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Spaggiari M, Lichvar A, Tzvetanov I, Carroll R, Gaitonde S, Setty S, Cocco PD, Alvarez JAA, Benedetti E. Temporary Deceased Donor Splenic Transplant Prior to Intestinal Transplantation: A New Strategy for Desensitization? Transplant Proc 2021; 53:2602-2608. [PMID: 34503818 DOI: 10.1016/j.transproceed.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/07/2021] [Indexed: 11/24/2022]
Abstract
Intestinal transplantation is a therapeutic treatment option for patients with irreversible intestinal failure. The presence of donor-specific antibodies (DSAs) has been associated with increased antibody-mediated rejection and allograft loss for recipients of all the solid organ transplants. This case report describes the posttransplant course in the first year of a patient who received a T-cell and B-cell flow cross-match (FXM) and complement-dependent cytotoxicity cross-match positive intestinal transplant in the presence of several class I and class II DSAs who underwent a "temporary desensitization" using the donor spleen. The temporary donor splenic transplant removed several class I and II DSAs as demonstrated by the negative subsequent T-cell FXM, the decreased mean channel shift of the positive B-cell FXM with a significant decrease in DSA mean florescence intensity post temporary splenic transplant. The patient experienced an isolated incidence of acute rejection, which responded to therapy. He had no infectious or cancerous sequelae from the immunosuppression modalities. He was able to discontinue total parenteral nutrition and gained weight after the procedure. Long-term effects are not able to be determined from this approach; hence, further research is warranted to better evaluate the real efficacy of this strategy.
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Affiliation(s)
- Mario Spaggiari
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois.
| | - Alicia Lichvar
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois; Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois
| | - Ivo Tzvetanov
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Robert Carroll
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Sujata Gaitonde
- Department of Pathology, University of Illinois at Chicago, Chicago, Illinois
| | - Suman Setty
- Department of Pathology, University of Illinois at Chicago, Chicago, Illinois
| | - Pierpaolo Di Cocco
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Jorge A Almario Alvarez
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Enrico Benedetti
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
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3
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Canovai E, Ceulemans LJ, Gilbo N, Duchateau NM, De Hertogh G, Hiele M, Jochmans I, Vanuytsel T, Maleux G, Verhaegen M, Monbaliu D, Pirenne J. Multivisceral Transplantation for Diffuse Portomesenteric Thrombosis: Lessons Learned for Surgical Optimization. Front Surg 2021; 8:645302. [PMID: 33681286 PMCID: PMC7933591 DOI: 10.3389/fsurg.2021.645302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 01/28/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Multivisceral transplantation entails the en-bloc transplantation of stomach, duodenum, pancreas, liver and bowel following resection of the native organs. Diffuse portomesenteric thrombosis, defined as the complete occlusion of the portal system, can lead to life-threatening gastrointestinal bleeding, malnutrition and can be associated with liver and intestinal failure. Multivisceral transplantation is the only procedure that offers a definitive solution by completely replacing the portal system. However, this procedure is technically challenging in this setting. The aim of this study is to describe our experience, highlight the challenges and propose technical solutions. Materials and Methods: We performed a retrospective analysis of our cohort undergoing multivisceral transplantation for diffuse portomesenteric thrombosis at our institution from 2000 to 2020. Donor and recipient demographics and surgical strategies were reviewed in detail and posttransplant complications and survival were analyzed. Results: Five patients underwent MVTx. Median age was 47 years (23–62). All had diffuse portomesenteric thrombosis with life-threatening variceal bleeding. Major blood loss during exenteration was avoided by combining two techniques: embolization of the native organs followed by a novel, staged extraction. This prevented major perioperative blood loss [median intra-operative transfusion of 3 packed red blood cell units (0–5)]. Median CIT was 330 min (316–416). There was no perioperative death. One patient died due to invasive aspergillosis. Four others are alive and well with a median follow-up of 4.1 years (0.3–5.9). Conclusions: Multivisceral transplantation should be considered in patients with diffuse portomesenteric thrombosis that cannot be treated by any other means. We propose a standardized surgical approach to limit the operative risk and improve the outcome.
