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Raveh Y, Raveh D, Nicolau-Raducu R. Point-of-Care Ultrasound Frailty Assessments: Comment. Anesthesiology 2022; 137:372-373. [PMID: 35834776 DOI: 10.1097/aln.0000000000004299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] [Imported: 08/29/2023]
Affiliation(s)
- Yehuda Raveh
- University of Miami/Jackson Memorial Hospital, Miami, Florida (Y.R.).
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Yehuda R, Ramona NR. Abdominal Pressure and Fluid Status After Kidney Transplantation. Kidney Int Rep 2022; 7:1727. [PMID: 35812287 PMCID: PMC9263241 DOI: 10.1016/j.ekir.2022.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 12/05/2022] [Imported: 08/29/2023] Open
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Raveh Y, Simkins J, Nicolau-Raducu R. Antigen testing and non-infectious shedding of SARS-COV-2. Infection 2021; 49:795-796. [PMID: 33566319 PMCID: PMC7874031 DOI: 10.1007/s15010-021-01579-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/18/2021] [Indexed: 11/28/2022] [Imported: 08/29/2023]
Affiliation(s)
- Yehuda Raveh
- Department of Anesthesia, Jackson Memorial Hospital, University of Miami, Miami, FL, USA.
| | - Jacques Simkins
- Division of Infectious Diseases, Department of Medicine, Miami Transplant Institute, University of Miami School of Medicine, Miami, FL, USA
| | - Ramona Nicolau-Raducu
- Department of Anesthesia, Jackson Memorial Hospital, University of Miami, Miami, FL, USA
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Raveh Y, Beduschi T, Hosein PJ, Vianna R, Tekin A, Selvaggi G, Nicolau-Raducu R. Intestinal Autotransplantation and In-Situ Resection of Recurrent Pancreatic Head Intraductal Tubulopapillary Neoplasm with Portal Cavernoma: A Case Report. Transplant Proc 2021; 53:2598-2601. [PMID: 34274118 DOI: 10.1016/j.transproceed.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/15/2021] [Accepted: 05/04/2021] [Indexed: 11/29/2022] [Imported: 08/29/2023]
Abstract
BACKGROUND Intraductal tubulopapillary neoplasm (ITPN) is a new entity of a rare premalignant pancreatic neoplasia, and a radical curative resection is indicated. As with other tumors of the root of the mesentery, the proximity of the lesion to large splanchnic vessels, abdominal aorta, and inferior vena cava poses major risks of a massive hemorrhage and visceral ischemia using conventional surgical techniques. At times, these lesions are amenable for resection using novel techniques developed from organ transplantation. Multivisceral (allo-) transplantation should be considered when radical resection of a benign tumor is likely to compromise portal flow and possibly precipitate acute liver failure, but it may be associated with a long waitlist time and tumor progression. Autotransplantation offers a safe and curative resection of otherwise inoperable tumors in a bloodless field, an excellent exposure, and prevention of warm ischemic injury to the affected viscera, which are then autotransplanted. METHODS We describe the en bloc resection of a large and recurrent ITPN of the pancreas, distal stomach, proximal duodenum, transverse colon, superior mesenteric vein, and portal cavernoma, followed by intestinal autotransplantation. RESULTS A complete tumor resection was achieved with negative margins, adequate cold preservation of the reimplanted intestine, and without significant hemorrhage. The patient was discharged from the hospital 10 days later. The histopathologic examination revealed free-margin resection of ITPN with an associated invasive carcinoma. The patient received adjuvant chemotherapy with folinic acid, fluorouracil, and oxaliplatin and remains disease-free 20 months after surgery. CONCLUSIONS Autotransplantation offers curative resection of otherwise unresectable lesions of the root of the mesentery.
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Affiliation(s)
- Yehuda Raveh
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida.
| | - Thiago Beduschi
- Department of Surgery, University of Florida, Gainesville, Florida
| | - Peter J Hosein
- Department of Medicine, Division of Hematology/Oncology, University of Miami/Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Rodrigo Vianna
- Department of Surgery, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Akin Tekin
- Department of Surgery, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Gennaro Selvaggi
- Department of Surgery, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Ramona Nicolau-Raducu
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
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Raveh Y, Simkins J, Vianna R, Tekin A, Nicolau-Raducu R. A Less Restrictive Policy for Liver Transplantation in Coronavirus Disease 2019 Positive Patients, Based Upon Cycle Threshold Values. Transplant Proc 2021; 53:1126-1131. [PMID: 33610305 PMCID: PMC7816591 DOI: 10.1016/j.transproceed.2021.01.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/06/2021] [Accepted: 01/14/2021] [Indexed: 02/06/2023] [Imported: 08/29/2023]
Abstract
Coronavirus disease 2019 drastically impacted solid organ transplantation. Lacking scientific evidence, a very stringent but safer policy was imposed on liver transplantation (LT) early in the pandemic. Restrictive transplant guidelines must be reevaluated and adjusted as data become available. Before LT, the prevailing policy requires a negative severe acute respiratory syndrome coronavirus 2 real-time polymerase chain reaction (RT-PCR) of donors and recipients. Unfortunately, prolonged viral RNA shedding frequently hinders transplantation. Recent data reveal that positive test results for viral genome are frequently due to noninfectious and prolonged convalescent shedding of viral genome. Moreover, studies demonstrated that the cycle threshold of quantitative RT-PCR could be leveraged to inform clinical transplant decision-making. We present an evidence-adjusted and significantly less restrictive policy for LT, where risk tolerance is tiered to recipient acuity. In addition, we delineate the pretransplant clinical decision-making, intra- and postoperative management, and early outcome of 2 recipients of a liver graft performed while their RT-PCR of airway swabs remained positive. Convalescent positive RT-PCR results are common in the transplant arena, and the proposed policy permits reasonably safe LT in many circumstances.
