RESUMEN
BACKGROUND: Simultaneous pancreas-kidney transplantation (SPK) has become the treatment of choice for type 1 diabetes mellitus (T1DM) patients with chronic renal failure. Type 2 diabetes mellitus (T2DM), was once considered to be a contraindication for pancreas transplantation; however, it has been accepted as a new indication, under strict criteria. Although favorable results have increase the indication for T2DM in developed countries, there have been no reports of long-term results for this indication from Latin American centers. METHODS: From April 2008 to March 2016, patients receiving SPK or pancreas transplant alone (PTA) for T2DM were included and compared with T1DM recipients. Variables were compared between groups with the use of χ2 and t tests; Kaplan-Meier with log rank was used for patient and graft survivals; P < .05 was considered to be significant. RESULTS: A total of 45 SPK and 1 PTA were performed, 35 (76.1%) for T1DM and 11 (24.5%) for T2DM. Mean pre-transplantation C-peptide was significantly higher in the T2DM group (P = .01); HbA1c was higher in the T1DM group (P = .03). No differences were found in weight, body mass index, and pre-transplantation glycemia. Patient survivals for T1DM recipients were 88.2% and 84.8% at 1 and 5 years, respetively, versus 100% and 74.1% for T2DM recipients (P = .87). CONCLUSIONS: Our initial prospective experience in a single Latin American center showed that medium- and long-term outcomes for T1DM and T2DM individuals receiving pancreas transplants are similar, under strict selection criteria.
Asunto(s)
Diabetes Mellitus Tipo 1/cirugía , Diabetes Mellitus Tipo 2/cirugía , Trasplante de Páncreas/métodos , Adulto , Femenino , Supervivencia de Injerto , Humanos , Fallo Renal Crónico/cirugía , Trasplante de Riñón/efectos adversos , Trasplante de Riñón/métodos , América Latina , Masculino , Persona de Mediana Edad , Trasplante de Páncreas/efectos adversos , Estudios Prospectivos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Graft survival after small bowel transplantation remains impaired due to acute cellular rejection (ACR), the leading cause of graft loss. Although it was shown that the number of enteroendocrine progenitor cells in intestinal crypts was reduced during mild ACR, no results of Paneth and intestinal stem cells localized at the crypt bottom have been shown so far. Therefore, we wanted to elucidate integrity and functionality of the Paneth and stem cells during different degrees of ACR, and to assess whether these cells are the primary targets of the rejection process. We compared biopsies from ITx patients with no, mild, or moderate ACR by immunohistochemistry and quantitative PCR. Our results show that numbers of Paneth and stem cells remain constant in all study groups, whereas the transit-amplifying zone is the most impaired zone during ACR. We detected an unchanged level of antimicrobial peptides in Paneth cells and similar numbers of Ki-67+ IL-22R+ stem cells revealing cell functionality in moderate ACR samples. We conclude that Paneth and stem cells are not primary target cells during ACR. IL-22R+ Ki-67+ stem cells might be an interesting target cell population for protection and regeneration of the epithelial monolayer during/after a severe ACR in ITx patients.
Asunto(s)
Rechazo de Injerto/fisiopatología , Supervivencia de Injerto , Intestino Delgado/fisiopatología , Intestino Delgado/trasplante , Trasplante de Órganos/efectos adversos , Células de Paneth/citología , Células Madre/citología , Adolescente , Adulto , Femenino , Estudios de Seguimiento , Rechazo de Injerto/etiología , Humanos , Masculino , Células de Paneth/metabolismo , Pronóstico , Factores de Riesgo , Células Madre/metabolismo , Adulto JovenRESUMEN
BACKGROUND: Despite the progressively increasing gap between patients waiting for liver transplant under the Model for End-stage Liver Disease MELD system and the availability of deceased donor organs, the use of right extended split liver grafts (RESLG) has not been accepted by all centers. In this study, we compared the results obtained using RESLG vs a group of matched whole liver graft (WLG) recipients at a single center in Latin America. METHODS: A single-center retrospective review performed between August 2009 and December 2015. RESULTS: Fifteen RESLGs were implanted to recipients between 13 and 70 years of age; 80% were performed ex situ. The "biological MELD" score for the RESLG group was 17.5 ± 5.6, and it was 12.8 ± 4.5 for the WLG group (P = .01). Cold ischemia times were significantly longer in RESLG recipients compared with WLG recipients (528 minutes vs 420 minutes; P < .01). No significant differences were found in biliary (leak or strictures P = .40) and arterial complications (hepatic artery thrombosis, P = .06). RESLG patients benefited from a considerable reduction on their waiting time in list. The 1-, 3-, and 5-year patient survival rates were 93%, 93%, and 93% respectively, for RESLG recipients vs 100%, 95.7%, and 86.1%, respectively, for WLG recipients. The 1-, 3-, and 5-year graft survival rates were 79.4%, 79.4%, and 79.4% for RESLG recipients and 89.7%, 89.7%, and 89.7% for WLG recipients, respectively. No statistical differences were observed. CONCLUSION: RESLG allows expeditious transplantation for low MELD recipients. Its use should be expanded in Latin America and worldwide as a valid alternative to increase the donor pool as it has been used in other regions.
