ObjectiveTo evaluate the authors' experience with periduodenal perforations to define a systematic management approach. Summary Background DataTraditionally, traumatic and atraumatic duodenal perforations have been managed surgically; however, in the last decade, management has shifted toward a more selective approach. Some authors advocate routine nonsurgical management, but the reported death rate of medical treatment failures is almost 50%. Others advocate mandatory surgical exploration. Those who favor a selective approach have not elaborated distinct management guidelines.

Due to increasing use of allografts from donation after cardiac death (DCD) donors, we evaluated DCD liver transplants and impact of recipient and donor factors on graft survival. Liver transplants from DCD donors reported to UNOS were analyzed against donation after brain death (DBD) donor liver transplants performed between 1996 and 2003. We defined a recipient cumulative relative risk (RCRR) using significant risk factors identified from a Cox regression analysis: age; medical condition at transplantation; regraft status; dialysis received and serum creatinine. Graft survival from DCD donors (71% at 1 year and 60% at 3 years) were significantly inferior to DBD donors (80% at 1 year and 72% at 3 years, p < 0.001). Low-risk recipients (RCRR ≤ 1.5) with low-risk DCD livers (DWIT < 30 min and CIT < 10 h, n = 226) achieved graft survival rates (81% and 67% at 1 and 3 years, respectively) not significantly different from recipients with DBD allografts (80% and 72% at 1 and 3 years, respectively, log-rank p = 0.23). Liver allografts from DCD donors may be used to increase the cadaveric donor pool, with favorable graft survival rates achieved when low-risk grafts are transplanted in a low-risk setting. Whether transplantation of these organs in low-risk recipients provides a survival benefit compared to the waiting list is unknown.

A major obstacle that limits the potential of human gene therapy is the inefficiency of gene delivery to appropriate sites in vivo. Previous studies demonstrated that the physiological surveillance function performed by von Willebrand factor (vWF) could be incorporated into retroviral vectors by molecular engineering of the MuLV ecotropic envelope (Env) protein. To advance the application of vWF targeting technology beyond laboratory animals, we prepared an extensive series of Env proteins bearing modified vWF-derived matrix-binding sequences and assembled these chimeric proteins into targeted vectors that are capable of transducing human cells. Initially, a dual envelope configuration was utilized, which required coexpression of a wild-type amphotropic Env. Subsequently, streamlined "escort" Env proteins were constructed wherein the inoperative receptor-binding domain of the targeting partner was replaced by the vWF-derived collagen-binding motif. Ultimately, an optimal construct was developed that exhibited properties of both extracellular matrix (ECM)-targeting and near wild-type amphotropic infectivity, and could be arrayed as a single envelope on a retroviral particle. On intraarterial instillation, enhanced focal transduction of neointimal cells (approximately 20%) was demonstrated in a rat model of balloon angioplasty. Moreover, transduction of tumor foci (approximately 1-3%) was detected after portal vein infusion of a matrix-targeted vector in a nude mouse model of liver metastasis. We conclude that the unique properties of these targeted injectable retroviral vectors would be suitable for improving therapeutic gene delivery in numerous clinical applications, including vascular restenosis, laser and other surgical procedures, orthopedic injuries, wound healing, ischemia, arthritis, inflammatory disease, and metastatic cancer.

MS is rare, but preoperative diagnosis or intraoperative suspicion is important. Laparoscopic cholecystectomy may be possible in selected type I cases. Open cholecystectomy is the standard of care for type II MS.

Acceptable outcomes are achievable after liver transplantation in patients with MELD scores of 40 or higher but come at high pretransplantation and posttransplantation resource utilization.

No abstract

Congenital intestinal malrotation is a developmental anomaly resulting from interruption of the physiological herniation and return to the abdominal cavity of the midgut during the 6th to 10th week of embryological development. Normal vascular and anatomic relationships used as landmarks during pancreaticoduodenectomy (PD) are altered in patients with congenital malrotation. We present 3 cases of PD in adults with congenital intestinal rotation disorders. Three adult patients with congenital rotational disorders required PD. Two of these patients had bilio-pancreatic tumors, and 1 cadaveric donor underwent total pancreatectomy during pancreas allograft procurement. All patients had arterial and venous anomalies around the celiac trunk and mesenteric vessels, respectively. The midgut and hindgut in each case were shifted toward opposite sides of the abdominal cavity. Modifications to the standard approach to PD were made, and outcomes were favorable in each case. Each patient showed anatomic abnormalities with the need for identifying vascular structures through their expected (or projected) course and location before parenchymal division or ligation of any vessel. This approach becomes crucial in cases of vascular anomalies, such as ones occurring in congenital malformations, and can be used in similar situations encountered during pancreaticoduodenectomy.

No abstract