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Pancreatic cancer is the 10th leading cause of death worldwide. It is a very lethal and aggressive tumor, with a 5-year overall survival rate under 5 % for confirmed ductal adenocarcinoma. Even though many genes have been identified as possible treatment targets, surgery remains the only curative treatment. Imaging is essential to the initial workup and is mostly based on CT-scan and MRI studies. Resectability is based on the absence of distant metastases and arterial vasculature infiltration. 3D imaging reconstruction could add precision to the surgical evaluation. Many phase II non randomized studies have shown that neo-adjuvant chemotherapy had a positive effect on pancreatic cancer. Nevertheless this approach is only reserved for cases with locally advanced tumors., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

An appendix tumour is found every 100 appendectomies. It can also be incidental discovery during a routine radiological examination and presents as a mucocele of the appendix. Appendix tumours are of varied histological type, and include mainly neuroendocrine tumours as well as epithelial tumours. The latter, when they secrete mucin, can give rise to peritoneal pseudomyxoma, a particular form of carcinosis harbouring serious complications. The management of appendix tumours responds to specific recommendations and, in advanced cases, requires the expertise of a university centre specialized in digestive oncology. The role of the primary care practitioner lies in the diagnosis and referral of patients with appendix tumours., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Acute pancreatitis is a frequent disease, with a simple course in 80 % of the cases but a high morbidity and mortality in its severe form. Biliary origin and alcohol represent 80 % of the etiologies. Except endoscopic removal of gallstone for biliary origin, treatment remains symptomatic and focuses on fluid resuscitation, effective antalgia and adapted management of nutrition. This article focuses on the novelties introduced by the revision of the Classification of Atlanta in 2012 and details current guidelines for the management of the disease. The evolution of conservative treatment has allowed to reduce and postpone need for surgery and requires an interdisciplinary collaboration between surgeons, gastroenterologists, interventional radiologists and intensivists., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Advanced surgical procedures have traditionally been a domain of open surgery. However, minimally invasive approaches are evolving with the development of robotic technology which appears capable to overcome technical limitations of conventional laparoscopy. While traditionally perceived as impossible indications for minimally invasive surgery, reports on robotic organ transplantations have surfaced with promising results.

Regenerative medicine aims to replace a body function or specific cell loss. It includes therapies at the forefront of modem medicine, issuing from translational biomedical research. Transplantation of organs and cells has revolutionized the management of patients for whom medical treatment is a failure. Unfortunately, organ shortage is limiting treatment possibility. As an example, among the 15,000 patients with type I diabetes in Switzerland, only approximately 30 can receive a pancreas or an islet transplant per year. Second example, 500 patients die each year in Switzerland from alcoholic cirrhosis because no treatment is available. Transplantation of islet cells, hepatocytes, mesenchymal stem cells or dopaminergic neurons represents hope fora therapy available for large populations of patients.

The aim of xenotransplantation is to allow the transplantation of animal organs or cells to humans. This approach would immediately eliminate the human organ shortage that is responsible for a significant mortality of patients on the waiting list for transplantation of organs. The immune differences between pig and human induce an immediate rejection of porcine tissues by humans. This rejection has recently been partially controlled by genetic engineering of pigs, the use of new immunosuppressive drugs and encapsulation of isolated cells. However, due to the risk of transmission of animal infectious agents to humans, the WHO recommends that clinical application of xenotransplantation only takes place if adequate regulations are in place.

Introduction: Marginal kidneys must be reanimated before their transplantation. Reanimation is conducted with hypothermic pulsatile perfusion. The tests used generally to demonstrate the viability is the vascular resistance which is not convenient for everybody. We have developed a magnetic resonance compatible perfusional technology allowing us to test the organs during the perfusion by Gd-perfusion MRI., Methods and Results: We have used pigs' kidneys with no warm ischemic time to establish the basis in a normal kidney. After an eight-hour hypothermic pulsatile perfusion, kidneys are submitted to a Gd perfusion. First, we measure the anatomy of the vessels, then the distribution of Gd in the kidney. We obtain simultaneously a dynamic study of the organs where T0 represents the Gd bolus arrival in the cortex and TP the maximum saturation time of Gd., Conclusion: We have observed that a normal T0 is inferior to 30s and TP is inferior to one minute. We have compared these values with ATP resynthesis in these organs and found that they correlate. We hope for the future through that predictive use of Gd-MRI to avoid the clinical use of "too" marginal kidneys or the discard of good kidneys but not corresponding with the vascular resistance theory.

