Alan N Langnas

University of Nebraska at Omaha | UN Omaha · Department of Surgery

Importance A new liver allocation policy was implemented by United Network for Organ Sharing (UNOS) in February 2020 with the stated intent of improving access to liver transplant (LT). There are growing concerns nationally regarding the implications this new system may have on LT costs, as well as access to a chance for LT, which have not been cap...

Importance Normothermic regional perfusion (NRP) is an emerging recovery modality for transplantable allografts from controlled donation after circulatory death (cDCD) donors. In the US, only 11.4% of liver recipients who are transplanted from a deceased donor receive a cDCD liver. NRP has the potential to safely expand the US donor pool with impro...

Background Normothermic regional perfusion (NRP) is a technique that is intended to enhance organ transplant outcomes from donation circulatory death (DCD) donors. Study Design A retrospective analysis of data from the Scientific Registry of Transplant Recipients (SRTR) was performed. DCD donors were screened for inclusion based on date of donatio...

Background/aims: Hepatocellular carcinoma (HCC) recurrence following liver transplantation (LT) is highly morbid and occurs despite strict patient selection criteria. Individualized prediction of post-LT HCC recurrence risk remains an important need. Methods: Clinico-radiologic and pathologic data of 4981 patients with HCC undergoing LT from the...

NAFLD will soon be the most common indication for liver transplantation (LT). In NAFLD, HCC may occur at earlier stages of fibrosis and present with more advanced tumor stage, raising concern for aggressive disease. Thus, adult LT recipients with HCC from 20 US centers transplanted between 2002 and 2013 were analyzed to determine whether NAFLD impa...

Objective: To define benchmark values for liver transplantation (LT) in patients with perihilar cholangiocarcinoma (PHC) enabling unbiased comparisons. Background: Transplantation for PHC is used with reluctance in many centers and even contraindicated in several countries. While benchmark values for LT are available, there is a lack of specific...

Background: Previous cholecystectomy is common in patients with short bowel syndrome (SBS). An intact gallbladder is beneficial in preventing cirrhosis in SBS patients, but the nutritional consequences of cholecystectomy are largely unknown. Our aim was to evaluate the effect of pre-SBS cholecystectomy on need for chronic parenteral nutrition (PN)...

Background: Pediatric myelodysplastic syndrome is a rare but life-threatening condition requiring prompt recognition and management. Methods: We herein present the only reported case of a pediatric multi-organ transplant recipient developing myelodysplastic syndrome. Results: The patient was a 14-year-old girl on chronic calcineurin inhibitor...

Persistent interest in controlled donation after circulatory death (cDCD) liver transplantation exists due to supply-demand discrepancy for liver allografts. In the United States over 2000 patients die or become too sick while awaiting liver transplant annually. cDCD liver transplantation has increased the source of donor organs; however, is associ...

The incidence of hepatocellular carcinoma (HCC) is growing in the US, especially among the elderly. Older patients are increasingly getting transplanted for HCC, but the impact of advancing age on long‐term post‐transplant outcomes is not clear. To study this, we used data from the US Multicenter HCC Transplant Consortium (UMHTC) of 4980 patients....

Ingestion of rare‐earth magnet beads in children has been a public health concern. The potential risk of swallowing multiple magnets is related to magnet attraction to each other, resulting in serious gastrointestinal complications, such as entero‐enteric fistula formation, peritonitis, bowel ischemia or necrosis, bowel perforation, and potentially...

Background and aims: The Organ Procurement and Transplantation Network recently approved liver transplant (LT) prioritization for patients with hepatocellular carcinoma (HCC) beyond Milan Criteria (MC) who are down-staged (DS) with locoregional therapy (LRT). We evaluated post-LT outcomes, predictors of down-staging, and the impact of LRT in patie...

Objective: The aim of the study was to determine the rate, predictors, and impact of complete pathologic response (cPR) to pretransplant locoregional therapy (LRT) in a large, multicenter cohort of hepatocellular carcinoma (HCC) patients undergoing liver transplantation (LT). Background: LRT is used to mitigate waitlist dropout for patients with...

