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Hanks J, Girard C, Sehgal S. Acute rejection post lung transplant. Curr Opin Pulm Med 2024; 30:391-397. [PMID: 38656281 DOI: 10.1097/mcp.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW To review what is currently known about the pathogenesis, diagnosis, treatment, and prevention of acute rejection (AR) in lung transplantation. RECENT FINDINGS Epigenomic and transcriptomic methods are gaining traction as tools for earlier detection of AR, which still remains primarily a histopathologic diagnosis. SUMMARY Acute rejection is a common cause of early posttransplant lung graft dysfunction and increases the risk of chronic rejection. Detection and diagnosis of AR is primarily based on histopathology, but noninvasive molecular methods are undergoing investigation. Two subtypes of AR exist: acute cellular rejection (ACR) and antibody-mediated rejection (AMR). Both can have varied clinical presentation, ranging from asymptomatic to fulminant ARDS, and can present simultaneously. Diagnosis of ACR requires transbronchial biopsy; AMR requires the additional measuring of circulating donor-specific antibody (DSA) levels. First-line treatment in ACR is increased immunosuppression (pulse-dose or tapered dose glucocorticoids); refractory cases may need antibody-based lymphodepletion therapy. First line treatment in AMR focuses on circulating DSA removal with B and plasma cell depletion; plasmapheresis, intravenous human immunoglobulin (IVIG), bortezomib, and rituximab are often employed.
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Affiliation(s)
- Justin Hanks
- Department of Pulmonary Medicine, Integrated Hospital Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Muylle E, Maes A, De Hertogh G, Van De Winkel N, Kerckhofs G, Dubois A, Vandecaveye V, Thorrez L, Hennion I, Emonds MP, Pans S, Deferm NP, Monbaliu D, Canovai E, Vanuytsel T, Pirenne J, Ceulemans LJ. Multilevel Analysis of the Neovascularization and Integration Process of a Nonvascularized Rectus Fascia Transplantation. Transplant Direct 2024; 10:e1624. [PMID: 38757048 PMCID: PMC11098214 DOI: 10.1097/txd.0000000000001624] [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: 01/22/2024] [Accepted: 02/05/2024] [Indexed: 05/18/2024] Open
Abstract
Background Failure to close the abdominal wall after intestinal transplantation (ITx) or multivisceral Tx remains a surgical challenge. An attractive method is the use of nonvascularized rectus fascia (NVRF) in which both layers of the donor abdominal rectus fascia are used as an inlay patch without vascular anastomosis. How this graft integrates over time remains unknown. The study aims to provide a multilevel analysis of the neovascularization and integration process of the NVRF. Methods Three NVRF-Tx were performed after ITx. Clinical, radiological, histological, and immunological data were analyzed to get insights into the neovascularization and integration process of the NVRF. Moreover, cryogenic contrast-enhanced microfocus computed tomography (microCT) analysis was used for detailed reconstruction of the vasculature in and around the NVRF (3-dimensional histology). Results Two men (31- and 51-y-old) and 1 woman (49-y-old) underwent 2 multivisceral Tx and 1 combined liver-ITx, respectively. A CT scan showed contrast enhancement around the fascia graft at 5 days post-Tx. At 6 weeks, newly formed blood vessels were visualized around the graft with Doppler ultrasound. Biopsies at 2 weeks post-Tx revealed inflammation around the NVRF and early fibrosis. At 6 months, classical 2-dimensional histological analysis of a biopsy confirmed integration of the fascia graft with strong fibrotic reaction without signs of rejection. A cryogenic contrast-enhanced microCT scan of the same biopsy revealed the presence of microvasculature, enveloping and penetrating the donor fascia. Conclusions We showed clinical, histological, and microCT evidence of the neovascularization and integration process of the NVRF after Tx.
