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Couper MR, Valamparampil J, Thyagarajan M, Hartley J, Gupte G. Intestinal ultrasound may be a useful tool in monitoring acute rejection following intestinal transplantation. Pediatr Transplant 2023; 27:e14574. [PMID: 37458363 DOI: 10.1111/petr.14574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 06/29/2023] [Accepted: 07/03/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Acute rejection is the leading cause of mortality and morbidity for children following intestinal transplantation. Rapid detection and prompt treatment are critical; however, the only reliable method of diagnosis and monitoring is endoscopic graft biopsies. The required regular anesthetics are particularly problematic in children, and non-invasive strategies are needed. METHODS We describe the intestinal ultrasound findings of three children before and after treatment for rejection. Ultrasounds were performed within 24 h of endoscopically obtained biopsies which were used to establish a diagnosis of rejection and to define severity. A single sonographer performed the ultrasounds and was blinded to biopsy results at the time of the scanning. These findings are provided in the context of the ultrasound appearance of seven children who had no features of rejection on surveillance biopsies. RESULTS Intestinal ultrasound demonstrated increased bowel wall thickness, vascularity, and mesenteric inflammation during moderate to severe rejection episodes. The submucosal layer was particularly thickened, which may represent a finding more specific for rejection. All patients demonstrated improvement in all quantitative ultrasound features correlating with the resolution of acute cellular rejection on histology. Patients with no evidence of rejection on biopsy had a bowel wall thickness range of 0.9-2.8 mm, suggesting a normal upper limit of 3 mm. CONCLUSION Moderate and severe acute rejection may be detected and response to treatment can be monitored by intestinal ultrasound and, correlating with clinical improvement, can aid in follow-up.
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Affiliation(s)
- Michael R Couper
- Liver Unit (Including Small Bowel Transplantation), Birmingham Women's, and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Joseph Valamparampil
- Liver Unit (Including Small Bowel Transplantation), Birmingham Women's, and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Manigan Thyagarajan
- Radiology Department, Birmingham Women's, and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Jane Hartley
- Liver Unit (Including Small Bowel Transplantation), Birmingham Women's, and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Girish Gupte
- Liver Unit (Including Small Bowel Transplantation), Birmingham Women's, and Children's Hospital NHS Foundation Trust, Birmingham, UK
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Pugliesi RA, Dasyam AK, Borhani AA. Intestinal and Multivisceral Transplantation: Indications and Surgical Techniques. Radiol Clin North Am 2023; 61:861-870. [PMID: 37495293 DOI: 10.1016/j.rcl.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Intestinal transplantation and multivisceral transplantation are technically challenging and complex procedures mainly performed on patients with irreversible and non-medically manageable end-stage intestinal failure. Increasingly, other organs besides small intestines are included in the allograft for which the terms "composite intestinal transplantation" and "multivisceral transplantation" are used. Commonly, complex vascular reconstructions are used for these procedures. Knowledge of surgical anatomy hence is essential for accurate interpretation of postoperative imaging in these patients. This article reviews the indications and most common surgical techniques for intestinal and multivisceral transplantations.
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Affiliation(s)
- Rosa Alba Pugliesi
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 North St. Claire Street, Suite 800, Chicago, IL 60611, USA
| | - Anil K Dasyam
- Department of Radiology, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Amir A Borhani
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 North St. Claire Street, Suite 800, Chicago, IL 60611, USA.
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Hollins AW, Napier K, Wildman-Tobriner B, Erdmann R, Sudan DL, Ravindra KV, Erdmann D, Atia A. Using Radiographic Domain for Evaluating Indications in Abdominal Wall Transplantation. Ann Plast Surg 2021; 87:348-354. [PMID: 33559994 DOI: 10.1097/sap.0000000000002708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is currently no description of abdominal domain changes in small bowel transplantation population or consensus of criteria regarding which patients are at high risk for immediate postoperative abdominal wall complications or would benefit from abdominal wall vascularized composite allotransplantation. METHODS A retrospective chart review was performed on 14 adult patients receiving intestinal or multivisceral transplantation. Preoperative and postoperative computed tomography scans were reviewed, and multiple variables were collected regarding abdominal domain and volume and analyzed comparing postoperative changes and abdominal wall complications. RESULTS Patients after intestinal or multivisceral transplantation had a mean reduction in overall intraperitoneal volume in the immediate postoperative period from 9031 cm3 to 7846 cm3 (P = 0.314). This intraperitoneal volume was further reduced to an average of 6261 cm3 upon radiographic evaluation greater than 1 year postoperatively (P = 0.024). Patients with preexisting abdominal wound (P = 0.002), radiation, or presence of ostomy (P = 0.047) were significantly associated with postoperative abdominal wall complications. No preoperative radiographic findings had a significant association with postoperative abdominal wall complications. CONCLUSIONS Computed tomography imaging demonstrates that intestinal and multivisceral transplant patients have significant reduction in intraperitoneal volume and domain after transplantation in the acute and delayed postoperative setting. Preoperative radiographic abdominal domain was not able to predict patients with postoperative abdominal wall complications. Patients with abdominal wounds, ostomies, and preoperative radiation therapy were associated with acute postoperative abdominal complications and may be considered for need of reconstructive techniques including abdominal wall transplantation.
