Proposed protocol to reduce bacterial infectious complications in living related small bowel transplant recipients.
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Antibiotic Prophylaxis↗
Biomedical subjects
M Asolati
Publications and source records attributed to M Asolati.
Low infectious complications in segmental living related small bowel transplantation in adults.
Clinical small bowel transplantation (SBTx) has been associated with a high rate of infectious complications. Laparotomy, preservation injury, abnormal motility, lymphatic disruption, aberrant systemic venous drainage, rejection and antibiotic therapy could all be implicated in the etiology of these complications. In addition to the underlying disease, total parental nutrition could determine infections and liver impairment. Recently, standardized techniques for segmental living related SBTx (LR-SBTx) have been developed. This technique allows reduction of some of these factors, thus resulting in a reduced incidence of infections. We report the infectious complications observed in 3 patients with short bowel syndrome treated with LR-SBTx at our institution. A segment of 180-200 cm of ileum was transplanted with a neglectably short cold ischemia time (CIT). The donor bowel was decontaminated. Oral tacrolimus, prednisone and IV induction with ATG were used for immunosuppression. Blood, stool, urine, sputum and peritoneal fluids were collected and cultured as a routine surveillance. All recipients are alive with a current follow-up time up to 21 months. No bacterial infections were observed during the post-transplant period. One patient developed cytomegalovirus (CMV) enteritis 4 months after LR-SBTx and was treated successfully with IV ganciclovir. In our limited experience, LR-SBTx is associated with a low infection rate. This could be due to optimal graft decontamination, short CIT and to the reduced incidence of rejection and lower immunosuppression used in this immunologically well-matched combination.
Adult↗
Comparison of jejunal and ileal surveillance biopsies in a porcine model of intestinal transplantation.
BACKGROUND: The optimal biopsy site of bowel allografts for rejection surveillance remains controversial. We compared the results of jejunal (JBx) and ileal (IBx) biopsies after bowel transplantation in a porcine model. METHODS: Eighteen Yorkshire-Landrace pigs served as donors. Eighteen recipient pigs underwent total enterectomy followed by orthotopic small bowel transplantation with or without the colon. A jejunostomy and a Bishop-Koop ileostomy were constructed for biopsies. Immunosuppression consisted of FK506 (target level 10-15 ng/ml by enzyme immunoparticle assay) and prednisone administered via the jejunostomy. Simultaneous JBx and IBx were performed twice weekly. Acute rejection was graded as mild, moderate, or severe based on previously published criteria. RESULTS: Mean overall survival after the transplant was 17.4 days. A total of 162 specimens were collected and evaluated for rejection (JBx, 81; IBx, 81). Acute rejection was detected in 41 JBx cases (50.7%) and 40 IBx cases (49.4%). The presence or absence of rejection was concordant between JBx and IBx in 70 of 81 case pairs (86.4%). Of the 11 discordant case pairs, 6 were JBx positive/IBx negative, whereas 5 were JBx negative/IBx positive. A total of 35 case pairs were synchronously positive, 24 (68.8%) of which demonstrated the same degree of rejection. CONCLUSIONS: The correlation between JBx and IBx of bowel allografts in diagnosing the presence of acute rejection is quite good. However, performing IBx alone would have missed about 7.5% of the rejection episodes. Because the early treatment of rejection in bowel transplantation is of paramount importance, in selected cases, biopsies from both the ileum and jejunum should be considered if technically feasible.
Animals↗
Comparison of rejection rate and functional outcome of small bowel transplantation alone or in conjunction with the ileocecal valve versus combined small and large bowel transplantation.
Preservation of the ileocecal valve improves absorptive function and decreases the amount of small bowel needed for survival in patients with short gut syndrome. We compared the results of small and large bowel transplant (SLBTx), small bowel transplant only (SBTx), and SBTx with the ileocecal valve (ICVTx) in a porcine model. Total enterectomy was performed on 18 Yorkshire-Landrace pigs followed by orthotopic SBLTx (n = 6), SBTx (n = 6), and ICVTx (n = 6). A jejunostomy and an ileostomy were constructed for biopsies. Overall mean survival was 17 d with no statistically significant difference between groups. Rejection was seen in 6/6 SLBTx, 4/6 SBTx, and 4/6 ICVTx recipients. Acute rejection was seen in 84.3% of SLBTx, 52.3% of SBTx, and 42.5% of the ICVTx mucosal biopsy samples. Two cases of intra-abdominal infection were in the ICVTx group only. Weight loss was 147 g/d in the SLBTx group, 643 g/d in the SBTx group, and 393 g/d in the ICVTx group. While the functional outcome after SLBTx and ICVTx was noticeably better than the SBTx group, the increased rejection and intra-abdominal infection rates make transplanting the large bowel or the ileocecal valve a less attractive clinical option.
