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Serradilla J, Andrés Moreno AM, Talayero P, Burgos P, Machuca M, Camps Ortega O, Vallejo MT, Rubio Bolívar FJ, Bueno A, Sánchez A, Zambrano C, De la Torre Ramos CA, Rodríguez O, Largo C, Serrano P, Prieto Bozano G, Ramos E, López Santamaría M, Stringa P, Hernández F. Preclinical Study of DCD and Normothermic Perfusion for Visceral Transplantation. Transpl Int 2023; 36:11518. [PMID: 37745640 PMCID: PMC10514355 DOI: 10.3389/ti.2023.11518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/25/2023] [Indexed: 09/26/2023]
Abstract
Considering recent clinical and experimental evidence, expectations for using DCD-derived intestines have increased considerably. However, more knowledge about DCD procedure and long-term results after intestinal transplantation (ITx) is needed. We aimed to describe in detail a DCD procedure for ITx using normothermic regional perfusion (NRP) in a preclinical model. Small bowel was obtained from pigs donors after 1 h of NRP and transplanted to the recipients. Graft Intestinal samples were obtained during the procedure and after transplantation. Ischemia-reperfusion injury (Park-Chiu score), graft rejection and transplanted intestines absorptive function were evaluated. Seven of 8 DCD procedures with NRP and ITx were successful (87.5%), with a good graft reperfusion and an excellent recovery of the recipient. The architecture of grafts was well conserved during NRP. After an initial damage of Park-chiu score of 4, all grafts recovered from ischemia-reperfusion, with no or very subtle alterations 2 days after ITx. Most recipients (71.5%) did not show signs of rejection. Only two cases demonstrated histologic signs of mild rejection 7 days after ITx. Interestingly intestinal grafts showed good absorptive capacity. The study's results support the viability of intestinal grafts from DCD using NRP, contributing more evidence for the use of DCD for ITx.
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Affiliation(s)
- Javier Serradilla
- Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain
- Transplant Research Group, Institute for Health Research IdiPaz, Madrid, Spain
| | - Ane Miren Andrés Moreno
- Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain
- Transplant Research Group, Institute for Health Research IdiPaz, Madrid, Spain
| | - Paloma Talayero
- Department of Immunology, University Hospital 12 de Octubre, Madrid, Spain
| | - Paula Burgos
- Transplant Research Group, Institute for Health Research IdiPaz, Madrid, Spain
- Department of Cardiovascular Surgery, La Paz University Hospital, Madrid, Spain
| | - Mariana Machuca
- Special Pathology Laboratory, Faculty of Veterinary Sciences, National University of La Plata, La Plata, Argentina
| | - Onys Camps Ortega
- Molecular Imaging and Immunohistochemistry Laboratory, Institute for Health Research IdiPaz, Madrid, Spain
| | - María Teresa Vallejo
- Molecular Imaging and Immunohistochemistry Laboratory, Institute for Health Research IdiPaz, Madrid, Spain
| | | | - Alba Bueno
- Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain
- Transplant Research Group, Institute for Health Research IdiPaz, Madrid, Spain
| | - Alba Sánchez
- Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain
- Transplant Research Group, Institute for Health Research IdiPaz, Madrid, Spain
| | - Cristina Zambrano
- Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain
| | - Carlos Andrés De la Torre Ramos
- Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain
- Transplant Research Group, Institute for Health Research IdiPaz, Madrid, Spain
| | - Olaia Rodríguez
- Department of Biochemistry, La Paz University Hospital, IdiPaz, Madrid, Spain
| | - Carlota Largo
- Transplant Research Group, Institute for Health Research IdiPaz, Madrid, Spain
- Department of Experimental Surgery, La Paz University Hospital, Madrid, Spain
| | - Pilar Serrano
- Intestinal Rehabilitation and Transplantation Unit, La Paz University Hospital, Madrid, Spain
| | - Gerardo Prieto Bozano
- Intestinal Rehabilitation and Transplantation Unit, La Paz University Hospital, Madrid, Spain
| | - Esther Ramos