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Affiliation(s)
- Andrew W Hollins
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery
| | | | | | - Ralph Erdmann
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery
| | - Debra L Sudan
- Division of Abdominal Transplant Surgery, Department of Surgery, Duke University Health System, Durham, NC
| | - Kadiyala V Ravindra
- Division of Abdominal Transplant Surgery, Department of Surgery, Duke University Health System, Durham, NC
| | - Detlev Erdmann
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery
| | - Andrew Atia
- From the Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery
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Varkey J. Graft assessment for acute rejection after intestinal transplantation: current status and future perspective. Scand J Gastroenterol 2021; 56:13-19. [PMID: 33202155 DOI: 10.1080/00365521.2020.1847318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Intestinal transplantation has since its inception evolved as a lifesaving treatment option for patients with irreversible intestinal failure who can no longer be sustained on parenteral nutrition. Improvement in short-term survival after transplantation has also justified the expansion of treatment indications. Unfortunately, success is somewhat limited by a plateau observed in long-term survival. The reason for this sub-optimal long-term result experienced in this cohort may in part be attributed to the intestinal graft with the lymphoid content it carries inflicting the host with multiple complications where acute cellular rejection is one of the most common causes for graft loss. Graft monitoring is for this reason of paramount importance and detection of rejection at an early stage essential to enable early instigation of treatment and successful reversal of the pathology. Due to the challenges in diagnosing acute rejection with a noninvasive marker we are still limited to a surveillance protocol using endoscopy and biopsies for the diagnosis of rejection. The purpose of our paper is to review the adequacy of different methods in monitoring the graft for acute rejection using biomarkers, endoscopy and imaging. In conclusion, the evidence base continues to support the use of histology for the diagnosis of acute rejection. The role of biomarkers are still debatable, although markers such as calprotectin might be beneficial in excluding an ongoing process.
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Affiliation(s)
- Jonas Varkey
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Sahlgrenska Intestinal Failure and Transplant Centre, Gothenburg, Sweden
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Abstract
BACKGROUND Small bowel transplant (SBT) is a surgical procedure that may be used in patients with pathology resulting in severe intestinal failure resistant to conventional forms of surgical and nonsurgical treatment. Intestinal failure is defined as the failure of enterocytes to absorb sufficient macronutrients, water, and/or electrolytes to sustain homeostasis and/or promote growth. With the advancement of surgical techniques and advancements in perioperative transplant management, SBT has become an increasingly common treatment for intestinal failure, with survival rates for SBT comparable to those for other solid organ transplants. MATERIALS AND METHODS This review provides background on SBT, its variations, and the associated preoperative and postoperative imaging studies with regard to surgical planning and anticipated complications. RESULTS AND CONCLUSIONS With the increasing use of SBT, radiologists will be expected to be familiar with the diagnostic studies and available endovascular interventions associated with this procedure.
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Hakim B, Myers DT, Williams TR, Nagai S, Bonnett J. Intestinal transplants: review of normal imaging appearance and complications. Br J Radiol 2018; 91:20180173. [PMID: 29770706 DOI: 10.1259/bjr.20180173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Intestinal transplant (IT) is one of the least common forms of organ transplant but is increasing both in volume of cases and number of centers performing intestinal transplants, with the busiest centers in North America and Europe. IT can be performed in isolation or as part of a multivisceral transplant (MVT). Intestinal failure either in the form of short gut syndrome or functional bowel problems is the primary indication for IT. The normal post-surgical anatomy can be variable due to both recipient anatomy in regard to amount of residual bowel and status of native vasculature as well as whether the transplant is isolated or part of a multivisceral transplant. Complications of isolated IT and IT as part of an MVT include complications shared with other types of organ transplants such as infection, rejection, post-transplant lymphoproliferative disorder and graft versus host disease. Mechanical bowel complications of the graft include bowel obstruction, stricture, leak, perforation and enterocutaneous fistula. Lastly, vascular complications of both the venous and arterial anastomoses including stricture and pseudoaneurysm occur.
