that pancreatic exocrine insufficiency (PEI) is more common during clinical follow-up after PG than it is after PJ. Research design and methods:This study compares the prevalence of PEI in patients undergoing PD for malignancy with reconstruction by PG versus reconstruction by PJ. PEI during the first year of followup was defined as the intake of pancreatic enzyme replacement therapy (PERT) within one year postoperatively and/or an abnormal exocrine function test.Results: A total of 186 patients, having undergone surgery at two university hospitals, were included in the study. PEI during the first year postoperatively was present in 75.0% of the patients with PG, compared to 45.7% with PJ (p < 0.001). Intake of PERT within one year after surgery was found to be more prevalent in the PG group, i.e. 75.8% versus 38.5% (p < 0.001). There was a trend towards more disturbed exocrine function tests after PG (p = 0.061).Conclusions: PEI is more common with PG reconstruction than with PJ reconstruction after pancreaticoduodenectomy for malignancy.

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Although deterioration of endocrine function was expected after pancreatic resection, improvement is frequently observed in patients with newly diagnosed diabetes. Exocrine function deteriorates after pancreaticoduodenectomy.

WHAT THIS PAPER ADDS Patients with chronic kidney disease have disturbances of mineral metabolism, which may interfere with the vascular remodelling process required for successful maturation of arteriovenous fistulae. To the authors' knowledge, this is the first study of end stage renal disease patients, either undergoing or anticipated to soon require maintenance haemodialysis, to assess relationships between serum mineral metabolites and abnormalities of vein segments used to create haemodialysis arteriovenous fistulas, and with fistula maturation. Although these veins exhibit distinct unusual features, the measured mineral metabolism markers were not materially associated with functional arteriovenous fistula maturation.

Aims: Morbidity and mortality rates after pancreaticoduodenectomy remain still elevated. Recently, different scores to predict morbidity and mortality after pancreaticoduodenectomy have been published. This study aimed to validate the Braga score and the Early Mortality Risk Score (EMRS). Methods: A series of 245 patients who underwent pancreaticoduodenectomy in a single center from 2000 to 2012 was assessed. Complications were graded according to the Dindo-Clavien classification; major complications were defined as grade IIIa to IVb. The Braga score (ranging from 0 to 15) is based on pancreatic texture, main pancreatic duct diameter, blood loss, and ASA score. Score discriminant power was calculated using ROC curves. For the EMRS, only adenocarcinomas were included. Survival time and EMRS (based on age, tumor differentiation, tumor size, and comorbidities) were determined for 120 cancer patients. Relative risks (RR) of postoperative death at 9 and 12 months were calculated. Results: Major complications occurred in 31% of the 245 patients. Pancreatic texture and blood loss were statistically significant for increased morbidity. The areas under curve (C-statistic values) were 0.95 and 0.99 for 4-risk categories and for individual scores, respectively. For the EMRS group, overall median survival was 19 months. EMRS of 4 showed a mortality RR of 5.1 at 9 months (p = 0.048) and of 4.5 at 12 months (p = 0.020). Modified EMRS of 3 also showed a statistically significant increase of the mortality risk at 9 (RR = 3.7, p = 0.025) and 12 months (RR = 3.2, p = 0.017). Conclusions: The Braga score discriminated well between minor and major complications. EMRS of 4 and modified EMRS of 3 are predictors of mortality at 9 and 12 months after oncologic pancreaticoduodenectomy. Our validation studies confirmed that the Braga score could be helpful to detect patients at risk for major complications, while the EMRS may influence preoperative decision-making by predicting the short-term mortality after pancreaticoduodenectomy for adenocarcinoma.