Background: Post-Transplant Lymphoproliferative Disease (PTLD) is a heterogeneous disease that arises as a complication after solid organ transplants (SOT) and unusually after bone marrow transplants (BMT). PTLD is generally of recipient origin in SOT patients and donor origin in BMT patients. Knowing the cellular origin of PTLD may provide insight...

Background: No published study has explored gender differences in letters of recommendation for applicants entering surgical subspecialty fellowships. Methods: We conducted a retrospective review of letters of recommendation to a transplant surgery fellowship written for residents finishing general surgery residency programs. A dictionary of com...

Background: C. difficile is the most common cause of healthcare-associated infectious diarrhea. Risk factors for C. difficile infections (CDI) in intestinal transplant recipients (ITR) are not well defined. The aim of our study was to assess specific risk factors for CDI in ITR. Methods: This is a 1:3 case-control study that included 29 ITR who...

Objective: To evaluate the effect of pretransplant bridging locoregional therapy (LRT) on hepatocellular carcinoma (HCC) recurrence and survival after liver transplantation (LT) in patients meeting Milan criteria (MC). Summary background data: Pre-LT LRT mitigates tumor progression and waitlist dropout in HCC patients within MC, but data on its...

Background: Postresection intestinal adaptation is an augmented self-renewal process that might increase the risk of malignant transformation in the intestine. Furthermore, patients with short bowel syndrome (SBS) have other characteristics that might increase this risk. Our aim was to determine the incidence of new intestinal malignancy in SBS pat...

Background: Postresection intestinal adaptation is an augmented self-renewal process that might increase the risk of malignant transformation in the intestine. Furthermore, patients with short bowel syndrome (SBS) have other characteristics that might increase this risk. Our aim was to determine the incidence of new intestinal malignancy in SBS pa...

Background: Recently, an association has been proposed between cholecystectomy and various liver diseases. Our aim was to determine whether cholecystectomy in short bowel patients influences the risk of liver disease. Methods: We reviewed 422 adults: 182 underwent cholecystectomy prior to short bowel, 102 after developing short bowel, and 138 pa...

Compensation models for physicians are currently based primarily on the work relative value unit (wRVU) that rewards productivity by work volume. The value-based payment structure soon to be ushered in by the Centers for Medicare and Medicaid Services rewards clinical quality and outcomes. This has prompted changes in wRVU value for certain service...

The American Society of Transplantation (AST) and American Society of Transplant Surgeons (ASTS) convened a workshop on June 2-3, 2014, to explore increasing both living and deceased organ donation in the United States. Recent articles in the lay press on illegal organ sales and transplant tourism highlight the impact of the current black market in...

The Registry has gathered information on intestine transplantation (IT) since 1985. During this time, individual centers have reported progress but small case volumes potentially limit the generalizability of this information. The present study was undertaken to examine recent global IT activity. Activity was assessed with descriptive statistics, K...

A paediatric liver transplant programme was started at the Wits Donald Gordon Medical Centre, Johannesburg, South Africa (SA), in November 2005. We reported on the first 29 patients in 2012. Since then we have performed a further 30 transplants in 28 patients, having met the major challenge of donor shortage by introducing a living related donor pr...

Background: A paediatric liver transplant programme was started at the Wits Donald Gordon Medical Centre, Johannesburg, South Africa (SA), in November 2005. We reported on the first 29 patients in 2012. Since then we have performed a further 30 transplants in 28 patients, having met the major challenge of donor shortage by introducing a living rel...

Background: Sepsis is a serious complication of solid organ transplant (SOT). Evidence on survival differences between SOT recipients and non-SOT patients with sepsis is lacking. Methods: This was a matched, case-control propensity-adjusted study. Conditional logistic regression was performed for risk factor analysis, and Cox proportional hazard...

