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ABSTRACT: Gastroschisis is the most frequent cause of pediatric intestinal transplantation. This study reviews our experience of intestinal transplantation secondary to gastroschisis to elucidate those factors affecting the outcome of children with short bowel syndrome.
A retrospective review was performed for children who underwent intestinal transplantation for gastroschisis at the University of Miami between June 2003 and August 1994.
Thirty-two transplants were performed in 28 children with gastroschisis during the study period. Associated intestinal anomalies were present in 22 infants (atresia [n = 14], volvulus [n = 3], and/or ischemia [n = 16]). Spontaneous prenatal closure of gastroschisis, a rare anomaly associated with bowel atresia and ischemia because of a very small abdominal defect, was seen in 9 patients. Most of the patients had a complicated course and required multiple abdominal surgeries before transplant. Fifteen (53.6%) patients are currently alive at a median follow-up of 23.5 months. Short-term survival rate has significantly improved in recent years.
Patients with complex gastroschisis and intestinal anomalies have a significant risk for progression to short bowel syndrome. Intestinal transplantation can be a lifesaving option and provides a satisfactory outcome for children with short bowel syndrome secondary to gastroschisis.
Journal of Pediatric Surgery 12/2006; 41(11):1841-5. · 1.45 Impact Factor
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ABSTRACT: Although the most common cause of liver failure (LF) in hematologic patients is viral hepatitis, several episodes of sickle cell intrahepatic cholestasis (IHC) have been reported as rare but potentially causative of fulminant LF. Reviewing the literature, we have presented a single case of intrahepatic cholestasis after major liver resection, which was effectively treated by exchange transfusion.
Serial hemoglobin S, D levels and liver enzymes were monitored postoperatively.
Although the patient's intra- and postoperative courses were uneventful, an increased serum bilirubin was identified to be due to intrahepatic sinusoid congestion and subsequent cholestasis. Exchange transfusion was required to maintain HbS below 20% and reverse bilirubin levels to normal values.
Sickle cell anemia is a rare cause of cholestasis after major hepatic surgery. To our knowledge, this case is the only documented incidence of IHC following major hepatectomy that was effectively treated with exchange transfusion.
Transplantation Proceedings 07/2006; 38(5):1385-6. · 1.00 Impact Factor
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T Kato,
J J Gaynor,
S Nishida,
N Mittal,
G Selvaggi,
D Levi,
J Moon,
J Thompson,
P Ruiz, J Madariaga,
A G Tzakis
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ABSTRACT: The small bowel has been successfully transplanted in patients with irreversible intestinal failure. This report aims to describe endoscopic monitoring of small bowel rejection.
A magnification endoscope (zoom endoscope) was used in this study. In the first part of the study (October 1998 to March 2000, 271 endoscopy sessions), the specific endoscopic findings that correlated with rejection were determined. An analysis then was performed on data from the second period (March 2001 to November 2002, 499 sessions) to evaluate the zoom endoscope's accuracy in monitoring rejection.
Specific endoscopic findings of rejection found in the first period included background erythema, villous congestion, blunted villous tip, and shortened villous height. When the rejection was successfully treated, endoscopic appearance returned to normal. On the basis of these findings, five endoscopic criteria (villous shortening, villous blunting, background erythema, villous congestion, and mucosal friability) were used to score endoscopic sessions in the second period. Endoscopic diagnosis of rejection was compared with histology. Adult patients showed a sensitivity of 45%, a specificity of 98%, a positive predictive value of 82%, and a negative predictive value of 88%. In pediatric patients, these values were, respectively, 61%, 84%, 57%, and 86%. On 59 distinct occasions (30 in period 1 and 29 in period 2) in which the results were endoscopy negative yet biopsy positive (mild) for rejection, we elected not to treat these rejections on the basis of clinical evaluation, and 58 (98%) resolved without further therapy.
With the use of magnification, endoscopy is a useful tool for monitoring acute rejection in the small bowel allograft.