- Transplant Research Group, Institute for Health Research IdiPaz, Madrid, Spain
- Intestinal Rehabilitation and Transplantation Unit, La Paz University Hospital, Madrid, Spain
| | - Manuel López Santamaría
- Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain
- Transplant Research Group, Institute for Health Research IdiPaz, Madrid, Spain
| | - Pablo Stringa
- Transplant Research Group, Institute for Health Research IdiPaz, Madrid, Spain
- Institute for Immunological and Pathophysiological Studies (IIFP), National University of La Plata, National Council of Scientific and Technical Research (CONICET), La Plata, Argentina
| | - Francisco Hernández
- Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain
- Transplant Research Group, Institute for Health Research IdiPaz, Madrid, Spain
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Stringa P, Vecchio Dezillio LE, Talayero P, Serradilla J, Errea A, Machuca M, Papa-Gobbi R, Camps Ortega O, Pucci Molineris M, Lausada N, Andres Moreno AM, Rumbo M, Hernández Oliveros F. Experimental Assessment of Intestinal Damage in Controlled Donation After Circulatory Death for Visceral Transplantation. Transpl Int 2023; 36:10803. [PMID: 36713114 PMCID: PMC9878676 DOI: 10.3389/ti.2023.10803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 01/02/2023] [Indexed: 01/15/2023]
Abstract
There is an urgent need to address the shortage of potential multivisceral grafts in order to reduce the average time in waiting list. Since donation after circulatory death (DCD) has been successfully employed for other solid organs, a thorough evaluation of the use of intestinal grafts from DCD is warranted. Here, we have generated a model of Maastricht III DCD in rodents, focusing on the viability of intestinal and multivisceral grafts at five (DCD5) and twenty (DCD20) minutes of cardiac arrest compared to living and brain death donors. DCD groups exhibited time-dependent damage. DCD20 generated substantial intestinal mucosal injury and decreased number of Goblet cells whereas grafts from DCD5 closely resemble those of brain death and living donors groups in terms intestinal morphology, expression of tight junction proteins and number of Paneth and Globet cells. Upon transplantation, intestines from DCD5 showed increased ischemia/reperfusion damage compared to living donor grafts, however mucosal integrity was recovered 48 h after transplantation. No differences in terms of graft rejection, gene expression and absorptive function between DCD5 and living donor were observed at 7 post-transplant days. Collectively, our results highlight DCD as a possible strategy to increase multivisceral donation and transplantation procedures.
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Affiliation(s)
- Pablo Stringa
- Transplant Group, La Paz University Hospital Health Research Institute (IdiPAZ), Madrid, Spain,Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain,Institute for Immunological and Pathophysiological Studies (IIFP), School of Exact Sciences, National University of La Plata, National Council of Scientific and Technical Research (CONICET), La Plata, Argentina,Organ Transplant Laboratory, School of Medicine, National University of La Plata, La Plata, Argentina
| | - Leandro Emmanuel Vecchio Dezillio
- Institute for Immunological and Pathophysiological Studies (IIFP), School of Exact Sciences, National University of La Plata, National Council of Scientific and Technical Research (CONICET), La Plata, Argentina,Organ Transplant Laboratory, School of Medicine, National University of La Plata, La Plata, Argentina
| | - Paloma Talayero
- Immunology Department, 12 de Octubre University Hospital, Madrid, Spain
| | - Javier Serradilla
- Transplant Group, La Paz University Hospital Health Research Institute (IdiPAZ), Madrid, Spain,Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain
| | - Agustina Errea
- Institute for Immunological and Pathophysiological Studies (IIFP), School of Exact Sciences, National University of La Plata, National Council of Scientific and Technical Research (CONICET), La Plata, Argentina
| | - Mariana Machuca