Aplastic anemia (AA) has been observed in nearly a third of patients undergoing liver transplantation (LT) for non-A-E fulminant hepatic failure (FHF). Few of these patients have been successfully managed with sequential LT and bone marrow transplantation (BMT). No causative agent has been identified for the FHF or AA in these reported cases. At ou...

Multivisceral transplant is technically one of the most complex surgical procedures. It is primarily indicated in patients with life-threatening complications of intestinal failure. These patients are chronically ill, malnourished, have had multiple abdominal operations, and also have challenging vascular access. This chapter describes the techniqu...

Background: We aimed to evaluate and quantify the risk of serious opportunistic infections after induction with polyclonal antibodies versus IL-2 receptor antagonists (IL-2RAs) in randomized clinical trials. Methods: PRISMA guidelines were followed and random-effects models were performed. Results: 70 randomized clinical trials (10,106 patients) we...

Background: Induction immunosuppression with anti-thymocyte globulin (ATG) provides potential benefits after liver transplantation (LT). However, its use in patients with LT and hepatitis C (HCV) is controversial. Aim: To evaluate the 1- and 2-year patient survival and HCV recurrence rate in patients receiving ATG during the induction phase of i...

Obese patients developing short bowel syndrome (SBS) maintain a higher body mass index (BMI) and have increased risk of hepatobiliary complications. Our aim was to determine the effect of pre-resection gastric bypass (GBP) on SBS outcome. We reviewed 136 adults with SBS: 69 patients with initial BMI < 35 were controls; 43 patients with BMI > 35 wer...

GVHD has been reported in 8-10% of children after small bowel transplant (SBTx). Immunodeficient children may be predisposed to aggressive, steroid-resistant GVHD. There exists a unique association of immunodeficiency in children with MIA (MIAI). We report on our SBTx experience in patients with the diagnosis of MIAI, their high incidence of GVHD,...

Despite its vast potential, concerns about donor safety continue to limit the expansion of living-donor liver transplantation (LDLT) in Western countries. In light of the technical refinements, relatively lower risk of complications with left lobe (LL) LDLT with comparable outcomes, and the overriding concern for donor safety, there is renewed inte...

To analyze the effects of serial transverse enteroplasty (STEP) on parenteral and enteral calories in children with short bowel syndrome, and examine short- and long-term complications. A retrospective analysis of prospectively-collected data from a large single center cohort of patients undergoing STEP procedure was analyzed. Baseline demographic...

To examine treatment outcomes in pediatric patients with ultrashort small bowel (USSB) syndrome in an intestinal rehabilitation program (IRP). We reviewed IRP records for 2001-2011 and identified 28 children with USSB (≤20 cm of small bowel). We performed univariate analysis using the Fisher exact test and Wilcoxon rank-sum test to compare characte...

AIHA is a rare and serious complication of solid organ transplantation. Herein, we report four cases of warm or mixed AIHA in pediatric patients following combined liver, small bowel and pancreas transplant. The hemolysis was refractory to multiple treatment modalities including steroids, rituximab, IVIG, plasmapheresis, cytoxan, discontinuation of...

Intestinal transplantation (IT) has become a standard treatment for patients with intestinal failure and complications of parenteral nutrition. The pool of intestinal transplant recipients has been slowly growing over the last two decades. Of the 2191 ITs performed between 1 January 1990 and 31 March 2012, 50.5% were children less than 10 years of...

BACKGROUND: Valganciclovir was approved by the FDA in 2004 for cytomegalovirus (CMV) prophylaxis except for liver recipients because of their high incidence of CMV disease with this drug. However, surveys show its common off-label use for CMV prophylaxis in liver recipients. We aimed to evaluate the risk of CMV disease with valganciclovir prophylax...

Patients developing the short bowel syndrome (SBS) are at risk for hepatobiliary disease, as are morbidly obese individuals. We hypothesized that morbidly obese SBS individuals would be at increased risk for developing hepatobiliary complications. We reviewed 79 patients with SBS, 53 patients with initial body mass index (BMI) < 35 were controls. T...

