Surgical approaches and intestinal transplantation

Assessment and outcome of pediatric intestinal pseudo-obstruction: A tertiary-care-center experience from Turkey

BACKGROUND/AIMS

Pediatric intestinal pseudo-obstruction (PIPO) is a severe disorder of gut motility. In this rare and difficult-to-manage disease, complex treatment method, such as intestinal transplantation, is sometimes needed. This study evaluated the management and follow-up results of patients with PIPO who received treatment at our center.

MATERIALS AND METHODS

The cases of 13 patients with PIPO were reviewed retrospectively. Demographic data, clinical features, etiologies, pharmacological and surgical treatments, nutritional support, anthropometric findings, small bowel transplantation (SBT), and survival rates were assessed.

RESULTS

Two of the patients were diagnosed at 1 and 5 years of age, while other patients were diagnosed during neonatal period. The etiological cause could not be identified for 5 patients. Pharmacological treatment response was observed in 38.4% of patients. Post-pyloric feeding was applied in 4 patients, but no response was observed. Gastrostomy decreased the clinical symptoms in 3 patients during the abdominal distension period. Total oral nutrition was achieved in 38.4% of the total-parenteral-nutrition (TPN)-dependent patients. It was observed that anthropometric findings improved in patients with total oral nutrition. Liver cirrhosis developed in 1 patient. Venous thrombosis developed in 4 patients. The SBT was performed on 3 patients. One of these patients has been followed up for the last 4 years.

CONCLUSION

Pediatric intestinal pseudo-obstruction is a rare disease that can present with a wide range of clinical symptoms. While some patients require intestinal transplantation, supportive care may be sufficient in others. For this reason, patients with PIPO should be managed individually.

The role of osmotic self-inflatable tissue expanders in intestinal transplant candidates

Intestinal transplantation (ITx) is often associated with decreased abdominal domain, rendering abdominal closure difficult. Pre-transplant placement of tissue expanders (TE) can overcome this challenge; however it can be associated with life-threatening complications. This review aimed to comprehensively summarize all available literature on TE in ITx candidates and include the technical details of osmotic, self-inflatable TE -a technique undescribed before. PubMed, EMBASE and CCTR were searched until April 30, 2016. Based on structured data abstraction and detailed analysis, eighteen cases of TE (inflatable) in ITx candidates were found. Localisation of placement was: subcutaneously in 11; intraperitoneally in 4; 1 patient had 1 TE placed retromuscularly and 1 intraperitoneally; 1 patient had biplanar TE (intraperitoneally placed and extending retromuscularly) and in 1 localisation was unreported. Complication rate was high (61%), injection- or intraperitoneal-related, resulting in life-threatening infections/hematoma. With successful expansion, physiological graft protection -by skin+/-fascia- was always achieved. In completion of this review, we describe our own experience with two patients (7.5-, 34-year-old females), in whom osmotic TE were placed subcutaneously pre-ITx. No TE-related complications occurred and both patients underwent uncomplicated ITx with respectively primary skin and skin + fascia closure. The pros and cons of each TE type and placement are discussed, resulting in the overall conclusions that TE offer an important benefit in graft-protection following ITx. Osmotic TE are safer than conventional prostheses by avoiding percutaneous injections. Subcutaneous placement seems to be safer and more reliable.

Technical aspects for live-donor organ procurement for liver, kidney, pancreas, and intestine

PURPOSE OF REVIEW

This article reviews current strategies for living-donor organ procurement in liver, kidney, pancreas, and intestinal transplant.

RECENT FINDINGS

Here we summarize current open and laparoscopic approaches to living donation of abdominal organs.

SUMMARY

Living donation strategies expand the organ pool in the setting of a significant organ shortage.