Acute Disease↗
Long-term outcome of a prospective trial of steroid withdrawal after kidney transplantation.
BACKGROUND: Steroid withdrawal (SW) after kidney transplantation is desirable to avoid associated serious side effects. We studied the long-term outcome of a group of kidney transplant recipients who underwent SW. METHODS: Between 1991 and 1993, kidney transplant recipients (N = 12) who had posttransplantation diabetes were entered in a prospective trial of SW. These patients were compared with a demographically similar comparison cohort (N = 66). End points of the study were patient and graft survival, incidence of late acute and chronic rejection, and changes in diabetes management. RESULTS: Previously published data from the SW group at 15 months of follow-up indicated improvement in diabetes control without any adverse effect on patient or graft actuarial survival. At long-term follow-up (mean, 56 months) the improvement in diabetes management was not detectable. The incidence of late acute rejection in SW and cohort groups was 42% and 8%, respectively (P = .006). Likewise, the incidence of chronic rejection in the SW versus cohort group was 42% and 12%, respectively (P = .014). CONCLUSIONS: Although SW appeared to be successful initially, our long-term data indicate that SW significantly increases the risk of late acute rejection and chronic rejection episodes without benefits in posttransplantation diabetes management. Steroid withdrawal in patients with posttransplantation diabetes should be approached with caution.
Acute Disease↗
A prospective randomized clinical trial of perioperative treatment with octreotide in pancreas transplantation.
BACKGROUND: Technical failures continue to plague clinical pancreas transplantation. The somastatin analogue octreotide has been shown able to decrease morbidity after pancreatic resection. We studied the effect of perioperative treatment with octreotide on technical complications after pancreas transplant. PATIENTS AND METHODS: Seventeen recipients of bladder-drained transplant were randomized to receive either octreotide, 100 microg TID SQ for 5 days after transplant (n = 10) or no additional treatment (n = 7). We compared the two groups in terms of patient and graft survival and incidence of graft pancreatitis, intra-abdominal infections, and anastomotic leaks. RESULTS: In the untreated group, 1 patient developed a bladder leak and 2 had intra-abdominal infections, while no complications occurred in the octreotide-treated patients (P = 0.05). Six-month patient and pancreas survival was 100% and 90%, respectively, in octreotide-treated patients versus 86% and 86% in the control group (P = NS). CONCLUSION: Perioperative treatment with octreotide seems able to reduce the incidence of technical complications after pancreas transplantation.
Adult↗
Value of perioperative treatment with sandostatin after pancreas transplantation: a prospective randomized trial.
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Adult↗
Long-term outcome of kidney transplantation after steroid withdrawal.
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Azathioprine↗
Kidney transplantation in recipients with mental retardation: clinical results in a single-center experience.
Mental retardation has been a controversial relative contraindication to organ transplantation. Currently, there are few data available in the literature that describe the outcome of kidney transplantation in mentally retarded patients. In a series of 1,271 kidney transplantations performed between January 1968 and March 1996, we identified eight patients (0.6%) with significant mental retardation (IQ < 70). Only cooperative patients supervised by a reliable long-term caregiver, with long life expectancy, and able to take medication under supervision, were accepted as candidates, independent of the IQ level. At a mean follow-up of 7.3 years, seven patients are alive with functioning grafts, and one lost the kidney to chronic rejection 10 years after transplantation and died of sepsis after resuming dialysis. The 1- and 5-year patient and graft survival are thus 100%. Compliance with immunosuppressive treatment and clinical follow-up was excellent in all of the recipients. The patient quality of life and health were judged by the support persons as highly improved after transplantation in comparison to dialysis. We conclude that kidney transplantation in properly selected patients with mental retardation provides excellent patient and graft survival rates and improves quality of life. In such patients, the presence of mental retardation should not be considered a contraindication to kidney transplantation.
Adolescent↗
A prospective study of the predictive value of polymerase chain reaction assay for cytomegalovirus in asymptomatic kidney transplant recipients.