Advanced intra-abdominal desmoids tumors present with severe symptoms, complications or rapid growth, which lead to adverse outcomes. Our aim was to evaluate the treatment and outcome of patients with advanced intra-abdominal desmoids tumors, and develop guidelines for surgical management of these patients. We reviewed the clinical courses of 21 ad...

Objectives: Intestinal failure-associated liver disease (IFALD) is a multifactorial process, which can culminate in cirrhosis and need for transplantation. Fish oil-based lipid emulsions (FOE) reportedly reverse hyperbilirubinemia, but there are little data on their effect on the histopathology of IFALD. Methods: We blindly examined sequential l...

Background: Solid organ transplant recipients require lifetime immunosuppression and are highly susceptible to opportunist and non-opportunistic infections. Sepsis is a serious post-transplant complication and physicians commonly assume that survival from sepsis in transplant recipients is worse than survival in non-transplant patients, but evidenc...

Background: Nosocomial bloodstream infections (BSIs) are frequently reported after solid organ transplantation, however, the data is limited regarding their impact on survival outcome. Our objective was to evaluate if survival was affected by the presence versus the absence of nosocomial infections (infections occurring greater than 48h after hos...

Liver transplantation (LTx) is a life-saving treatment of end-stage liver disease. Cardiac complications including heart failure (HF) are among the leading causes of death after LTx. The aim is to identify clinical and echocardiographic predictors of developing HF after LTx. Patients who underwent LTx at the University of Nebraska Medical Center (U...

Data on immunosuppressant adherence of community-dwelling adult solid-organ transplant recipients (SOTRs) from rural populations in the United States are limited. Therefore, understanding the association of rurality and other factors of immunosuppressant adherence will help providers design and deliver patient-centered adherence enhancing intervent...

Little information regarding bloodstream infections (BSIs) in small bowel transplantation has been published. We reviewed the medical records of 98 pediatric patients who underwent small bowel transplantation. Patients' characteristics were analyzed with Wilcoxon rank-sum, χ or Fisher's exact tests. We estimated the overall survival by the Kaplan-M...

Incentives for organ donation, currently prohibited in most countries, may increase donation and save lives. Discussion of incentives has focused on two areas: (1) whether or not there are ethical principles that justify the current prohibition and (2) whether incentives would do more good than harm. We herein address the second concern and propose...

Florescu DF, Langnas AN, Grant W, Mercer DF, Botha J, Qiu F, Shafer L, Kalil AC. Incidence, risk factors, and outcomes associated with cytomegalovirus disease in small bowel transplant recipients. Abstract: Despite improved prophylaxis, monitoring, and more efficient immunosuppression, CMV infection remains a common opportunistic infection in trans...

Massive small bowel infarction in pregnancy is rare but has devastating complications. Diagnosis is difficult because pregnancy masks the symptoms. Our aim was to assess risk factors and outcomes of massive resection associated with pregnancy. We conducted a review of nine patients with short bowel syndrome (SBS) secondary to massive bowel resectio...

More data on the risk factors and outcomes after Staphylococcus aureus infections in liver transplantation are needed. Liver recipients with S. aureus infections (cases) were retrospectively identified and compared to gender-, age-, and transplant type-matched (1:2) non-S. aureus-infected controls. Risk factors associated with S. aureus infections...

Fungal infections are an important cause of morbidity and mortality after small bowel transplantation (SBT). Little information about risk factors for Candida infections in pediatric SBT is available. We performed a 1:1 matched retrospective case-control study including 23 Candida culture-positive patients (cases) and 23 culture-negative patients (...

No studies have evaluated the risk factors and outcomes of Staphylococcus aureus (SA) infections in small bowel (SBT) and multivisceral (including small bowel) transplantation (MVT). SBT and MVT recipients with SA infections (22 cases) were retrospectively identified and compared with matched non-SA-infected recipient controls (44). The characteris...