Asunto(s)
Hepatopatías/cirugía , Trasplante de Hígado/métodos , Complicaciones Posoperatorias/etiología , Adolescente , Adulto , Anciano , Argentina , Estudios de Casos y Controles , Isquemia Fría , Femenino , Humanos , Hepatopatías/patología , Trasplante de Hígado/mortalidad , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Tasa de Supervivencia , Donantes de Tejidos/provisión & distribución , Resultado del Tratamiento , Listas de Espera , Adulto JovenRESUMEN
BACKGROUND: The abdominal wall may be severely compromised in the vast majority of intestinal and multiorgan transplant candidates, and sometimes as a consequence of complex liver transplantation. Multiple options have been described to overcome this problem, varying from component separation to the extreme need of performing an abdominal wall transplantation. The aim of the present paper is to report the largest and longest-term results of patients that received an abdominal rectus fascia (ARF) after liver, intestinal, or multiorgan transplantation at a single transplant center. METHODS: This is a retrospective report of a prospectively collected dataset of all the patients that received ARF during liver, isolated intestine, combined, or multiorgan transplantation at Fundación Favaloro from May 2006 to June 2016. RESULTS: A total of 19 out of 528 patients (3.5%) that underwent abdominal organ transplant received an ARF graft: 17 patients after receiving an intestine-containing graft, and 2 after liver retransplantations. Three patients required changing the ARF, 2 with a synthetic mesh and 1 with another ARF. Five patients required late reoperations: A relaparotomy was performed by transecting the ARF without encountering adhesions on the inner ARF surface. None of the 2 patients who received liver retransplantations and ARF developed acute or chronic ventral defects. CONCLUSIONS: The use of ARF is a simple and reliable surgical option to close abdominal wall defects during transplantation, the fascia adequately incorporates to the abdominal wall, allowing it to be transected and resutured in the long term and preserving the integrity of the peritoneal layer.
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Técnicas de Cierre de Herida Abdominal , Fascia/trasplante , Intestino Delgado/trasplante , Trasplante de Hígado , Recto del Abdomen/trasplante , Adulto , Niño , Estudios de Seguimiento , Humanos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Intestinal failure (IF) patients received parenteral nutrition (PN) as the only available therapy until intestinal transplantation (ITx) evolved as an accepted treatment. The aim of this article is to report the long-term outcomes of a series of ITx performed in pediatric and adult patients at a single center 9 years after its creation. PATIENTS AND METHODS: This is a retrospective analysis of the ITx performed between May 2006 and January 2015. Diagnoses, pre-ITx mean time on PN, indications for ITx, time on the waiting list for types of ITx, mean total ischemia time, and warm ischemia time, time until PN discontinuation, incidence of acute and chronic rejection, and 5-year actuarial patient survival are reported. RESULTS: A total of 42 patients received ITx; 80% had short gut syndrome (SG); the mean time on PN was 1620 days. The main indication for ITx was lack of central venous access followed by intestinal failure-associated liver disease (IFALD) and catheter-related infectious complications. The mean time on the waiting list was 188 days (standard deviation, ±183 days). ITx were performed in 26 children and 14 adults. In all, 32 procedures were isolated ITx (IITX); 10 were multiorgan Tx (MOT; 3 combined, 7 multivisceral Tx (MVTx), 1 modified MVTx and 2 with kidney); 2 (4.7 %) were retransplantations: 1 IITx, 1 MVTx, and 5 including the right colon. Thirteen patients (31%) received abdominal rectus fascia. All procedures were performed by the same surgical team. Total ischemia time was 7:53 ± 2:04 hours, and warm ischemia time was 40.2 ± 10.5 minutes. The mean length of implanted intestine was 325 ± 63 cm. Bishop-Koop ileostomy was performed in 67% of cases. In all, 16 of 42 Tx required early reoperations. The overall mean follow-up time was 41 ± 35.6 months. The mean time to PN discontinuation after Tx was 68 days (P = .001). The total number of acute cellular rejection (ACR) episodes until the last follow-up was 83; the total number of grafts lost due to ACR was 4; and the total graft lost due to chronic rejection was 3. At the time of writing, the overall 5-year patient survival is 55% (65% for IITx vs 22% for MOT; P = .0001); 60% for pediatric recipients vs 47% for adults (P = NS); 64% when the indication for ITx was SG vs 25% for non-SG (P = .002). CONCLUSIONS: At this center, candidates with SG, in the absence of IFALD requiring IITx, showed the best long-term outcomes, independent of recipient age. A multidisciplinary approach is mandatory for the care of intestinal failure patients, to sustain a rehabilitation and transplantation program over time.