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Affiliation(s)
- Yehuda Raveh
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida.
| | - Jacques Simkins
- Department of Medicine, Division of Infectious Diseases, Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida
| | - Rodrigo Vianna
- Department of Surgery, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Akin Tekin
- Department of Surgery, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Ramona Nicolau-Raducu
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
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Raveh Y, Simkins J, Nicolau-Raducu R. Liver transplantation in COVID-19 positive patients. Am J Transplant 2021; 21:1978. [PMID: 33131211 PMCID: PMC9800490 DOI: 10.1111/ajt.16389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 10/09/2020] [Accepted: 10/26/2020] [Indexed: 01/25/2023] [Imported: 08/29/2023]
Affiliation(s)
- Yehuda Raveh
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA,
| | - Jacques Simkins
- Department of Medicine, Division of Infectious Diseases, Miami Transplant Institute, University of Miami School of Medicine, Miami, Florida, USA
| | - Ramona Nicolau-Raducu
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
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Raveh Y, Shatz V, Lindsay M, Nicolau-Raducu R. Disseminated intravascular coagulation during liver transplantation unleashed by protamine. J Clin Anesth 2019; 57:117-118. [DOI: 10.1016/j.jclinane.2019.04.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 03/29/2019] [Accepted: 04/10/2019] [Indexed: 11/29/2022] [Imported: 08/29/2023]
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Nicolau-Raducu R, Livingstone J, Salsamendi J, Beduschi T, Vianna R, Tekin A, Selvaggi G, Raveh Y. Visceral arterial embolization prior to multivisceral transplantation in recipient with cirrhosis, extensive portomesenteric thrombosis, and hostile abdomen: Performance and outcome analysis. Clin Transplant 2019; 33:e13645. [PMID: 31230385 DOI: 10.1111/ctr.13645] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 06/13/2019] [Indexed: 11/28/2022] [Imported: 08/29/2023]
Abstract
Multivisceral transplant (MVT) for cirrhosis, and portomesenteric vein thrombosis (PVT), is fraught with life-threatening thrombo-hemorrhagic complications. Embolization of native viscera has been attempted in a handful of cases with mixed results. We carried out a comparative analysis of angiographic, intra-operative, and pathological findings in three recipients of MVT who were deemed exceptionally high hemorrhagic risk and therefore underwent preoperative visceral embolization. All recipients were male with cirrhosis, PVT, and a surgical history indicative of diffuse visceral adhesions; status post-liver transplantation (n = 2) and proctocolectomy (n = 1). The first patient had two Amplatzer II embolization plugs placed 2 cm from the origins of celiac and superior mesenteric (SMA) arteries. Distal migration of the celiac plug into gastroduodenal artery (GDA) and ensuing ischemia reperfusion injury, presumably contributed to severe disseminated intravascular coagulation (DIC) and intra-operative mortality. In the other two recipients, distal Gelfoam embolization of the SMA, GDA, and splenic arteries was performed, and although remarkable hemorrhage and coagulopathy occurred, embolization, undoubtedly, facilitated exenteration and improved outcomes. Pathologic examination in these cases confirmed ischemic necrosis of eviscerated bowel. In conclusion, liver-sparing, preoperative distal embolization of native viscera with Gelfoam is beneficial, but entails several pitfalls. It should currently be reserved for MVT recipients who otherwise are at unacceptably high risk.