Patients developing short bowel syndrome (SBS) are at risk for hepatobiliary complications. Radiation enteritis and radiation-induced liver disease are potential complications of radiation therapy (XRT). The authors hypothesized that SBS patients with a history of abdominal XRT would be at increased risk for hepatobiliary complications. The authors...

Background Obese patients developing short bowel syndrome (SBS) maintain a higher body mass index (BMI) and have increased risk for hepatobiliary complications. Our aim was to determine the effect of pre resection gastric bypass (GBP) on SBS outcome. Methods We reviewed 136 adults with SBS: 69 patients with initial BMI <35 were controls; 43 with B...

Small intestine transplantation is the only life-saving therapy available for patients with intestinal failure and life-threatening complications of parenteral nutrition, but it is still plagued by high levels of early acute rejection. The ability to diagnose rejection noninvasively, ideally before pathologic manifestations, would be a major advanc...

Like all other areas of transplantation, vascularized composite allografts (VCA) has the capacity to transform the lives of patients, for the better or for the worse. It is this duality that mandates VCA be performed in centers prepared for the intricacies accompanying other transplant procedures. Similarly, the complexities of VCA require that the...

Data on the incidence, timing, and outcome of fungal infections in pediatric small bowel transplantation (SBT) are lacking. Cases of pediatric SBT from January 2003 through December 2007 were collected. Standard induction was with thymoglobulin and/or basiliximab and maintenance immunosuppression was a tacrolimus-based regimen. Chi-square was used...

Limited information regarding the usefulness of bowel lengthening in adult patients with short bowel syndrome is available. Retrospective review of a single center series of intestinal lengthening over 15-year period in patients ≥ 18 years old. Twenty adult patients underwent Bianchi (n = 6) or serial transverse enteroplasty (STEP) (n = 15). Median...

Adult-to-adult living donor liver transplantation (AA-LDLT) has better outcomes when a graft weight to recipient weight ratio (GW/RW) > 0.8 is selected. A smaller GW/RW may result in small-for-size syndrome (SFSS). Portal inflow modulation seems to effectively prevent SFSS. Donor right hepatectomy is associated with greater morbidity and mortality...

Adenovirus is commonly isolated from pediatric small bowel transplant recipients, but its clinical consequences remain poorly understood. The medical records of pediatric small bowel transplant recipients transplanted between January 2003 and December 2007 were reviewed. Thymoglobulin and basiliximab induction and tacrolimus-based immunosuppression...

Improving short-term results with intestine transplantation have allowed more patients to benefit with nearly 700 patients alive in the United States with a functioning allograft at the end of 2007. This success has led to an increase in demand. Time to transplant and waiting list mortality have significantly improved over the decade, but mortality...

Small bowel transplantation provides a potentially life-saving treatment of severe intestinal failure. Lack of a noninvasive marker of disease makes diagnosis of rejection dependent on frequent endoscopy and biopsy. We hypothesized that increased plasma nitrite and nitrate (NOx) levels measured after small bowel transplant would be associated with...

Adult-to-adult living donor liver transplantation is an accepted treatment option for patients with end-stage liver disease. It is generally acknowledged that a graft weight to recipient body weight ratio > 0.8 is required in order to prevent the development of small-for-size syndrome. Size mismatch, however, is not the only factor responsible for...

The American Society of Transplant Surgeons (ASTS) was asked to endorse the 'The Declaration of Istanbul on Organ Trafficking and Transplant Tourism.' The document has been reviewed by the ASTS Ethics Committee and their ensuing report was presented, discussed and approved by the ASTS Council. The ASTS vigorously supports the principles outlined in...

New strategies that modify the coagulation/inflammatory cascades may be applicable to solid organ transplant (SOT) recipients in the treatment of complications. However, data on kinetics of post-SOT cascades are needed before considering these strategies. Prospectively collected pre-transplant serum measurements of inflammatory (high-sensitive C-re...