Asunto(s)
Rechazo de Injerto/epidemiología , Intestinos/trasplante , Fallo Renal Crónico/cirugía , Fallo Hepático/cirugía , Trasplante de Hígado , Nutrición Parenteral Total/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Síndrome del Intestino Corto/cirugía , Adulto , Argentina , Niño , Femenino , Humanos , Enfermedades Intestinales/complicaciones , Enfermedades Intestinales/cirugía , Fallo Renal Crónico/complicaciones , Fallo Hepático/etiología , Masculino , Nutrición Parenteral Total/efectos adversos , Reoperación , Estudios Retrospectivos , Síndrome del Intestino Corto/complicaciones , Listas de Espera , Isquemia TibiaRESUMEN
BACKGROUND: We report the case of a 7-year-old girl with intestinal failure owing to a cystic lymphangioma compromising the root of the mesentery, not amenable to resection, leading to intestinal failure. Oncologic treatment was attempted to reduce tumor size with no response; therefore, she was listed for multivisceral transplantation. PROCEDURE: Resection of the tumor required resection of all abdominal organs with vascular inflow and outflow. A multivisceral graft (liver, stomach, duodenum-pancreas and spleen complex, small bowel, and right colon) was implanted. For vascular reconstruction, donor's superior vena cava was sutured to the recipient's suprahepatic veins in a common patch. For arterial inflow, an arterial conduit was placed directly to the infrarenal aorta, and sutured to an aortic patch of the graft. Cold ischemia time was 8:45 hours; warm ischemia time was 35 minutes. A double-layer gastrogastric anastomosis and piloroplasty was made; and the distal reconstruction was performed with ileocolic side-to-end anastomosis that allowed to perform of a Bishop-Koop ileostomy for endoscopic monitoring. OUTCOME: The patient recovered well after the procedure and was discharged 36 days after transplantation with intestinal sufficiency. To the best of our knowledge, this is the first report describing cystic lymphangioma as an indication for multivisceral transplantation.
Asunto(s)
Intestinos/trasplante , Trasplante de Hígado/métodos , Linfangioma Quístico/cirugía , Mesenterio , Trasplante de Páncreas/métodos , Neoplasias Peritoneales/cirugía , Bazo/trasplante , Niño , Femenino , HumanosRESUMEN
CASE REPORT: A 24-year-old man diagnosed with Peutz-Jeghers syndrome as a child underwent multiple surgeries owing to intussusception. Pretransplant workup showed >150 polyps along the gastrointestinal (GI) tract, some of them with high-grade dysplasia. Despite having intestinal sufficiency, a modified multivisceral transplantation was offered. PROCEDURE: An 18-year-old donor was procured using University of Wisconsin solution. The recipient's surgery started with a midline incision. Mobilization of the right colon and the root of the mesentery was done to isolate the superior mesenteric artery. The same maneuver was done with the left and sigmoid colon. The common bile duct was then isolated and transected at the cystic duct level. The abdominal portion of the esophagus and the proximal stomach were isolated and divided at the gastroesophageal junction. After that, the pancreas was mobilized, preserving the spleen with the splenic vessels. The distal GI tract was transacted at the level of the proximal rectum. For engraftment, an arterial conduit was placed in the infrarenal aorta and anastomosed to the graft's aortic patch. End-to-side portal reconstruction was made at the level of the portal vein, allowing performing a duct-to-duct biliary reconstruction over a 5-Fr T-tube. A hand-sewn gastrogastric anastomosis and piloroplasty were performed; the distal anastomosis was done with circular staplers. A gastrojejunostomy and a loop ileostomy were the final steps of the procedure. RESULTS: The patient stayed in intensive care for 2 days and enteral feeds were started on day 7. Currently, 23 months after transplant he is alive with an excellent quality of life.