Background: Cystic lymphangioma is a rare malformative benign tumor of the lymphatic vessels. In the abdomen it generally develops as a mesenteric and/or retroperitoneal cyst, but any organ can be involved. The present retrospective study aims to define the symptoms, complications and differences noted between adults and children suffering from abdominal cystic lymphangioma; it is based on patients who underwent surgery for this condition at the Geneva University Hospital., Patients and Methods: Since 1995, 16 patients (9 adults and 7 children) were surgically treated for abdominal cystic lymphangioma. Their medical files were reviewed retrospectively. The follow-up was based either on the last physical examination or on a telephone interview with the patients., Results: The mean follow-up was 45 months. The most common presenting symptom was abdominal pain (38%). Ultrasonography was the most efficacious diagnostic modality. The lesions were mostly micropolycystic (44%), and found in retroperitoneal locations (50%). The surgical excision was complete in 14 patients and partial in 2 patients. These last 2 were the only ones who developed complications after the surgery, including one recurrence., Conclusions: A total surgical excision, if feasible without a major sacrifice of adjacent organs, seems to be the best therapeutic option to minimize the risk of recurrence of symptomatic abdominal cystic lymphangiomas. In our clinical experience, the presentation and evolution of the abdominal cystic lymphangioma seemed to be similar in adults and children.

Introduction: Vacuum-assisted closure (VAC) is a promising approach for the management of complex abdominal and perineal wounds. This paper summarizes our experience with this therapeutic modality and demonstrates its efficacity in difficult situations., Patients and Methods: From January 2003 until December 2005, 48 patients (age 30-89) were treated with VAC therapy for open abdomen, infected laparotomy wounds, or tissue loss due to debridement of Fournier's gangrene. Wound dressings were changed every 2-3 days., Results: Thirty-eight patients (79%) had major co-morbid conditions liable to impact negatively on wound healing. The treatment duration with VAC varied from 20-30 days with an average of eleven dressing changes (minimum 3-maximum 18). Treatment was effective in all patients. Spontaneous closure was achieved in 36 cases (75%); nine patients (19%) required a split-thickness skin graft, and three (6%) underwent delayed secondary closure., Conclusion: In our institution, VAC has become the treatment of choice for complex abdominal and perineal wounds. It is a safe, simple, and effective technique to speed wound healing and it has reduced the duration of hospital treatment in difficult clinical situations and in patients whose general condition is often severely compromised.

Alternative to nephrotoxic calcineurin inhibitors regimens are feasible in renal transplantation. Sirolimus is an effective immunosuppressive drug with less drug-induced nephrotoxicity. Enteric-coated mycophenolate sodium provides a safety and efficacy alternative to mycophenolate mofetil. In peritoneal effluent, cancer antigen 125 (Ca 125) is a mesothelial cell marker and of in vivo biocompatibility of the new dialysis solutions. Longterm PD and peritoneal sclerosis are associated with a low number of mesothelial cells and a low concentration of dialysate Ca 125. Exposure to glucose and degradation products (GDPs) is important in the genesis of mesothelial damage. Short results of the more biocompatible solutions are promising (increasing of Ca 125). In the future, exposure to glucose can be reduced by using combinations of various osmotic agents, each in a low concentration (glycerol and amino acid solution).

Introduction: Alveolar Echinicoccosis is a severe parasitic disease: its natural evolution is comparable to a slowly progressive malignant liver tumour. There is no definitive medical therapy. Surgery remains the only option to assure a cure. This report is our surgical experience for the care of this affection., Patients and Method: Between 1980 and 2002, 12 patients were operated for an hepatic alveolar echinococcosis. For 11 of them, the affection was primary. Lesions were located in the right liver lobe (n = 9), in the left lobe (n = 1), in both lobes (n = 1) and close to the hilar region (n = 1). Twice there was a diaphragmatic infiltration and once a pleural infiltration. Resections consisted in: segmentectomies in the right lobe (n = 4), right hepatectomy (n = 5, associated once with a partial I and IV segmentectomy), left hepatectomy (n = 1), one liver transplantation (n = 1), one drainage of a parasitic cavity (n = 1). One pleurectomy and a partial diaphragmatic resection were made. All patients were treated postoperatively with benzimidazole chemotherapy., Results: Three patients presented some complications: segmental necrosis with biloma (n = 1), biliary fistula tract (n = 1), subdiaphragmatic hematoma (n = 1), cholangitis (n = 1). 10 patients are alive (median follow-up of 10 years). Two patients still present some parasitic lesions; the situation remains doubtful for one of them. Two patients died (one of them in the context of a disease progression)., Conclusion: Surgical treatment, associated with medical therapy, assured a control of the parasitic lesions or a definitive cure in most cases. When the disease is limited to the liver with no possibility for partial hepatectomy, a transplantation is an option.