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Affiliation(s)
- Ramona Nicolau-Raducu
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Joshua Livingstone
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Jason Salsamendi
- Department of Interventional and Vascular Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Thiago Beduschi
- Department of Surgery, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Rodrigo Vianna
- Department of Surgery, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Akin Tekin
- Department of Surgery, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Gennaro Selvaggi
- Department of Surgery, Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
| | - Yehuda Raveh
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
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Raveh Y, Ciancio G, Burke GW, Figueiro J, Chen L, Morsi M, Namias N, Singh BP, Lindsay M, Alfahel W, Sleem MS, Nicolau-Raducu R. Susceptibility-directed anticoagulation after pancreas transplantation: A single-center retrospective study. Clin Transplant 2019; 33:e13619. [PMID: 31152563 DOI: 10.1111/ctr.13619] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 05/09/2019] [Accepted: 05/28/2019] [Indexed: 02/06/2023] [Imported: 08/29/2023]
Abstract
Pancreas transplant achieves consistent long-term euglycemia in type 1 diabetes. Allograft thrombosis (AT) causes the majority of early graft failure. We compared outcomes of four anticoagulation regimens administered to 95 simultaneous kidney-pancreas or isolated pancreas transplanted between 1/1/2015 and 11/20/2018. Early postoperative anticoagulation regimens included the following: none, subcutaneous heparin/aspirin, with or without dextran, and heparin infusion. The regimens were empirically selected based on each surgeon's assessment of hemostasis of the operative field and personal preference. A sonographic-based global scoring system of AT is presented. The 47-month recipients and graft survival were 95% and 86%, respectively. Recipients with or without AT had similar survival. Five and four grafts were lost due to death and AT, respectively. Outcomes of prophylaxis regimens correlated with intensity of anticoagulation. Compared with no anticoagulation, an increase in hemorrhagic complications occurred exclusively with iv heparin. The higher arterial AT score found in regimens lacking antiplatelet therapy highlights the importance of early antiaggregants therapy. Abnormal fibrinolysis was associated with an increase in AT score. Platelet dysfunction, warm ischemia time, and enteric drainage were predictive of AT and, along with other known risk factors, were incorporated into an algorithm that matches intensity of early postoperative anticoagulation to the thrombotic risk.
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Affiliation(s)
- Yehuda Raveh
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida.,Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Gaetano Ciancio
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida.,Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - George W Burke
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida.,Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Jose Figueiro
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida.,Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Linda Chen
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida.,Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Mahmoud Morsi
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida.,Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Nicholas Namias
- Department of Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Bhavna P Singh
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Martine Lindsay
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Waseem Alfahel
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Mahmoud S Sleem
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida
| | - Ramona Nicolau-Raducu
- Department of Anesthesia, University of Miami/Jackson Memorial Hospital, Miami, Florida.,Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Florida
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Nicolau-Raducu R, Beduschi T, Vianna R, Diez C, Sleem M, Singh BP, Vasileiou G, Raveh Y. Fibrinolysis Shutdown Is Associated With Thrombotic and Hemorrhagic Complications and Poorer Outcomes After Liver Transplantation. Liver Transpl 2019; 25:380-387. [PMID: 30548128 DOI: 10.1002/lt.25394] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 11/26/2018] [Indexed: 12/17/2022] [Imported: 08/29/2023]
Abstract
Detrimental consequences of hypofibrinolysis, also known as fibrinolysis shutdown (FS), have recently arisen, and its significance in liver transplantation (LT) remains unknown. To fill this gap, this retrospective study included 166 adults who received transplants between 2016 and 2018 for whom baseline thromboelastography was available. On the basis of percent of clot lysis 30 minutes after maximal amplitude, patients were stratified into 3 fibrinolysis phenotypes: FS, physiologic fibrinolysis, and hyperfibrinolysis. FS occurred in 71.7% of recipients, followed by physiologic fibrinolysis in 19.9% and hyperfibrinolysis in 8.4%. Intraoperative and postoperative venous thrombosis events occurred exclusively in recipients with the FS phenotype. Intraoperative thrombosis occurred with an overall incidence of 4.8% and was associated with 25.0% in-hospital mortality. Incidence of postoperative venous thrombosis within the first month was deep venous thrombosis/pulmonary embolism (PE; 4.8%) and portal vein thrombosis/hepatic vein thrombosis (1.8%). Massive transfusion of ≥20 units packed red blood cells was required in 11.8% of recipients with FS compared with none in the other 2 phenotype groups (P = 0.01). Multivariate analysis identified 2 pretransplant risk factors for FS: platelet count and nonalcoholic steatohepatitis/cryptogenic cirrhosis. Recursive partitioning identified a critical platelet cutoff value of 50 × 109 /L to be associated with FS phenotype. The hyperfibrinolysis phenotype was associated with the lowest 1-year survival (85.7%), followed by FS (95.0%) and physiologic fibrinolysis (97.0%). Infection/multisystem organ failure was the predominant cause of death; in the FS group, 1 patient died of exsanguination, and 1 patient died of massive intraoperative PE. In conclusion, there is a strong association between FS and thrombohemorrhagic complications and poorer outcomes after LT.
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Affiliation(s)
| | - Thiago Beduschi
- Miami Transplant Institute, Jackson Memorial Hospital, Miami, FL
| | - Rodrigo Vianna
- Miami Transplant Institute, Jackson Memorial Hospital, Miami, FL
| | - Christian Diez
- Department of Anesthesia, Jackson Memorial Hospital, University of Miami, Miami, FL
| | - Mahmoud Sleem
- Department of Anesthesia, Jackson Memorial Hospital, University of Miami, Miami, FL
| | - Bhavna P Singh
- Department of Anesthesia, Jackson Memorial Hospital, University of Miami, Miami, FL
| | | | - Yehuda Raveh
- Department of Anesthesia, Jackson Memorial Hospital, University of Miami, Miami, FL
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