Surgical Endoscopy 06/2006; 20(5):773-82. · 4.01 Impact Factor
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T Kato,
H Yoshida,
K Sadfar,
E Martinez,
S Nishida,
J Moon, J Madariaga,
G Selvaggi,
D Levi,
P Ruiz,
E Schiff,
A Tzakis
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ABSTRACT: Recurrence of hepatitis C (HepC) has been a most difficult dilemma in liver transplantation (OLT) because the effects of immunosuppression with steroid, mycophenolate mofetil (MMF) calcineurin antagonists, and anti-interleukin-2 antibody as well as the role of preemptive antiviral therapy are uncertain. In this study, we randomized OLT recipients with HepC into two treatment arms: tacrolimus+daclizumab+MMF (study arm) versus tacrolimus+steroids+MMF (control arm). The study arm only received steroids for the treatment of biopsy-proven rejection episodes. Both arms received preemptive anti-viral therapy with Pegasys and ribavirin. The 39 enrolled patients (among 50 to be enrolled) have median follow-up of 458 days with 23 patients (8 in study arm, 15 in control arm) having reached 1 year. The incidences of rejection episodes within 0 to 3 months, 3 to 6 months, and 6 to 12 months were (study vs control): 0% vs 28%; 0% vs 6%; and 13% vs 20%; respectively (P = NS). The 1-year protocol biopsies showed advanced fibrosis (stage 3 or greater) in 20% (3 of 15) of the control arm, but none (0 of 7) of the study arm (P = NS). We compared anticipated side effects of steroids in the first 3 months (study vs control): hypertension (36% vs 58%, P = NS), PTDM (7% vs 43%, P = .02), and wound infections (14% vs 37%, P = NS). In conclusion, liver transplant recipients with HepC tolerate a steroid-free protocol. There was a trend toward reduced steroid side effects and a lower incidence of advanced fibrosis in 1-year biopsy samples among patients receiving the steroid-free protocol.
Transplantation Proceedings 04/2005; 37(2):1217-9. · 1.00 Impact Factor
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ABSTRACT: Adequate immune suppression following liver transplantation in recipients with recurrence of hepatitis C virus (HCV) is not standardized. The aim of this study was to evaluate the association between immune suppression protocol and the clinical/histological parameters in HCV transplant recipients with an HCV recurrence.
A retrospective analysis was performed on recipients of liver transplants from June 1998 to October 2003 who experienced HCV recurrence. Only patients with liver biopsies at 3 to 5 years following liver transplantation were included in the analysis. The data set included: patient demographics, immune suppression, antiviral therapies, as well as histology to evaluate ductopenia and chronic rejection. Patients divided into groups of high, medium, and low immune suppression were subdivided by treatment with versus without interferon. A control group with similar demographics suffering from cryptogenic cirrhosis was used for comparison.
During this period 45 patients had liver biopsies at 3 to 5 years posttransplantation. Their mean age was 56.5 years and mean time from transplant to biopsy was 1543 days. Their average posttransplant survival was 1964 days. There was no difference among the three groups with respect to HCV RNA levels (log(10) IU/mL), age, gender, time from transplant, donor age, and UNOS status. Median HCV RNA levels within the three groups were comparable at various time periods pre- and posttransplant.
The development of chronic allograft damage following transplantation in recipients with recurrent HCV tended to be worse among patients with low levels of immune suppression, suggesting the importance of therapy to maintain allograft function.
Transplantation Proceedings 01/2005; 36(10):3065-7. · 1.00 Impact Factor
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ABSTRACT: Liver transplant recipients with allograft failure due to recurrent hepatitis C virus (HCV) infection often develop marked muscle wasting and ascites prior to death and are denied repeat liver transplantation. We sought to determine whether topical testosterone therapy is associated with improved muscle mass and survival in patients with chronic allograft failure post-liver transplant.
We performed a retrospective review of liver transplant recipients with chronic allograft failure. Group 1 patients were treated for >6 months with testosterone gel 1%; group 2 patients were untreated.
Fourteen patients were identified with stage 3 or 4 fibrosis, muscle wasting, and allograft failure due to recurrent HCV. Group 1 (n=9) patients had statistically significant improvement in albumin, testosterone, muscle strength, well-being, and MELD/CTP scores, while there was no improvement seen for any of these parameters in group 2 (n=5). There were no deaths in group 1, while four of five patients in group 2 died on average 84 days posttransplant. Adverse effects of testosterone treatment included lower extremity edema (which resolved upon dose adjustment), hypertension, and pruritus.
Topical testosterone gel appears to increase muscle strength, stimulate albumin synthesis, and improve survival in patients with allograft failure post-liver transplant.