The use of bi-planar tissue expanders to augment abdominal domain in a pediatric intestinal transplant recipient

Intestinal transplantation is a well-accepted treatment for SBS. However, patients with SBS often have decreased abdominal capacity, which makes size-matching of donor organs more difficult, thus decreasing organ availability. Reported approaches for addressing this problem include surgically reducing the graft size, leaving an open abdomen for a prolonged period, and cotransplanting rectus fascia as a non-vascularized allograft. Each approach has significant disadvantages. There has been one previous report of tissue expanders used intra-abdominally and two reports of subcutaneous use to increase intra-abdominal capacity prior to transplantation. We report the first use of bi-planar expander placement for this purpose. In our case, a two-yr-old male child with SBS due to malrotation was treated with tissue expanders 10 months prior to intestinal transplantation, thus allowing transplantation of a larger graft with the ability to close the abdomen safely. There were no complications, and the patient is now doing well and tolerating diet off PN. The use of tissue expanders prior to intestinal transplantation is a promising approach for such patients and avoids the morbidity associated with other approaches. This approach requires a multidisciplinary effort by gastroenterology, transplant surgery, and plastic surgery teams.

Medical and surgical management of the pediatric patient with intestinal failure

Until recently, extreme short bowel due primarily to massive resection in the neonatal period had been considered incompatible with long-term survival. Indeed, parents of infants with midgut volvulus or other causes of very extensive intestinal necrosis still may be informed that resection is futile. The advent of intestinal transplantation as a potential therapy and its evolution into a standard therapy for irreversible intestinal failure have led to changing attitudes regarding these catastrophic gastrointestinal events. The experience gained from aggressively maintaining infants with little if any functional small bowel while awaiting transplantation has led to the increasing recognition that long-term survival is possible in many of these children with and often without intestinal transplantation. Even children with very small lengths of residual intestine ultimately may adapt and grow sufficiently to allow enteral autonomy. Achievement of these outcomes requires early referral to a dedicated multidisciplinary intestinal care team well versed in the management options for such children. Initial assessment often involves an inpatient evaluation followed by very close outpatient follow-up. Aggressive management is imperative for all patients with intestinal failure, allowing time for full enteral adaptation before complications become life-threatening; those with no possibility of significant adaptation can achieve optimal growth while awaiting transplantation. Along with medical and nutritional therapy and nontransplant surgery, intestinal transplantation should be seen as one of many modalities available for the optimal management of this population of patients. Thus, patients with irreversible intestinal failure and those with indications for transplantation (even those for whom hope remains that sufficient enteral adaptation still may occur) should be evaluated by the transplant team. If there is no intestinal transplant program at the center undertaking the intestinal failure management, strong links and regular communication with an intestinal transplant program that can partner in the care of these patients should be established. Multicenter collaborative and interventional studies are necessary to clearly demonstrate outcomes and to move the field forward.

Evaluation of hemodynamic, metabolic, and electrolytic changes after graft reperfusion in a porcine model of intestinal transplantation

BACKGROUND

We sought to establish an anesthetic protocol to evaluate the hemodynamic, metabolic, and electrolytic changes after graft reperfusion in pigs undergoing orthotopic intestinal transplant (ITx).

METHODS

Fifteen pigs were distributed into two groups: GI (n = 6), without immunosuppression, and GII (n = 9), immunosuppressed before surgery with tacrolimus (0.3 mg/kg). The animals were premedicated at 1 hour before surgery with IM acepromazine (0.1 mg/kg), morphine (0.4 mg/kg), ketamine (10 mg/kg), and atropine (0.044 mg/kg IM). Anesthesia induction used equal proportions of diazepam and ketamine (0.1-0.15 mL/kg/IV) and for maintenance in IV infusion of xylazine (1 mg/mL), ketamine (2 mg/mL), and guaiacol glyceryl ether 5% (50 mg/mL), diluted in 250 mL of 5% glucose solution. In addition, recipient pigs were treated with isofluorane inhalation. Heart rate (HR), systolic (SAP), mean (MAP), and diastolic (DAP) arterial pressure, pulse oximetry, respiratory frequency (f), capnography, body temperature (T), blood gas analysis (pH, Paco(2), Pao(2), base excess, BE; Hco(3)(-), Sato(2)), serum potassium (K), calcium (Ca), sodium, hematocrit (Hct), and glucose (Glu) were measured at four times; M0: after incision (basal value); M1: 10 minutes before reperfusion; and M2 and M3: 10 and 20 minutes after graft reperfusion.