Cytomegalovirus (CMV) infection carries the potential for high morbidity in transplant recipients. The institution of pre-emptive therapy prior to the onset of clinical disease on the basis of CMV-polymerase chain reaction (PCR) is very attractive. We prospectively studied 52 asymptomatic kidney transplant recipients to test the hypothesis that serial CMV-PCR assays during the first 3 months post-transplant would identify patients at risk for CMV disease. Twenty-three patients (44.2%) had positive CMV-PCR tests at least once; 2 (8.6%) developed CMV. None of the 29 patients continuously negative for CMV-PCR developed CMV disease. CMV-PCR status did not influence patient and graft survival or the incidence of acute rejection. We conclude that while a substantial number of kidney transplant recipients become positive for CMV-PCR in the early post-transplant period, only a minority will develop CMV disease. Negative CMV-PCR assay is an accurate negative predictor for CMV disease but the value of CMV-PCR as a guide for pre-emptive anti-CMV therapy in kidney transplant recipients appears limited.
Adult↗
Intrasplenic hepatocyte allotransplantation in dalmation dogs with and without cyclosporine immunosuppression.
Hepatocyte allotransplantation has been performed successfully in several small animal models for the amelioration of inborn metabolic errors. Before a human clinical trial of hepatocyte allotransplantation can be attempted, preliminary experience in a large animal model is needed. We transplanted isolated mongrel hepatocytes into the spleen of dalmatians in the attempt to cure their inborn error of uric acid metabolism. Of 10 dalmatian recipients, two that received 9-10 x 10(9) mongrel hepatocytes died early after surgery of acute portal hypertension and hemorrhage. The eight long-term survivors received 5-6 x 10(9) hepatocytes and were randomized either to no treatment or to oral cyclosporine (CsA). Levels of CsA were adjusted to maintain trough levels between 400 and 800 ng/ml. In the four nonimmunosuppressed dalmatians, a reproducible average reduction in urinary uric acid excretion (UUAEx) of 23.7% was achieved; values returned to baseline within 14 days. In the CsA-immunosuppressed dalmatians, the average decline in UUAEx was 30%. The partial correction of the metabolic defect persisted for an average of 25 days in three immunosuppressed dogs, whereas in one dog, the partial correction lasted for over 90 days. No change in UUAEx was observed in two dalmatians that underwent sham laparotomy and intrasplenic injection of saline solution; CsA given alone to dalmatians did not modify UUAEx. We conclude that the dalmatian dog is a valuable large animal model for studies of the role of hepatocyte transplantation in the cure of inborn hepatic metabolic errors.
Animals↗
Thrombocytopenia in an established solitary pancreas graft recipient.
Isolated, life-threatening thrombocytopenia from a previously well tolerated pancreas allograft has not been reported in the literature. Herein we report such a case where a 31-year-old, Caucasian, Type I diabetic male developed severe thrombocytopenia 6 months following isolated pancreas transplantation and 2 wk after enteric conversion of the graft. Despite extensive diagnostic work-up, the cause remained unclear and his thrombocytopenia did not remit with standard treatment, but did resolve upon explantation. Pathologic examination of the pancreatic graft showed evidence of chronic rejection along with CMV pancreatitis. We conclude that unremitting isolated thrombocytopenia in solitary pancreas grafts may reflect a localized DIC phenomenon that requires graft explantation.
Adult↗
Iliac reconstruction with arterial allograft during pancreas-kidney transplantation.
An intraoperative dissection of the external iliac artery during pancreas transplantation was successfully repaired using the donor iliac artery allograft as a conduit between the internal iliac and distal external iliac artery. An angiogram performed 6 months after surgery showed a patent bypass without stricture or pseudoaneurysm. At 1 yr follow-up after transplant the grafts are functioning well, and the affected extremity is normal. In immunosuppressed recipients of solid organ transplants, fresh arterial allografts may be successfully used for iliac artery reconstruction. Further study will be needed to determine the role of arterial allografts for lower extremity bypass surgery in immunosuppressed patients.
Adult↗
Single-layered cervical esophageal anastomoses: a prospective study of two suturing techniques.