Asunto(s)
Trasplante de Órganos/métodos , Síndrome de Peutz-Jeghers/cirugía , Bazo/cirugía , Adolescente , Humanos , Masculino , Adulto JovenRESUMEN
Intestinal transplantation (ITx) faces the challenge of grafting a high immunogenic organ, which is certainly one of the major obstacles for intestinal allograft acceptance. The allograft has to guarantee the proper functioning of the mucosal immune machinery under immunosuppressive conditions. Recently, it has been elucidated that isolated lymphoid follicles (ILFs) are an indispensable part of mucosal immunity to maintain IgA synthesis and consequently to control commensal microflora. No data about these follicular structures in the setting of ITx are available so far. Therefore, we addressed the question whether constitution, integrity and function of allograft ILFs are disturbed by immunosuppressive regimen. We compared allograft ILFs from terminal ileum of transplant patients with ILFs from nontransplant patients via flow cytometry, quantitative real-time polymerase chain reaction and immunohistochemistry. We found that host leukocytes rapidly repopulate allograft ILFs and that maintenance immunosuppressive regimen, tacrolimus and corticosteroids, does not affect their cellular integrity and function. However, allograft ILFs revealed a higher maturation state than control samples and IgA positive plasma cells were increased in number in allograft mucosa. Our results open the path for a better understanding of allograft mucosal immunity.
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Intestinos/trasplante , Tejido Linfoide/inmunología , Adolescente , Adulto , Secuencia de Bases , Niño , Preescolar , Cartilla de ADN , Femenino , Humanos , Inmunidad Mucosa , Inmunoglobulina A/metabolismo , Lactante , Intestinos/inmunología , Masculino , Repeticiones de Microsatélite , Persona de Mediana Edad , Reacción en Cadena en Tiempo Real de la Polimerasa , Linfocitos T Colaboradores-Inductores/inmunología , Trasplante , Adulto JovenRESUMEN
INTRODUCTION: Understanding abdominal vascular anatomy is crucial for multiorgan recovery. In this case report, we have described a common hepatic artery that arises from the superior mesenteric artery but follows an intrapancreatic course. METHODS: The donor was ideal for multiorgan recovery and the recipient was a 29-year-old woman awaiting a second transplant owing to primary nonfunction of her first engrafted organ. The indication for transplantation was secondary biliary cirrhosis. A type I diabetic recipient on dialysis therapy was awaiting the kidney and pancreas. RESULTS: The urgent condition of our liver recipient combined with the anatomical finding prioritized liver procurement, therefore the pancreas was discarded. CONCLUSIONS: The recognition of all anatomic variations will allow us to improve the use of the scarce resource of deceased donor organs.
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Hepatectomía , Arteria Hepática/anomalías , Arteria Hepática/cirugía , Cirrosis Hepática Biliar/cirugía , Trasplante de Hígado , Arteria Mesentérica Superior/anomalías , Arteria Mesentérica Superior/cirugía , Donantes de Tejidos/provisión & distribución , Recolección de Tejidos y Órganos , Adulto , Femenino , Humanos , Pancreatectomía , Reoperación , Resultado del TratamientoRESUMEN
Normal small bowel length (SBL) has been reported within a wide range, but never studied in a cohort of either pediatric or adult deceased donors. Between 5/2006 and 2/2011, SBL was measured in all grafts procured for intestinal transplantation at a single center and used for either isolated intestinal transplant (15) or multiorgan transplants (5) employing a standardized method. SBL was the only not significantly different variable among pediatric and adult donors divided by age 16. Furthermore, donors were classified in 3 groups: group 1: Height < 70 cm, group 2: 71-150 cm and group 3: ≥ 151 cm. Mean age was: 0.58, 5.6, 22.01 years, respectively. Mean height and weight were 65.8, 123.2, 166.1 cm (p = 0.001) and 6.9, 23.8, 65.2 kg (p = 0.001), for each group. The SBL by group was: 283.0, 324.7, 356.0 cm, remaining as the only nonsignificant variable (p = 0.06), in contrast to BMI, BSA (p = 0.001). The SBL/height ratio: 4.24, 2.7, 2.12 (p = 0.001; rho: -0.623) or SBL/BSA ratio was 8.36, 3.7, and 2.03, respectively (p : 0.0001; rho: -0.9). SBL does not increase with growth like other anthropometric variables. The SBL/height ratio significantly decreases with growth; however, bowel diameter increases, which needs further evaluation.