- Special Pathology Laboratory, Faculty of Veterinary Sciences, National University of La Plata, La Plata, Argentina
| | - Rodrigo Papa-Gobbi
- Transplant Group, La Paz University Hospital Health Research Institute (IdiPAZ), Madrid, Spain,Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain,Institute for Immunological and Pathophysiological Studies (IIFP), School of Exact Sciences, National University of La Plata, National Council of Scientific and Technical Research (CONICET), La Plata, Argentina
| | - Onys Camps Ortega
- Transplant Group, La Paz University Hospital Health Research Institute (IdiPAZ), Madrid, Spain,Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain
| | - Melisa Pucci Molineris
- Biochemistry Research Institute of La Plata, School of Medicine, National University of La Plata, National Council of Scientific and Technical Research (CONICET), La Plata, Argentina
| | - Natalia Lausada
- Organ Transplant Laboratory, School of Medicine, National University of La Plata, La Plata, Argentina
| | - Ane Miren Andres Moreno
- Transplant Group, La Paz University Hospital Health Research Institute (IdiPAZ), Madrid, Spain,Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain
| | - Martin Rumbo
- Institute for Immunological and Pathophysiological Studies (IIFP), School of Exact Sciences, National University of La Plata, National Council of Scientific and Technical Research (CONICET), La Plata, Argentina
| | - Francisco Hernández Oliveros
- Transplant Group, La Paz University Hospital Health Research Institute (IdiPAZ), Madrid, Spain,Department of Pediatric Surgery, La Paz University Hospital, Madrid, Spain,Executive Operational Committee, ERN TransplantChild, Madrid, Spain,*Correspondence: Francisco Hernández Oliveros,
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Luminal Preservation Protects the Small Intestine in a Brain-dead Rat Model. Transplant Direct 2022; 8:e1378. [PMID: 36176723 PMCID: PMC9514830 DOI: 10.1097/txd.0000000000001378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/12/2022] [Accepted: 07/23/2022] [Indexed: 11/27/2022] Open
Abstract
Intestinal transplantation depends on donation after brain death (DBD). Luminal preservation (LP) has been beneficial against preservation injury in previous studies in animal models, but none include DBD. This study aims to investigate whether these benefits occur also with DBD.
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Søfteland JM, Bagge J, Padma AM, Casselbrant A, Zhu C, Wang Y, Hellström M, Olausson M, Oltean M. Luminal polyethylene glycol solution delays the onset of preservation injury in the human intestine. Am J Transplant 2021; 21:2220-2230. [PMID: 33249756 DOI: 10.1111/ajt.16418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 10/12/2020] [Accepted: 11/13/2020] [Indexed: 01/25/2023]
Abstract
The organ damage incurred during the cold storage (CS) of intestinal grafts has short and long-term consequences. Animal studies suggest that additional luminal preservation (LP) with polyethylene glycol (PEG) may alleviate this damage. This study aims to validate these findings using human intestines. Ileal segments, perfused intravascularly with IGL-1 solution, were procured from 32 multiorgan donors and divided into two parts: one containing a PEG 3350-based solution introduced luminally (LP group) and another one without luminal treatment (control). Sampling was performed after 4 h, 8 h, 14 h, and 24 h of CS. Histology was assessed using the Chiu/Park score. Tight junctions (TJ), several inflammatory markers, and transcription factors were examined by immunofluorescence, ddPCR, and western blot. Tissue water content (edema) was also measured. Apoptotic activity was assessed with caspase -2, -3, and -9 assays. LP significantly lowered mucosal injury at all time points. Redistribution of TJ proteins occurred earlier and more severely in the control group. After 24 h of CS, LP intestines showed an emerging unfolding protein response. Increased caspase-3 and -9 activity was found in the control group. The current results indicate that luminal PEG is safe and effective in reducing damage to the intestinal epithelium during CS.