Transplantation Proceedings 01/2005; 36(10):3071-4. · 1.00 Impact Factor
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ABSTRACT: Surgical principles and techniques derived from organ transplantation surgery can provide novel applications in general surgery. We present an update on our 5-year experience with intestinal autotransplantation and abdominal wall transplantation. Nine patients underwent intestinal or multivisceral transplantation with the addition of 10 abdominal wall grafts to cover the large open areas from previous surgeries. Seven patients underwent near-total abdominal evisceration, ex vivo resection of masses at the base of the mesentery, followed by intestinal autotransplantation; 44% of the abdominal wall graft recipients are alive, but none of the fatalities were related to the graft itself. In two cases the graft had to be removed due to venous thrombosis. Of patients with intestinal autotransplants, 71% are alive with two mortalities due to recurrent metastatic malignancy. In only one case, the intestinal autograft had to be removed because of venous thrombosis. All surviving patients but one are on a regular diet; two are on supplemental enteral feeds. These results show that anastomotic and resection techniques derived from the experience in solid organ transplant can be utilized in complex wound closure, as is the case of abdominal wall transplantation, or resection of large retroperitoneal tumors with intestinal autotransplantation.
Transplantation Proceedings 07/2004; 36(5):1561-3. · 1.00 Impact Factor
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ABSTRACT: Arterial reconstruction remains the most important technical issue in paediatric transplantation. The arteries of paediatric donors as well as recipients are small and friable. The aim of this study was to assess the use of the donor aorta as a conduit for arterial reconstruction in paediatric liver and multivisceral transplantation.
Between June 1994 and January 2002, 284 paediatric transplants, including 197 cadaveric liver and multivisceral transplants, were performed in children at this centre. Of these, 41 (20.8 per cent), including nine cadaveric liver transplants and 32 multivisceral transplants, were revascularized by donor aortic reconstruction. Patient demographics, types of donor arterial reconstruction, technical complications and incidence of hepatic artery thrombosis were reviewed.
None of the 41 donor aortic reconstructions used in revascularization of paediatric liver and multivisceral transplants thrombosed. There were no bleeding complications and no pseudoaneurysms developed.
Arterial reconstruction using donor aorta is a useful option with a low incidence of thrombosis in paediatric transplantation.
British Journal of Surgery 07/2004; 91(6):705-8. · 4.61 Impact Factor
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P Ruiz,
M F Soares,
M Garcia,
M Nicolas,
T Kato,
N Mittal,
S Nishida,
D Levi,
G Selvaggi, J Madariaga,
A Tzakis
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ABSTRACT: Posttransplant lymphoproliferative disorders (PTLD) are a frequent complication in bowel transplant recipients. Histological changes in PTLD range from expansile lymphoplasmacytic (LP) hyperplasia to frank lymphoma. Small bowel allograft biopsies obtained in the first 250 days posttransplant were retrospectively graded after patients had received induction immunosuppression with either anti-CD52 (Campath) or anti-CD25 (Zenapax) monoclonal antibodies. The biopsies were analyzed with respect to the onset intensity of lymphoplasmacytic infiltrates and presence of in situ EBV hybridization (EBER) positivity. We observed that lymphoplasmacytic infiltrates were a frequent change in all bowel transplant patients over the examined period. Campath-treated patients developed earlier LP infiltrates of mild to moderate intensity between day 1 and 100 posttransplant, thereafter decreasing to mild. No EBER positivity was detected in this group. Zenapax-treated patients presented with LP infiltrates later of mild to moderate intensity through day 100 posttransplant. However, more persistent and intense LP infiltrates was observed after day 101 in this group, including a case of lymphoma and two cases of EBER positivity. We conclude that Campath immunosuppression results in an earlier appearance of LP lesions that are generally less intense than those evident with Zenapax. We attribute these findings to the more profound immunodeficiency and cell targeting following Campath treatment.
Transplantation Proceedings 04/2004; 36(2):386-7. · 1.00 Impact Factor
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ABSTRACT: Acute allograft rejection (AR) is a major contributor to morbidity and mortality among patients who undergo multivisceral transplantation. Critical to the assessment of AR is detection of apoptosis in the glandular epithelium of the gastrointestinal allograft. We utilized the TUNEL stain (TdT-mediated biotin 16-dUTP nick-end labeling) to test whether this method improved detection of apoptosis compared to standard slide evaluation. TUNEL and H&E stains were performed on paraffin-embedded tissue sections to estimate the number of apoptotic bodies per 10 high power fields, as determined by independent pathologists in blinded fashion. Both methodologies showed similar numbers and distributions of apoptotic foci present among the epithelial cells. There was a correlation between the number of apoptosis and the grade of rejection (P <.001). This is the first use of the TUNEL stain in gastrointestinal allograft biopsies to our knowledge. The similarity in pattern and sensitivity of TUNEL with standard morphology confirms that biopsy assessment with routine H&E staining allows an accurate appraisal of epithelial cell apoptosis. Therefore, current staining protocols for endoscopically derived mucosal biopsies of gastrointestinal allografts are sufficiently accurate to enumerate the critical feature of epithelial apoptosis as a determinant of the grade of acute rejection.