RESULTS

All groups behaved in a similar pattern. There was significant hypotension after graft reperfusion in GI and GII (M2 = 56.2 +/- 6.4 and M3 = 57.2 +/- 8.3 mm Hg and M2 = 65.7 +/- 10.2 and M3 = 67.8 +/- 16.8 mm Hg, respectively), accompanied by elevated HR. The ETco(2) was elevated at M2 (42 mm Hg) and M3 (40 mm Hg). Metabolic acidosis was observed after reperfusion, with significant increase in K levels.

CONCLUSION

The anesthetic protocol for donors and recipients was safe to perform the procedure, allowing control of hemodynamic and metabolic changes after reperfusion without differences regarding immunosuppression.

La greffe intestinale

Even though surgical techniques for isolated intestine, liver-intestine, and multivisceral transplantations were developed in the 1960's, very few patients were transplanted before 1990 because initial immunosuppression regimens were insufficient, making intestine transplantation impossible. Intestine transplantation resulted in death in most patients within days or months. The discouraging results of the first clinical trials were due to technical complications, sepsis, and the failure of conventional immunosuppression to control rejection. By 1990 the development of tacrolimus-based immunosuppression and improved surgical techniques, the increased array of potent immunosuppressive medications, infection prophylaxis, and suitable patient selection helped improve actuarial graft and patient survival rates for all types of intestine transplantation. The aims of this review are to describe the current status of intestine transplantation including the underlying diseases and conditions that may be indications for intestine transplantation, to identify patient populations for this indication, to provide key steps for patient evaluation, to summarize current recommendations for immunosuppression, to list the most common postoperative complications, and to discuss the international experience of small bowel transplantation compiled and analyzed by the International Intestine Transplant Registry since 1985.

Sustainability of mechanically lengthened bowel in rats

INTRODUCTION

It has been shown that the length of an intestinal segment may be doubled by applying gradual mechanical stretching. This study evaluated whether the lengthened intestinal segment retained the structure and function after the stretching device was removed.

METHODS

A 1.5-cm jejunal segment was separated from intestinal continuity in 20 rats. After advancing a screw into the isolated jejunal segment by 5 mm 3 times a week until it was stretched by 3 cm, the screw was removed. Three weeks later, the jejunal segments were retrieved for analyses. Comparisons were made between the lengthened jejunal segments.

RESULTS

The jejunal segment doubled its length after gradual stretching and retained this length 3 weeks after the screw removal (3.1 +/- 0.8 vs 3.2 +/- 0.4 cm, P > .05). The villous height, the muscular thickness, and the total alkaline phosphatase and lactase activities of the stretched jejunal segments were also unchanged 3 weeks after the screw removal.

CONCLUSIONS

Mechanical force induced the sustained lengthening of isolated jejunal segments in rats. The histologic and enzymatic alterations also persisted 3 weeks after the mechanical force was removed. This phenomenon may provide a novel method for the treatment of short bowel syndrome.

[Short bowel syndrome]

Short bowel syndrome (SBS) is defined in adults as a malabsorption disorder as a result of shortening the bowel to <200 cm. The severity of symptoms is less dependent on the amount of residual intestine than on the anatomical position of the resected bowel, the type of operative reconstruction, and the type and quality of nutritional, medical, and surgical treatment. Numerous complications and deficiency symptoms are associated with SBS. The extent of deficient nutrition should be determined. The need to create accesses for enteral and parenteral delivery, to supply supplementation as needed, perform pharmacological therapy, and in individual cases surgical treatment all necessitate a broad knowledge of nutritional medicine. The goals of therapy are correction and prevention of malnourishment, restoration of a normal nutritional status, and the normal thriving of children. Complications should be avoided, particularly those problems associated with parenteral nutrition. The frequency of diarrhea should be reduced. Overall, the aim is to achieve an optimized quality of life.