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Affiliation(s)
- John M Søfteland
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Clinical Sciences, Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jasmine Bagge
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Clinical Sciences, Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Arvind M Padma
- Institute of Clinical Sciences, Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anna Casselbrant
- Institute of Clinical Sciences, Department of Gastrosurgical Research and Education, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Changlian Zhu
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yafeng Wang
- Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Institute of Neuroscience and Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mats Hellström
- Institute of Clinical Sciences, Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Michael Olausson
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Clinical Sciences, Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mihai Oltean
- The Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Clinical Sciences, Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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17β-Estradiol as a New Therapy to Preserve Microcirculatory Perfusion in Small Bowel Donors. Transplantation 2020; 104:1862-1868. [PMID: 32345867 DOI: 10.1097/tp.0000000000003280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intestine graft viability compromises retrieval in most brain-dead donors. Small bowel transplantation is a complex procedure with worse outcomes than transplantation of other abdominal organs. The hormone 17β-estradiol (E2) has shown vascular protective effects in lung tissue of brain death (BD) male rats. Thus, estradiol might be a treatment option to improve the quality of intestinal grafts. METHODS Male Wistar rats were divided into 3 groups (n = 10/group): rats that were trepanned only (sham-operated), rats subjected to rapid-onset BD, and brain-dead rats treated with E2 (280 µg/kg, intravenous) (BD-E2). Experiments performed for 180 minutes thereafter are included: (a) laser-Doppler flowmetry and intravital microscopy to evaluate mesenteric perfusion; (b) histopathological analysis; (c) real-time polymerase chain reaction of endothelial nitric oxide synthase (eNOS) and endothelin-1; (d) immunohistochemistry of eNOS, endothelin-1, P-selectin, intercellular adhesion molecule 1, and vascular cell adhesion molecule 1 expression; and (e) ELISA for cytokines and chemokines measurement. RESULTS 17β-Estradiol improved microcirculatory perfusion and reduced intestinal edema and hemorrhage after BD. The proportions of perfused small vessels were (mean ± scanning electron microscope) BD rats (40% ± 6%), sham-operated rats (75% ± 8%), and BD-E2 rats (67% ± 5%) (P = 0.011). 17β-Estradiol treatment was associated with 2-fold increase in eNOS protein (P < 0.0001) and gene (P = 0.0009) expression, with no differences in endothelin-1 expression. BD-E2 rats exhibited a reduction in vascular cell adhesion molecule 1 expression and reduced cytokine-induced neutrophil chemoattractant 1 and interleukina-10 serum levels. CONCLUSIONS 17β-Estradiol was effective in improving mesenteric perfusion and reducing intestinal edema and hemorrhage associated with BD. The suggestion is that E2 might be considered a therapy to mitigate, at least in part, the deleterious effects of BD in small bowel donors.
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The Impact of Age and Luminal Preservation on the Development of Intestinal Preservation Injury in Rats. Transplantation 2020; 104:e8-e15. [PMID: 31651796 DOI: 10.1097/tp.0000000000002999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Organs from older donors are believed to withstand ischemia worse than those from younger donors. The effect of age on the development of intestinal preservation injury (IPI) is unclear. METHODS We compared the development of IPI in intestines from young (3 mo), adult (14 mo), and old (20 mo) rat donors and assessed if luminal preservation (LP) is effective in delaying IPI. Small intestines were perfused with, and stored in, preservation solution (Custodiol) with or without LP solution (polyethylene glycol 3350). IPI was studied using histology (Chiu score, Alcian blue staining), Western blot, and electrophysiological assessment (Ussing chamber) at 4, 8, and 14 hours. RESULTS Intestines of old rats did not show major histological alterations, whereas their aortas and kidneys revealed typical age-related changes (arteriosclerosis and glomerulosclerosis). Intestines from old rats fared similarly to their younger counterparts at all time points regarding preservation injury and goblet cells count. Intestines undergoing LP showed fewer histological signs of damage and higher goblet cells count when compared with samples without LP, regardless of donor age. Ussing chamber experiments indicated a time-dependent deterioration of all parameters studied, which was delayed by the use of LP. CONCLUSIONS Older intestines did not convincingly demonstrate a faster IPI compared with intestines from adult and young donors. The small differences between the age groups were nullified by the use of LP. LP significantly delayed the IPI in all age groups and may allow for longer preservation periods without an increased risk of mucosal damage.