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Affiliation(s)
- Bashir Hakim
- 1 Department of Radiology, Henry Ford Hospital , Detroit, MI , USA
| | - Daniel T Myers
- 1 Department of Radiology, Henry Ford Hospital , Detroit, MI , USA
| | - Todd R Williams
- 1 Department of Radiology, Henry Ford Hospital , Detroit, MI , USA
| | - Shunji Nagai
- 2 Department of Transplant Surgery, Henry Ford Hospital , Detroit, MI , USA
| | - John Bonnett
- 1 Department of Radiology, Henry Ford Hospital , Detroit, MI , USA
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Frongia G, Majlesara A, Saffari A, Emami G, Golriz M, Günther P, Mehrabi A. The optimal intestinal segment length for experimental size-mismatched intestinal transplantation: Defining the maximum length with the lowest blood flow needs in a porcine model. Pediatr Transplant 2018; 22. [PMID: 29349849 DOI: 10.1111/petr.13135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2017] [Indexed: 11/30/2022]
Abstract
Transplanted Intestinal Segments (IS) must match the perfusion capacities of the recipient. This can be challenging during a size-mismatched SBTX. In this study, we defined the maximum IS length with lowest blood flow needs in a porcine model by evaluating the physiological perfusion rates of different IS lengths. Blood flow in the SMA, aorta segment four, and general circulatory parameters were monitored before and after sequential intestinal resection. IS lengths of 30 cm, 60 cm, 120 cm, and 300 cm (n = 8 each) were compared. The IS blood flow requirements increased with IS length (30 cm: 19.5 ± 3.4 mL/min; 60 cm: 16.9 ± 6.7 mL/min; 120 cm: 34.9 ± 8.5 mL/min; 300 cm: 62.9 ± 11.6 mL/min). Absolute IS blood flow (P = .004), percentage IS blood flow uptake from the SMA (P = .001), and percentage IS blood flow uptake from the aorta (P = .005) increased significantly between 60 cm and 120 cm. We concluded that 60 cm was the maximum IS length before blood flow demands significantly increased in a porcine model.
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Affiliation(s)
- Giovanni Frongia
- Division of Pediatric Surgery, Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ali Majlesara
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arash Saffari
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Golnaz Emami
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Mohammad Golriz
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Patrick Günther
- Division of Pediatric Surgery, Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
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Rees MA, Amesur NB, Cruz RJ, Borhani AA, Abu-Elmagd KM, Costa G, Dasyam AK. Imaging of Intestinal and Multivisceral Transplantation. Radiographics 2018. [DOI: 10.1148/rg.2018170086] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Mitchell A. Rees
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Nikhil B. Amesur
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Ruy J. Cruz
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Amir A. Borhani
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Kareem M. Abu-Elmagd
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Guilherme Costa
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
| | - Anil K. Dasyam
- From the Departments of Radiology (M.A.R., N.B.A., A.A.B., A.K.D.) and Surgery (R.J.C.), University of Pittsburgh Medical Center, 200 Lothrop St, Radiology Suite 200, East Wing E2051B, Pittsburgh, PA 15213; and Department of Surgery, Cleveland Clinic Foundation, Cleveland, Ohio (K.M.A., G.C.)
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Stanescu AL, Hryhorczuk AL, Chang PT, Lee EY, Phillips GS. Pediatric Abdominal Organ Transplantation. Radiol Clin North Am 2016; 54:281-302. [DOI: 10.1016/j.rcl.2015.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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10
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Extravascular complications following abdominal organ transplantation. Clin Radiol 2015; 70:898-908. [DOI: 10.1016/j.crad.2015.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 03/03/2015] [Accepted: 04/09/2015] [Indexed: 12/15/2022]
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Detection of postoperative intestinal ischemia in small bowel transplants. J Transplant 2012; 2012:970630. [PMID: 23209878 PMCID: PMC3504410 DOI: 10.1155/2012/970630] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 10/10/2012] [Indexed: 01/18/2023] Open
Abstract
Small bowel transplantation is acknowledged as auto- and allotransplantation. In both instances, there is up to a 4%–10% risk of postoperative ischemia, and as the small bowel is extremely susceptible to ischemia, the timely diagnosis of ischemia is important. The location of the transplant, whether it is buried in the abdominal cavity or in the neck region, increases the challenge, as monitoring becomes more difficult and the consequences of neglect more dangerous. All methods for the early detection of postoperative ischemia in small bowel transplants are described together with the requirements of the ideal monitoring method.
A small bowel transplant can be inspected directly or indirectly; the blood flow can be monitored by Doppler or by photoplethysmography, and the consequences of the blood flow can be monitored. The ideal monitoring method should be reliable, fast, minimally invasive, safe, objective, easy, cheap, and comfortable. No monitoring methods today fulfill the criteria of the ideal monitoring method, and evidence-based guidelines regarding postoperative monitoring cannot be made. The choice of whether to implement monitoring of ischemia—and if so, which method to choose—has to be made by the individual surgeon or center.
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