10% of chronic pancreatitis (CP) cases are complicated by splenic vein thrombosis (SVT) which is responsible for upper digestive haemorrhages. To improve our approach to treatment we reviewed 30 cases of SVT associated with CP treated in our centre from 1985 to 1995. 14 patients were treated conservatively. Six of them were refused for surgery due to extension of splenic vein thrombosis into the portal vein. Two patients without extrinsic compression of the vein were treated with anticoagulants. 16 patients were treated by surgery with low morbidity and without mortality. The standard treatment in fourteen cases was splenopancreatectomy. The average follow-up of seven years shows that these patients have preserved their body mass index (BMI). The results suggest that early surgical intervention is beneficial in preventing progression of SVT to the portomesenteric vein.

Introduction: Preservation of physiological endocrine pancreatic function represents a major problem in pancreatectomised patients. In 40 to 100%, pancreatic resection can result in diabetes, which is often difficult to manage. Islet autotransplantation has been proposed to prevent this severe metabolic consequence., Patients and Methods: Between March 1992 and January 1997 we performed 9 human islet autotransplantations in Geneva. The patients comprised 6 males and 3 females aged 40 to 81 years (median: 51 years). The pancreatectomy was total in 3 cases, subtotal (95%) in 2 cases and partial (40-80%) in the others. Indications for resection were alcohol-induced chronic pancreatitis (6 cases) and focal benign pancreatic pathologies (3 cases). After collagenase digestion, unpurified islets were injected intraportally and embolised into the liver. Patient metabolic status was regularly tested by 24-hour serum glucose profile, measurement of glycosylated haemoglobin, oral and intravenous glucose tolerance tests and glucagon stimulation test., Results: Immediately after autotransplantation, one patient had persistent insulin-dependent diabetes. Among the 8 patients who were insulin-independent soon after the graft, 4 presented a progressive deterioration of endocrine pancreatic function and required insulin therapy 5, 8, 24 and 36 months after the graft. Currently, 4 patients are insulin-independent: three of them have normal glucose tolerance tests (24, and 48 months after the graft) and the last presented with glucose intolerance 22 months after the graft but still does not require exogenous insulin., Conclusion: Islet autotransplantation can be considered a useful therapeutic option serving to prevent or delay the occurrence of surgically-induced diabetes. In our opinion, islet autotransplantation should be offered to any non diabetic patient needing to undergo major pancreatic resection.

Pig islets are considered the best alternative to human islets in the treatment of insulin-dependent diabetes. Pigs could represent a potential islet donor for xenotransplantation in humans because of the close similarity between human and porcine insulin and the theoretically unlimited availability of porcine pancreas. From November 1991 to January 1997 we performed 221 pig islet isolations from 3 pig sources: group 1: minipigs (age 9-18 months) and white pigs (3-8 months), group 2: large white pigs (5-8 months), group 3: large white pigs (12-24 months). Islets were isolated according to a semi-automated method using enzymatic digestion and purification through discontinuous Euro-Ficoll gradients. The pancreases were surgically removed in our laboratory for group 1, while pancreases from groups 2 and 3 were removed at the slaughterhouse with an average warm ischemia time of 15 minutes. In vitro islet function was assessed by static incubations and perifusions, and in vivo islet function by transplantation under the kidney capsule of nude diabetic mice. The results were as follows: [table: see text] Insulin secretion increased twofold after in vitro glucose stimulation. We obtained restoration of euglycemia in diabetic mice which survived > 3 months after the graft and returned to diabetes after nephrectomy. This study shows that our isolated pig islets are viable and functional in vitro and in vivo after transplantation.