Transplantation Proceedings 03/2004; 36(2):338-9. · 1.00 Impact Factor
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A G Tzakis,
P Tryphonopoulos,
T Kato,
S Nishida,
D M Levi,
J R Nery, J Madariaga,
W De Faria,
N Mittal,
J F Thompson,
P Ruiz
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ABSTRACT: Campath-1H is being used as induction immunosuppression for intestinal/multivisceral transplantation. Patient and graft survival in this preliminary experience is similar to previous studies but there has been a significant decrease in the incidence and severity of acute rejections without increase of opportunistic infections. Collage of the abdominal wall (transplantation of a composite graft of the abdominal wall) can provide biologic coverage of the newly transplanted abdominal organs if necessary. Partial abdominal exenteration, ex vivo resection, and intestinal autotransplantation may be useful in removing otherwise unresectable lesions of the root of the mesentery.
Transplantation Proceedings 09/2003; 35(5):1925-6. · 1.00 Impact Factor
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C Loinaz,
T Kato,
S Nishida,
D Weppler,
D Levi,
L Dowdy, J Madariaga,
J R Nery,
R Vianna,
N Mittal,
A Tzakis
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ABSTRACT: The frequency of bacterial infections (BI) in intestinal transplant (IT) patients is high with sepsis being the leading cause of death after this procedure. We herein report our experience with major BI to ascertain the incidence, microbiological and clinical factors, risk factors and outcome.
124 patients (72 children and 52 adults) received 135 grafts: namely, 39 isolated intestine, 33 liver-intestine and 63 multivisceral. Only major BI were considered, namely, those associated with serious morbidity/mortality requiring specific therapy. Patient data were retrieved from computerized databases, flow-charts, and medical records.
92.7% patients showed BI. There were 327 episodes, representing 2.6 episodes/patient (2.8/patients with infection): 193 episodes of bacteremia (1.7/patient with BI) including 29.5% due to catheter related sepsis, 16.5% from abdominal source, 5.7% from respiratory origin and 4.1% from the wound. The organ locations includes 46 respiratory infections, 33 intraabdominal abscesses or infected fluid collections, 8 diffuse peritonitis, 34 wound infections and other miscellaneous sites: empyema, soft tissue infections, cholangitis em leader etc. Median time of infection was nine days after surgery (mean 22+/-3 days), with 67.7% patients having at least one BI before the end of the first month. Infection was present in 76.2% of the 63 deceased patients. An infectious episode during month 1, a clinically manifest abdominal infection and a positive intraabdominal culture had negative impacts on patient survival.
BI are common and early complications after IT. The high rate of bacteremia, line sepsis and abdominal and respiratory infections reflect the recipient's condition, with chronic deterioration superimposed with the effects of prolonged abdominal visceral surgery.
Transplantation Proceedings 09/2003; 35(5):1929-30. · 1.00 Impact Factor
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Transplantation Proceedings 09/2002; 34(5):1889-91. · 1.00 Impact Factor
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Transplantation Proceedings 06/2002; 34(3):910. · 1.00 Impact Factor
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Transplantation Proceedings 06/2002; 34(3):913. · 1.00 Impact Factor
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Transplantation Proceedings 06/2002; 34(3):868. · 1.00 Impact Factor
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A G Tzakis,
T Kato,
N Mittal,
J F Thompson,
S Nishida,
D Levi,
J Nery,
W De Faria,
A Pinna, J Madariaga,
P Ruiz
Transplantation Proceedings 06/2002; 34(3):908-9. · 1.00 Impact Factor
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Transplantation Proceedings 06/2002; 34(3):937. · 1.00 Impact Factor
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Transplantation Proceedings 06/2002; 34(3):957. · 1.00 Impact Factor
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Transplantation Proceedings 06/2002; 34(3):961-2. · 1.00 Impact Factor