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Intestino Delgado/anatomía & histología , Intestino Delgado/trasplante , Trasplante de Órganos , Donantes de Tejidos , Adolescente , Adulto , Estatura , Índice de Masa Corporal , Peso Corporal , Niño , Preescolar , Estudios de Cohortes , Femenino , Humanos , Lactante , Masculino , Estudios Retrospectivos , Adulto JovenRESUMEN
Domino liver transplantation, introduced in 1997, originally consisted of a graft from a patient with familial amyloidotic polyneuropathy used as a donor for a compatible recipient, thus increasing the pool of hepatic grafts for liver transplantation. The aim of this report was to present a modification on the technique for outflow reconstruction in domino liver transplantation first proposed by Liu et al and Cescon et al. In this description we proposed a new technique that differs from the one mentioned above by performing a neo-suprahepatic cava, constructed using only an iliac vein graft, facilitating the anastomosis as if it was a regular cadaveric liver transplant.
Asunto(s)
Trasplante de Hígado/métodos , Adulto , Humanos , MasculinoRESUMEN
During intestinal transplant (ITx) operation, intestinal lymphatics are not reconstituted. Consequently, trafficking immune cells drain freely into the abdominal cavity. Our aim was to evaluate whether leucocytes migrating from a transplanted intestine could be recovered from the abdominal draining fluid collected by a peritoneal drainage system in the early post-ITx period, and to determine potential applications of the assessment of draining cellular populations. The cell composition of the abdominal draining fluid was analysed during the first 11 post-ITx days. Using flow cytometry, immune cells from blood and draining fluid samples obtained the same day showed an almost complete lymphopenia in peripheral blood, whereas CD3(+) CD4(+) CD8(-) , CD3(+) CD4(-) CD8(+) and human leucocyte antigen D-related (HLA-DR)(+) CD19(+) lymphocytes were the main populations in the draining fluid. Non-complicated recipients evolved from a mixed leucocyte pattern including granulocytes, monocytes and lymphocytes to an exclusively lymphocytic pattern along the first post-ITx week. At days 1-2 post-Itx, analysis by short tandem repeats fingerprinting of CD3(+) CD8(+) sorted T cells from draining fluid indicated that 50% of cells were from graft origin, whereas by day 11 post-ITx this proportion decreased to fewer than 1%. Our results show for the first time that the abdominal drainage fluid contains mainly immune cells trafficking from the implanted intestine, providing the opportunity to sample lymphocytes draining from the grafted organ along the post-ITx period. Therefore, this analysis may provide information useful for understanding ITx immunobiology and eventually could also be of interest for clinical management.
Asunto(s)
Intestinos/inmunología , Sistema Linfático/inmunología , Linfocitos/inmunología , Inmunología del Trasplante , Cavidad Abdominal/cirugía , Antígenos CD19/metabolismo , Complejo CD3/metabolismo , Linfocitos T CD4-Positivos/citología , Linfocitos T CD4-Positivos/inmunología , Linfocitos T CD4-Positivos/metabolismo , Linfocitos T CD8-positivos/citología , Linfocitos T CD8-positivos/inmunología , Linfocitos T CD8-positivos/metabolismo , Movimiento Celular/inmunología , Drenaje/métodos , Citometría de Flujo , Antígenos HLA-DR/metabolismo , Humanos , Intestinos/trasplante , Sistema Linfático/citología , Sistema Linfático/metabolismo , Recuento de Linfocitos , Linfocitos/citología , Linfocitos/metabolismo , Factores de TiempoRESUMEN
Introducción: El neumomediastino se define como la presencia de aires en el espacio mediastinito. Desde su introducción en la literatura por Hamman se ha podido determinar su origen en la lesión alveolar por barotrauma. Generalmente tiene un curso benigno afectando a hombres entre los 20-30 años de edad.Objetivo: Revisión bibliográfica y presentación de caso.Lugar de aplicación: Hospital polivalente de alta complejidad.Caso Clínico: Varón de 22 años que consulta por dolor en hemotórax derecho, alteración del tono de vos y enfisema subcutáneo cervical. Al examen físico se constata signo de Hamman. Se solicita radiografía de tórax haciéndose diagnóstico de neumomediastino. Se instaura tratamiento médico con buena evolución sin requerir tratamiento quirúrgico.Discusión: El neumomediastino es una patología poco frecuente de curso generalmente benigno. Su diagnóstico obliga a descartar otras causas como la perforación esofágica o lesión del árbol traqueobronquial. Su tratamiento implica medidas de sostén y en algunos casos oxígeno a altas dosis, reservando el tratamiento quirúrgico a las complicaciones como el taponamiento cardíaco o neumotórax hipertensivo.