Pseudocysts of the pancreas may require drainage or resection during their evolution. External drainage can be considered as a treatment of first resort with low related morbidity. It also offers a means of treating patients with major contraindications for surgery. In our experience, however, only 55% of external drainages prove successful. Therefore, surgical treatment, even at the cost of low-rate morbidity, remains the only final treatment for complications linked to pseudocysts of the pancreas. In the long term, however, these results depend on the etiology of the pseudocysts.

We report on a patient with alcoholic chronic pancreatitis and intermittent upper gastrointestinal haemorrhage. Old blood was seen in the duodenum but no bleeding source could be identified by endoscopy. Computed tomography scanner and angiography disclosed an arterial pseudoaneurysm of the pancreatic tail, and left splenopancreatectomy was performed. In cases of upper gastrointestinal haemorrhage, the pancreas should be considered as a bleeding source if endoscopies remain negative and the patient presents with chronic pancreatitis.

Objective: To review patients who presented lesions of the pancreas following blunt abdominal trauma, in order to determine which elements contributed to or on the contrary delayed the diagnosis. Construction of a diagnostic procedure which could be followed in order to maximize the rapidity and efficency of treatment., Design: Retrospective study., Patients and Method: Patients from 1985 to 1997 having suffered blunt trauma were studied. The lesions of the pancreas were classified according to Lucas. The grounds for indication and the information that the echography, the CT-Scan and the wirsungographie brought to the diagnosis was determined for each patient. Elements which delayed diagnosis were retrospectively evaluated., Results: We treated 11 patients having suffered blunt abdominal trauma resulting in pancreatic damage. 7 patients were operated. Five had emergency laparotomies. Three of these were unable to reveal an existing rupture of the pancreatic duct., Conclusions: Surgical exploration is difficult and pancreatic lesions are frequently missed. The wirsungography done before or during the operation should, therefore, be more often used as a diagnostic tool.

Since the development of new immunosuppressive agents, as FK506, the results of small bowel transplantation have greatly improved. The patient survival at one year has increased from 25% during the cyclosporin era to 65% in 1995 and the graft survival from 19% to 57% respectively. Clearly, the postoperative complications are still frequent and severe and do not allow a wide generalisation of this method. However, total parental nutrition is not an appropriate solution for the long term management of patients with terminal intestinal insufficiency. In Switzerland, these patients survive for several years and finally die of problems that small bowel transplantation could already successfully overpass.

Small bowel transplantation is theoretically the best treatment for patients with short bowel syndrome and receiving total parenteral nutrition (TPN). The aim of our study was to determine the number of potential candidates for small bowel transplantation in Switzerland. We analyzed the clinical parameters of patients treated by TPN for short bowel syndrome obtained from university pediatric clinics, the SVK (Schweizerischer Verband für Gemeinschaftsaufgaben der Krankenkassen) and referring physicians. In 1995, 7 adults and 2 children were under TPN for short bowel syndrome. In the adult group (mean age 57), the causes of short bowel syndrome were 3 cases of mesenteric infarct, 2 cases of mechanical ileus, one Gardner syndrome and one inflammatory bowel disease. In the pediatric group, the causes of intestinal insufficiency were in one chronic enteropathy with malabsorption and in one congenital malformation. The average duration of TPN was 4.4 (1-10) years for the adults and 13 months for the children. The various complications related to TPN were repeated catheter sepsis in 5 patients, 2 cases of catheter thrombotic occlusion and 3 cases of cholestatic hepatopathy. The contraindications to small bowel transplantation were age, a history of malignant tumor, pulmonary hypertension and a psychiatric disorder. 4 patients were considered potential candidates for transplantation: 2 adults and 2 children, corresponding to an incidence of 0.5/million inhabitants. Considering that the prevalence and incidence of short bowel syndrome in Switzerland are comparable to those in other western countries, we think it should be possible to initiate a small bowel transplantation program in Switzerland.