Early approaches to intestinal failureHistory of intestinal transplantationReferences

Intestinal failure is a challenging, emerging field that has been the subject of much research and debate in recent years and has only recently become widely accepted as a distinct clinical syndrome. This comprehensive book provides an in-depth review of scientific theory and clinical practice relating to intestinal failure with specific emphasis o...

The optimal dosing protocol for rabbit anti-thymocyte globulin (rATG) induction in renal transplantation has not been determined, but evidence exists that rATG infusion before renal allograft reperfusion improves early graft function. Infusing a large rATG dose over a short interval has not previously been evaluated for its effect on renal function...

Feasibility of repeat lengthening has been demonstrated in animals, but in humans, none of the three clinical case reports have achieved enteral autonomy after secondary lengthening with serial transverse enteroplasty (STEP). Institutional Review Board approved retrospective review of a single center series of repeat intestinal lengthening after pr...

To characterize infection control experience during a 6.5-year period in a cooperative care center for transplant patients. Descriptive analysis. A cooperative care center for transplanted patients, in which patients and care partners are housed in a homelike environment, and care partners assume responsibility for patient care duties. Nine hundred...

Review the clinical results of 24 years of intestinal lengthening procedures at one institution. Retrospective review of a single center experience comparing the outcome of 2 intestinal lengthening procedures (Bianchi and serial transverse enteroplasty [STEP]) in terms of survival, total parenteral nutrition (TPN) weaning, and complications. Sixty-...

To identify a noninvasive screening test for intestinal allograft monitoring. Intestinal allograft rejection is difficult to distinguish from other causes of diarrhea and can rapidly lead to severe exfoliation or death. Protocol biopsies are standard for allograft monitoring but may cause serious complications. No noninvasive test has shown clinica...

To analyze outcomes in children with intestinal failure treated by our Intestinal Rehabilitation Program (IRP) in a 4-year period. A total of 51 parenteral nutrition (PN)-dependent patients (20 male) were enrolled in the IRP. Median age was 1.7 years, with the primary diagnoses being gastroschisis, necrotizing enterocolitis, volvulus, and congenita...

This study examines the impact of donor liver macrovesicular steatosis on recurrence of hepatitis C virus (HCV) disease after liver transplantation. Between 1998 and 2004, 113 patients underwent liver transplantation for HCV-related cirrhosis. Time to histologic recurrence (fibrosis score >or=2) was the primary endpoint of the study. Recurrence was...

Consistent data for using CMV quantitative PCR (QnPCR) on initial presentation to predict outcomes after solid organ transplantation (SOT) are lacking. Recipients with measurable CMV QnPCR and either CMV-V (asymptomatic viremia) or CMV-D (symptomatic CMV infection) were analyzed over 24 months. Risk factors and outcomes were evaluated in relation t...

Mouse or human T cells developing in xenogeneic porcine thymus are functional. With efficient peripheral repopulation of mouse T cells by grafting fetal pig thymus (FP THY), B6 nude mice were immunized with inactivated syngeneic melanoma, B16 cells. Splenocytes from B16-immunized FP THY-grafted B6 nude mice efficiently killed B16, but not EL4 targe...

Differentiation and proliferation of haematopoietic progenitor cells occur in intimate contact with the bone marrow microenvironment which is composed of stromal cells and extracellular matrix proteins. MOP3 (also known as brain and muscle Arnt-like protein-1, BMAL1), a master regulator of circadian rhythm, plays important roles in the regulation o...

Everolimus is a macrolide immunosuppressive agent with known consistent absorption. In this double-blind study, we examined the safety and tolerability of everolimus vs. placebo in de novo liver transplant recipients. One hundred and nineteen liver allograft recipients were randomized to 1 of 4 groups: everolimus 0.5 mg bid, everolimus 1.0 mg bid,...

Hepatobiliary cancers are common worldwide and highly lethal. Hepatocellular carcinoma is the most common hepatobiliary malignancy and the seventh most common cancer worldwide. Gallbladder cancer is the most common biliary tract malignancy, accounting for approximately 5000 newly diagnosed cases in the United States. Cholangiocarcinomas are diagnos...