We carried out a prospective, randomized study over a 1-year period to compare the efficacy of a single layer of continuous absorbable monofilament (Maxon) with that of a single layer of interrupted Polyglactin sutures (Vicryl) in the performance of cervical esophagogastric anastomoses. Forty-two consecutive patients with carcinoma of the esophagus or cardia, in whom the stomach was transposed through the mediastinal route after esophagectomy, were enrolled in the study. There were 21 patients in each group. There was no hospital mortality. One asymptomatic anastomotic leak and two early anastomotic strictures requiring dilation occurred in patients in whom an interrupted technique was employed. The continuous technique required significantly less operative time (p < 0.0001), and the cost of the suture material was reduced markedly. We conclude that either a continuous or an interrupted monolayer esophagogastric anastomosis can give satisfactory results after esophagectomy for cancer, provided that the vascular supply to the gastric fundus is maintained adequately. The continuous technique has the advantages of being time-saving, cheaper, and easier to perform and to teach.
Adenocarcinoma↗
[Primary malignant melanoma of the esophagus. Report of 3 cases and review of the literature].
Primary malignant melanoma of the esophagus is an extremely rare tumour with a fatal prognosis. Only 122 cases have been reported to date in the literature, of which 105 are undoubtedly primary. This study presents three new cases which were surgically treated: two cases underwent subtotal esophageal resection and intrathoracic esophagogastroplasty, and one case underwent total esophageal resection and cervical esophagogastroplasty. The histogenesis, role of immunochemical markers and the therapeutic problems related to malignant esophageal melanoma are discussed in the light of a new review of the literature.
Adult↗
Temporary double exclusion of the perforated esophagus using absorbable staples.
A new method for double exclusion of the esophagus is presented. Temporary closure of the cervical and intraabdominal esophagus using absorbable staples allows effective healing of esophageal perforations. The procedure should be routinely combined with drainage of the periesophageal abscess. Complete recanalization of the esophagus occurs 1 to 2 weeks after operation.
Adolescent↗
Surgical treatment of carcinoma of the gastric cardia.
The ideal surgical treatment for adenocarcinoma of the gastric cardia is still controversial. In 189 consecutive patients who underwent resection, 127 esophagogastric resections and 62 total gastrectomies plus esophageal resection were performed. Short- and long-term results of the two surgical procedures were compared in order to define the specific indications for each. Abdominal nodes were metastatic in 73.5% of the cases, and mediastinal nodes in 29.1% of the patients who were also approached through the thorax. Neoplastic permeation of the esophageal resection margin occurred in 3.2% of the patients. No positive resection margins were found in the cases in whom 10 or more cm. of uninvolved esophagus were resected. The superiority of the laparotomy and right thoracotomy approach was thus evident in terms of oncologic radicality. Anastomotic leakage occurred in 8.7% of esophagogastric resection, and in 6.5% of total gastrectomy plus esophageal resection, patients. No correlation between the stage of the tumor or the neoplastic permeation of the section margin and the incidence of anastomotic leakage was found. Operative mortality was 3.9% after esophagogastric resection, and 6.5% after total gastrectomy plus esophageal resection; this may suggest that esophagogastric resection is the procedure of choice in poor risk and elderly patients. After curative resection, locoregional or systemic neoplastic recurrence was observed in 15.0% of the cases.(ABSTRACT TRUNCATED AT 250 WORDS)
Adenocarcinoma↗
[Cancer of the hypopharynx and cervical esophagus].
Between 1975 and 1988 we observed 169 patients with carcinoma of the cervical esophagus, 85 with a carcinoma involving the hypopharynx and the cervical esophagus, and 27 patients with a carcinoma of the cervical esophageal region arising after laryngectomy for laryngeal cancer. The mean age was 57.5 years (range 41-73). 167 patients underwent surgical exploration (operability rate 59.5%) and in 152 cases the tumor was resected (resectability rate 91.1%). The resection was complete in 129 patients (84.5%) and palliative in 23 (14.5%). In 33 cases a segmental laryngo-pharyngo-cervical esophagectomy with free intestinal loop transplantation was performed with an operative mortality of 6.1%. 101 patients underwent total laryngo-pharyngo esophagectomy and the gastrointestinal tract was reconstructed by means of pharyngo-gastrostomy and pharyngo-colostomy in 85 and 16 cases, with an operative mortality of 12.9% and 18.3%, respectively. Total esophagectomy without laryngectomy was performed in 18 patients with a carcinoma of the distal cervical esophagus refusing laryngectomy with a hospital mortality of 5.5%. The overall 5-year actuarial survival, excluding the operative mortality, was 15.8%. After complete resection, better results were recorded with patients operated for carcinoma of the hypopharynx than with patients with carcinoma of the cervical esophagus: the 2-year and 5-year actuarial survival was 59% vs 26% and 43% vs 17%, respectively. No patient undergoing palliative resection was alive at the 3-year interval.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