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Affiliation(s)
- Emilio Canovai
- Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Laurens J Ceulemans
- Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Chronic Diseases, Metabolism and Ageing, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Nicholas Gilbo
- Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Nicolas M Duchateau
- Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Gert De Hertogh
- Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Martin Hiele
- Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Ina Jochmans
- Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Tim Vanuytsel
- Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Geert Maleux
- Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Marleen Verhaegen
- Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Diethard Monbaliu
- Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Department of Microbiology, Immunology and Transplantation, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Intestinal Failure and Transplantation Center, University Hospitals Leuven, Leuven, Belgium.,Department of Abdominal Transplant Surgery and Transplant Coordination, University Hospitals Leuven, Leuven, Belgium
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4
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Intestinal transplantation: current improvements and perspectives. Curr Opin Organ Transplant 2017; 12:265-270. [PMID: 27711016 DOI: 10.1097/mot.0b013e32814a5a3b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the most recent relevant knowledge in clinical practice in the field of intestinal transplantation. RECENT FINDINGS Three important factors that have allowed improving results during the last few years are reviewed here. The first relates to the development of a different approach to tackle the underlying cause of intestinal failure and to the patient's characteristics in terms of liver function, age, and body size. The second involves immune modulation and especially the immunosuppressive regimen at induction. The third refers to posttransplantation monitoring, in particular the diagnosis and treatment of intestinal graft rejection and lymphoproliferative disorders. Patient status and referral for intestinal transplantation remain debated. The Intestinal Transplant Registry and a report from an individual program have demonstrated the relationship between a patient's pretransplant status and outcome. Candidacy for intestinal transplantation was analysed in a European survey of home parenteral nutrition patients. Early referral and listing are important for successful outcomes after intestinal grafting. SUMMARY Patient management should include therapies adapted to each stage of intestinal failure based on a multidisciplinary approach in centers involving surgery, gastroenterology, parenteral nutrition expertise, home parenteral nutrition programs, and liver-intestinal transplantation experience. Timing for referral of patients in specialized centers remains a crucial issue.
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6
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Hernandez F, Andres AM, Encinas JL, Domínguez E, Gamez M, Murcia FJ, Leal N, Martinez L, Molina M, Ramos E, Sarria J, Martinez-Ojinaga E, Prieto G, Frauca E, Lopez-Santamaria M. Preservation of the native spleen in multivisceral transplantation. Pediatr Transplant 2013; 17:556-60. [PMID: 23890077 DOI: 10.1111/petr.12124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2013] [Indexed: 11/29/2022]
Abstract
The native spleen is usually removed in patients undergoing MTV. The consequential asplenic state is associated with a high risk of sepsis, especially in immunosuppressed children. In contrast, the inclusion of an allogeneic spleen in multivisceral grafts has been associated with a high incidence of GVHD. We propose an alternative technique for patients undergoing MTV, consisting of the preservation of the native spleen. This approach avoids the additional risk of infection that characterizes the asplenic state without the detrimental side effects of the allogeneic spleen.
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Affiliation(s)
- F Hernandez
- Department of Pediatric Surgery, Hospital Universitario La Paz, Madrid, Spain.
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Chen ZS, Meng FY, Chen XP, Liu DG, Wei L, Jiang JP, Du DF, Zhang WJ, Ming CS, Gong NQ. Combined en bloc liver/pancreas transplantation in two different patients. World J Gastroenterol 2009; 15:2552-5. [PMID: 19469010 PMCID: PMC2686918 DOI: 10.3748/wjg.15.2552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Combined en bloc liver/pancreas transplantation (CLPT) was used primarily in the treatment of otherwise non-resectable upper abdominal malignancy. In fact, a more appropriate indication is in patients with liver disease and insulin-dependent diabetes mellitus (IDDM). Here, we report on two successful cases of CLPT at our hospital. One was a patient with non-resectable advanced liver cancer. The recipient survived for 23 mo and finally died of recurrent tumor. The other was a patient with severe biliary complication after orthotopic liver transplantation and preoperative IDDM. We performed CLPT with a modified surgical technique of preserving the native pancreas. He is currently liver-disease- and insulin-free more than 27 mo post-transplant. Based on our experience in two cases of abdominal cluster transplantation, we describe the technical details of CLPT and a modification of the surgical procedure.
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