One way to prevent the occurrence of insulin-dependent diabetes after major pancreatic resection is to perform islet of Langerhans autotransplantation. Thus far, we have performed nine autotransplantations. The last three autotransplantations were performed in patients with benign tumoral pathology (one corporeal mucinous cyst, one isthmic insulinoma and one corporeal cystadenoma). In these three cases, we performed a distal 40%, 75% and 80% pancreatectomy respectively, since enucleation was not indicated or not feasible. After resection and removal of the tumoral lesion, pancreatic segments were injected intraductally with collagenase and digested according to a modified semi-automated Ricordi's technique. We obtained 105,000, 415,000 and 144,300 non-purified islets which were then embolized into the liver by intraportal injection during the same operative procedure. After surgery, all patients were insulin-independent. There was no morbidity or mortality. In a patient who presented acute pancreatitis of the residual pancreas five months after transplantation, insulin therapy was introduced. More than one year after the graft, the two other patients remain insulin-independent. In conclusion, we propose islet autotransplantation after pancreatic resection for benign focal pathology, to prevent or delay the occurrence of insulin-dependent diabetes.

Surgery is the conventional form of treatment for perforated peptic ulcer. Conservative treatment has however been described, and is still used in rare situations. The present study analyzes the indications and results of conservative therapy in our hospital. Between 1978 and 1995, 332 patients were admitted for perforated peptic ulcer. Twelve (3.5%), with a mean age of 85 (67-93) years, underwent conservative treatment (gastric suction, H2-blockers and broad-spectrum antibiotics). The diagnosis was established on the basis of epigastric pain and the finding of a pleuriperitoneum on the plain film of the abdomen. The indication for conservative treatment was a prohibitive anesthesiological risk in 11 patients and absence of peritoneal sign in one. The evolution was favourable only in 4 patients, who were discharged after a median stay of 18 days. Mortality was 8/12 patients. In one of these, autopsy showed ischemic colonic perforation. Conservative treatment of perforated peptic ulcer is associated with very high mortality. The results suggest that frequent and careful clinical monitoring is essential during the first 24 hours. In the event of deterioration, surgery must be reconsidered. In addition, the diagnosis should be confirmed by ruling out perforation of another abdominal organ.

Islet transplantation represents an alternative to whole pancreas transplantation for the treatment of patients suffering from diabetes type I. The transplantation of a sufficient number of islets is an essential condition for successful allograft. Islet cryopreservation allows the storage of islet preparations for subsequent pooling, at the time of transplantation, of cryopreserved islets with a fresh preparation in order to increase the mass of transplanted pancreatic endocrine tissue. From May 1994 to April 1995, islets were isolated from 22 human pancreases using a modified automated method, and 19 preparations were cryopreserved. The function of cryopreserved islets was tested in vitro (static incubation and perifusion). The results of static incubation experiments confirmed that the insulin secretion of cryopreserved human islets in response to glucose stimulation was comparable to the response of islets that have not been frozen. In static incubation experiments, the mean (+/- SEM) insulin secretion of islets, prior to cryopreservation, was 239.3 (+/- 58.9) and 479.5 (+/- 59.5) pg/islet/15 min at 2.8 mM glucose and 16.7 mM glucose respectively. The mean (+/- SEM) insulin secretion of cryopreserved islets was 274 (+/- 103.2) and 468.5 (+/- 191.9) pg/islet/15 min at 2.8 mM and 16.7 mM glucose respectively. The perifusion experiments also demonstrated a significant increase of insulin secretion from cryopreserved islets perifused with a stimulating glucose concentration. Our experiments allow us to envisage the use of cryopreserved islet preparations for allotransplantation in diabetic patients.

From January 1986 to September 1995, 4 patients were hospitalized in our ward for gastrointestinal bleeding from ectopic varices. The patients were all female, aged 30 to 65 years. The etiology of portal hypertension in these patients was alcoholic cirrhosis, cirrhosis in Wilson's disease and previous alveolar echinococcosis treated by right hepatectomy, complicated by post-operative portal thrombosis. Clinical presentation in all 4 cases was lower gastrointestinal bleeding. Diagnosis was by emergency arteriography in 3 cases; no source was found in one case with recurrent hemorrhage. The 4 patients had a history of abdominal surgery. The location of the ectopic varices was small bowel and cecum. 3 patients were treated surgically: right colectomy, partial small bowel resection and porto-caval shunt with complete lysis of adhesions. One patient was treated conservatively with emergency placement of a TIPS (transjugular intrahepatic porto-systemic shunt), with simultaneous embolization of cecal varices. Upon laparotomy, all 3 surgical cases presented ectopic varices in post-operative adhesions. In conclusion, in a patient with portal hypertension presenting with lower gastrointestinal bleeding, hemorrhage from ectopic varices should be kept in mind and investigated by arteriography. A history of abdominal surgery seems to be a predisposing factor in development of ectopic varices by adhesion formation.