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Lysyy T, Finotti M, Maina RM, Morotti R, Munoz-Abraham AS, Bertacco A, Ibarra C, Barahona M, Agarwal R, D'Amico F, Rodriguez-Davalos MI, Mulligan D, Geibel J. Human Small Intestine Transplantation: Segmental Susceptibility to Ischemia Using Different Preservation Solutions and Conditions. Transplant Proc 2020; 52:2934-2940. [PMID: 32768284 DOI: 10.1016/j.transproceed.2020.06.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 06/09/2020] [Accepted: 06/29/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Among all transplanted abdominal organs, the small intestine is one of the most ischemia sensitive. Appropriate graft selection, procurement, and preservation are crucial for optimum graft and patient survival. We evaluated ischemic damage in human small intestine grafts under different hypothermic preservation conditions (cold static and continuous perfusion) and solutions: histidine-tryptophan-ketoglutarate (HTK) and University of Wisconsin (UW). METHODS Fourteen small intestinal grafts were procured from deceased donors. HTK and UW were used for the vascular perfusion at the cross clamp, and UW, HTK, or Ringer Lactate were used for the luminal flush at the back table. Therefore, part of the same harvested intestine was stored in cold static storage and in continuous perfusion preservation (with intestinal perfusion unit) simultaneously. Histological samples were collected from the jejunum and ileum at different time points and different preservation conditions. The samples were collected before the initiation of cold storage (T0), after 8 hours of cold static (ST8), or after 8 hours of continuous perfusion preservation (PT8) (n = 161 samples). Blinded histological evaluation was conducted and ischemic damage was determined using the Park/Chiu scale. RESULTS The ileum had less ischemic damage than the jejunum, regardless of using static or continuous perfusion preservation. There was no significantly ischemic damage difference between intestinal grafts flushed and perfused with UW or HTK. CONCLUSION The jejunum is more susceptible to ischemic injury than the ileum. UW and HTK are equivalent to preserve intestinal graft. This suggests that selective transplantation of ileum could reduce ischemia-related postoperative complications.
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Affiliation(s)
- Taras Lysyy
- Yale University School of Medicine, Department of Surgery, New Haven, CT, USA
| | - Michele Finotti
- Yale University School of Medicine, Department of Surgery, New Haven, CT, USA; University of Padua, Transplantation and Hepatobiliary Surgery, Padua, Padua, Italy
| | - Renee M Maina
- Yale University School of Medicine, Department of Surgery, New Haven, CT, USA
| | - Raffaella Morotti
- Yale University School of Medicine, Department of Surgery, New Haven, CT, USA
| | | | - Alessandra Bertacco
- University of Padua, Transplantation and Hepatobiliary Surgery, Padua, Padua, Italy
| | - Christopher Ibarra
- Yale University School of Medicine, Department of Surgery, New Haven, CT, USA
| | - Maria Barahona
- Yale University School of Medicine, Department of Surgery, New Haven, CT, USA
| | - Raghav Agarwal
- Yale University School of Medicine, Department of Surgery, New Haven, CT, USA
| | - Francesco D'Amico
- Yale University School of Medicine, Department of Surgery, New Haven, CT, USA; University of Padua, Transplantation and Hepatobiliary Surgery, Padua, Padua, Italy
| | | | - David Mulligan
- Yale University School of Medicine, Department of Surgery, New Haven, CT, USA
| | - John Geibel
- Yale University School of Medicine, Department of Surgery, New Haven, CT, USA.