Up to now, liver resections have been the initial treatment of almost all cancers and benign tumors limited to a liver lobe. This retrospective review assesses the results of a consecutive series of 113 major elective hepatic resections during a ten-year period. Major hepatectomy was defined by the resection of at least 3 Couinaud segments. Mean age was 52 years (20 to 79 years). There were 62 women and 51 men. 35 resections were performed for colorectal metastases, 22 for a benign tumor, 20 for non-colorectal metastases, 11 for hydatid disease, 10 for hepatocarcinoma, 7 for cholangiocarcinoma and 8 for other indications. The resections performed were 86 right hepatectomies with 18 extended right hepatectomies, 24 left hepatectomies with 4 extended left hepatectomies and 3 trisegmentectomies. Total vascular exclusion was used in 22 patients (19%). Mortality rate was zero. Significant morbidity was encountered in 24 patients (21%). These results suggest that the mortality rate may be independent of the extent of liver resection, provided that hepatic function is normal and preoperative selection adequate. With improving surgical management and techniques, and the use of intra-operative sonography, extensive liver surgery can now be performed with a very low mortality rate.

Type-I diabetes is considered an autoimmune disease, directed against pancreatic beta cells. Diabetes recurrence after pancreas transplantation is theoretically possible, and some cases have been reported after isotransplantation of segmental grafts in HLA-identical twins, where no rejection phenomenon is possible and where no immunosuppression was used. Diabetes recurrence has never been observed in a cadaveric allograft recipient, probably because immunosuppression efficiently blocks the autoimmune mechanism. Autoreactivity against beta cells exists life-long in type-I diabetes, and the immunosuppression used after transplantation becomes an advantage y preventing the recurrence of the disease.

Islet of Langerhans transplantation represents a promising treatment of diabetes. Use of porcine islets for xenotransplantation could offer a solution to shortage of organ donors. However, isolation of pig islets remains a real challenge because of their marked fragility. Using a modified automated method for islet isolation, we performed 10 intraportal islet allografts in pigs. Surgically pancreatectomized pigs were transplanted with purified islet preparations pooled from pancreases of 3 donors (slaughter-house pigs, age 5-8 months). Six recipients were not immunosuppressed and four received an immunosuppressive treatment of Cyclosporine and Azathioprine. In the first group (non-immunosuppressed recipients), insulin secretion was observed for a mean of 4.8 days after transplantation. In the second group (with immunosuppressive treatment) the recipients sustained an insulin secretion for 6-9 days. However, in both groups liver biopsies showed signs of acute rejection and destruction of the transplanted islets. Pig islet allotransplantation, using as recipients surgically pancreatectomized pigs, can be considered as a suitable model to assess the functional results of mass islet isolation. We were able to reverse diabetes transitory in a large animal, by transplantation of purified pig islet preparations. However, even when an immunosuppressive treatment was administered to the recipients, rejection seemed to represent an important factor in the functional outcome of the islet grafts.

For immediately vascularised xenografts, the presence of preformed antibodies associated with the activation of the complement induces a hyperacute humoral rejection in discordant combinations. For neovascularised xenografts, such as the islets of Langerhans, the absence of an initial vascularisation prevents the acute humoral rejection and there is some evidence to suggest that the rejection is cell mediated. To analyse the influence of species response to cellular transplantation, we compared the functional outcome and the immunohistochemical analysis of concordant and discordant xenotransplated islets with allotransplanted islets of Langerhans. In the concordant xenotransplantation experiment, rat (Sprague Dawley) purified islets (N = 600) were transplanted under the kidney capsule of streptozotocin diabetic mice. In the discordant experiment, purified human islets (N = 1000), in the allotransplantation model Balb mouse islets (N = 600) were transplanted under the kidney capsule of C57BL/6 mice. Daily blood glucose levels were monitored until rejection occurred (blood glucose > 11 mMol/L) and kidney biopsies were taken every second day for immunohistological examination. In allotransplanted mice, rejection occurred after a mean of 15 +/- 4 days, in concordant xenotransplanted mice after a mean of 10 +/- 3 days and in the discordant xenotransplanted mice after a mean of 8 +/- 1 days. The immunohistological analysis showed in both xenotransplantation models a deposit of IgM and C3 surrounding the grafted cells, starting at day 1 and persisting until rejection, associated with the presence of Mac-1 positive cells. The intensity of the humoral response was moderate to important in the concordant group, but very strong and unchanged until rejection in the disconcordant group. An invasion with CD4+ and CD8+ cells started between day 4 and 6 in both groups, progressively increasing until rejection. In the allotransplantation model, no humoral response was detectable and the cellular response started between day 10 and 12 after transplantation. We conclude, that a cellular response is involved in the rejection process of both concordant and discordant xenotransplanted islets of Langerhans. Compared to an allotransplantation model, the humoral response does not destroy the function of transplanted islets, but could trigger or accelerate the cell-mediated response.