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Characterization of Ischemic Changes in Small Bowel After Normothermic Regional Perfusion: Potential to Consider Small Bowel Grafts from DCD Donors? Transplantation 2016; 100:e156-e157. [PMID: 27575688 DOI: 10.1097/tp.0000000000001460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dalal A. Intestinal transplantation: The anesthesia perspective. Transplant Rev (Orlando) 2015; 30:100-8. [PMID: 26683875 DOI: 10.1016/j.trre.2015.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 06/30/2015] [Accepted: 11/11/2015] [Indexed: 12/12/2022]
Abstract
Intestinal transplantation is a complex and challenging surgery. It is very effective for treating intestinal failure, especially for those patients who cannot tolerate parenteral nutrition nor have extensive abdominal disease. Chronic parental nutrition can induce intestinal failure associated liver disease (IFALD). According to United Network for Organ Sharing (UNOS) data, children with intestinal failure affected by liver disease secondary to parenteral nutrition have the highest mortality on a waiting list when compared with all candidates for solid organ transplantation. Intestinal transplant grafts can be isolated or combined with the liver/duodenum/pancreas. Organ Procurement and Transplantation Network (OPTN) has defined intestinal donor criteria. Living donor intestinal transplant (LDIT) has the advantages of optimal timing, short ischemia time and good human leukocyte antigen matching contributing to lower postoperative complications in the recipient. Thoracic epidurals provide excellent analgesia for the donors, as well as recipients. Recipient management can be challenging. Thrombosis and obstruction of venous access maybe common due to prolonged parenteral nutrition and/or hypercoaguability. Thromboelastography (TEG) is helpful for managing intraoperative product therapy or thrombosis. Large fluid shifts and electrolyte disturbances may occur due to massive blood loss, dehydration, third spacing etc. Intestinal grafts are susceptible to warm and cold ischemia and ischemia-reperfusion injury (IRI). Post-reperfusion syndrome is common. Cardiac or pulmonary clots can be monitored with transesophageal echocardiography (TEE) and treated with recombinant tissue plasminogen activator. Vasopressors maybe used to ensure stable hemodynamics. Post-intestinal transplant patients may need anesthesia for procedures such as biopsies for surveillance of rejection, bronchoscopy, endoscopy, postoperative hemorrhage, anastomotic leaks, thrombosis of grafts etc. Asepsis, drug interactions between anesthetic and immunosuppressive agents and venous access are some of the anesthetic considerations for this group.
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Affiliation(s)
- Aparna Dalal
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, 1428 Madison Avenue, New York, NY 10029, United States.
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Intestinal preservation for transplantation: current status and alternatives for the future. Curr Opin Organ Transplant 2015; 20:308-13. [PMID: 25944227 DOI: 10.1097/mot.0000000000000187] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Among transplantable abdominal organs the intestine has the shortest cold storage time, raising significant medical and logistical challenges. Herein, established and innovative, emerging concepts in intestinal preservation are summarized. RECENT FINDINGS The method of intestinal preservation using an in-situ vascular perfusion followed by static storage remained unchanged for almost 30 years, despite suboptimal results. Advanced preservation injury occurs within 12 h and is little influenced by the type of solution used. Recent reports indicate that several customized luminal solutions containing various amino acids and macromolecules may delay its development. In addition, gaseous interventions in the storage solutions or in the lumen seem promising and easily applicable tools that may further reduce the ischemia-reperfusion injury and safely prolong the preservation time. Rodent models are not entirely suitable for direct translation to clinical practice as the development of preservation injury is faster than in humans. SUMMARY The limitations of intestinal preservation originate in the methods (vascular perfusion and static storage) rather than in the solutions used. Several additional strategies promise to prolong the cold storage and reduce its impact on the intestinal graft and deserve further exploration in large animals and clinical studies.
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