The incidence of recurrence of hepatitis B virus (HBV) following orthotopic liver transplantation (OLT) is as high as 80% when no attempt at prevention has been considered. HBV reinfection is associated with the reappearance of hepatitis B surface antigen (HBsAg) and HBV DNA in serum and, in most cases, with rapid severe graft damage. Immunoprophylaxis using polyclonal anti-HBs immunoglobulins reduces the risk of recurrence but this long-term therapy remains highly expensive. In this report, we use fresh frozen plasma (FFP) with high titers of anti-HBs immunoglobulins in an attempt to reduce HBV recurrence. From July 1987 to September 1993, 11 patients underwent OLT for HBV-related liver disease (18% of our OLT patients). FFP were administered to 6 patients continually for 7 to 46 months. Only one patient, under long-term immunosuppressive treatment before OLT, was reinfected 7 months after OLT. Rapid development of graft failure was observed with histologic manifestations of a fibrosing cholestatic hepatitis, leading to patient death after 12.5 months with concomitant bacterial infection. In this protocol, the rate of reappearance of HBsAg was 17%, a figure which can be favorably compared with other reports. All patients were subsequently tested for HCV and HIV and remained negative. In conclusion, FFP with high titers of anti-HBs immunoglobulins is at least as effective as polyclonal anti-HBs immunoglobulins in reducing the rate of HBV recurrence following OLT. The estimated cost of this new immunoprophylaxis method is less than 10% of the classical prophylaxis based on purified human polyclonal anti-HBs immunoglobulins.

Islet of Langerhans transplantation is an alternative to whole pancreas transplantation for type I diabetic patients, in whom exogenous insulin therapy has not prevented the occurrence of systemic complications. Thanks to a new isolation technique of human islets, 45 patients have been transplanted worldwide since 1988, of whom only 7 have become totally insulin-independent. Rejection and quality of the islet preparations are problems which remain to be solved. Autotransplantation of islets has been proposed in patients undergoing a pancreatectomy for benign disease. The present report concerns two of our patients who had a pancreatectomy with islet autotransplantation. Both patients are insulin-independent 3 and 11 months postoperatively, with satisfactory metabolic tests. Islet autotransplantation can be proposed when pancreatectomy for non-malignant disease is performed. This method may prevent the development of insulin-dependent diabetes, known to be particularly labile. Because of the sophisticated technical procedures required, human islet isolation is at present only performed in a small number of medical centers and still is in the field of medical experimentation.

Islet of Langerhans transplantation is an alternative to whole pancreas transplantation for type I diabetic patients, in whom exogenous insulin therapy has not prevented the occurrence of systemic complications. Thanks to a new isolation technique of human islets, 45 patients have been transplanted worldwide since 1988, of whom only 7 have become totally insulin-independent. Rejection and quality of the islet preparations are problems which remain to be solved. Autotransplantation of islets has been proposed in patients undergoing a pancreatectomy for benign disease. The present report concerns two of our patients who had a pancreatectomy with islet autotransplantation. Both patients are insulin-independent 3 and 11 months postoperatively, with satisfactory metabolic tests. Islet autotransplantation can be proposed when pancreatectomy for non-malignant disease is performed. This method may prevent the development of insulin-dependent diabetes, known to be particularly labile. Because of the sophisticated technical procedures required, human islet isolation is at present only performed in a small number of medical centers and still is in the field of medical experimentation.