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Affiliation(s)
- Ewout Muylle
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Leuven, Belgium
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Arne Maes
- Department of Materials Engineering, KU Leuven, Leuven, Belgium
- Biomechanics Lab, Institute of Mechanics, Materials and Civil Engineering, UCLouvain, Louvain-la-Neuve, Belgium
- Pole of Morphology, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
| | - Gert De Hertogh
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Leuven, Belgium
- Department of Pathology, University Hospitals Leuven, Leuven, Belgium
- Unit of Translational Cell- and Tissue Research, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Nele Van De Winkel
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Leuven, Belgium
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Unit of Urogenital, Abdominal and Plastic Surgery, KU Leuven, Leuven, Belgium
| | - Greet Kerckhofs
- Department of Materials Engineering, KU Leuven, Leuven, Belgium
- Biomechanics Lab, Institute of Mechanics, Materials and Civil Engineering, UCLouvain, Louvain-la-Neuve, Belgium
- Pole of Morphology, Institute of Experimental and Clinical Research, UCLouvain, Brussels, Belgium
- Prometheus Division of Skeletal Tissue Engineering, KU Leuven, Leuven, Belgium
| | - Antoine Dubois
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Leuven, Belgium
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Vincent Vandecaveye
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
- Translational MRI Unit, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Lieven Thorrez
- Tissue Engineering Lab, Department of Development and Regeneration, KU Leuven, KULAK campus Kortrijk, Kortrijk, Belgium
| | - Ina Hennion
- Tissue Engineering Lab, Department of Development and Regeneration, KU Leuven, KULAK campus Kortrijk, Kortrijk, Belgium
| | - Marie-Paule Emonds
- Histocompatibility and Immunogenetics Laboratory, Belgian Red Cross-Flanders, Mechelen, Belgium
| | - Steven Pans
- Department of Abdominal Surgery, Sint-Franciscusziekenhuis, Heusden-Zolder, Belgium
| | - Nathalie P. Deferm
- Department of Abdominal Surgery, Sint-Franciscusziekenhuis, Heusden-Zolder, Belgium
| | - Diethard Monbaliu
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Leuven, Belgium
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Emilio Canovai
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Tim Vanuytsel
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Leuven, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Leuven, Belgium
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Laurens J. Ceulemans
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Leuven, Belgium
- Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
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Muylle E, Van De Winkel N, Hennion I, Dubois A, Thorrez L, Deferm NP, Pirenne J, Ceulemans LJ. Abdominal Wall Closure in Intestinal and Multivisceral Transplantation: A State-Of-The-Art Review of Vascularized Abdominal Wall and Nonvascularized Rectus Fascia Transplantation. Gastroenterol Clin North Am 2024; 53:265-279. [PMID: 38719377 DOI: 10.1016/j.gtc.2023.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Failure to close the abdomen after intestinal or multivisceral transplantation (Tx) remains a frequently occurring problem. Two attractive reconstruction methods, especially in large abdominal wall defects, are full-thickness abdominal wall vascularized composite allograft (AW-VCA) and nonvascularized rectus fascia (NVRF) Tx. This review compares surgical technique, immunology, integration, clinical experience, and indications of both techniques. In AW-VCA Tx, vascular anastomosis is required and the graft undergoes hypotrophy post-Tx. Furthermore, it has immunologic benefits and good clinical outcome. NVRF Tx is an easy technique without the need for vascular anastomosis. Moreover, a rapid integration and neovascularization occurs with excellent clinical outcome.
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Affiliation(s)
- Ewout Muylle
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Nele Van De Winkel
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Abdominal Surgery, University Hospitals Leuven, UZ Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Development and Regeneration, Unit of Urogenital, Abdominal and Plastic Surgery, KU Leuven, Leuven, Belgium
| | - Ina Hennion
- Tissue Engineering Lab, Department of Development and Regeneration, KU Leuven, KULAK Campus Kortrijk, Etienne Sabbelaan 53, bus 7711, 8500 Kortrijk, Belgium
| | - Antoine Dubois
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology and Transplantation, KU Leuven, UZ Herestraat 49, bus 708, 3000 Leuven, Belgium
| | - Lieven Thorrez
- Tissue Engineering Lab, Department of Development and Regeneration, KU Leuven, KULAK Campus Kortrijk, Etienne Sabbelaan 53, bus 7711, 8500 Kortrijk, Belgium
| | - Nathalie P Deferm
- Department of General and Abdominal Surgery, Sint-Franciscushospital, Pastoor Paquaylaan 129, 3550 Heusden-Zolder, Belgium
| | - Jacques Pirenne
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Microbiology, Immunology and Transplantation, KU Leuven, UZ Herestraat 49, bus 708, 3000 Leuven, Belgium
| | - Laurens J Ceulemans
- Leuven Intestinal Failure and Transplantation (LIFT) Center, University Hospitals Leuven, Herestraat 49, bus 7003, 3000 Leuven, Belgium; Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium; Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.
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Stead TS, Brydges HT, Laspro M, Onuh OC, Chaya BF, Rabbani PS, Lu CP, Ceradini DJ, Gelb BE, Rodriguez ED. Minimally and Non-invasive Approaches to Rejection Identification in Vascularized Composite Allotransplantation. Transplant Rev (Orlando) 2023; 37:100790. [PMID: 37625211 DOI: 10.1016/j.trre.2023.100790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE Rejection is common and pernicious following Vascularized Composite Allotransplantation (VCA). Current monitoring and diagnostic modalities include the clinical exam which is subjective and biopsy with dermatohistopathologic Banff grading, which is subjective and invasive. We reviewed literature exploring non- and minimally invasive modalities for diagnosing and monitoring rejection (NIMMs) in VCA. METHODS PubMed, Cochrane, and Embase databases were queried, 3125 unique articles were reviewed, yielding 26 included studies exploring 17 distinct NIMMs. Broadly, NIMMs involved Imaging, Liquid Biomarkers, Epidermal Sampling, Clinical Grading Scales, and Introduction of Additional Donor Tissue. RESULTS Serum biomarkers including MMP3 and donor-derived microparticles rose with rejection onset. Epidermal sampling non-invasively enabled measurement of cytokine & gene expression profiles implicated in rejection. Both hold promise for monitoring. Clinical grading scales were useful diagnostically as was reflection confocal microscopy. Introducing additional donor tissue showed promise for preemptively identifying rejection but requires additional allograft tissue burden for the recipient. CONCLUSION NIMMs have the potential to dramatically improve monitoring and diagnosis in VCA. Many modalities show promise however, additional research is needed and a multimodal algorithmic approach should be explored.
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Affiliation(s)
- Thor S Stead
- Hansjorg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, United States of America.
| | - Hilliard T Brydges
- Hansjorg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, United States of America
| | - Matteo Laspro
- Hansjorg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, United States of America
| | - Ogechukwu C Onuh
- Hansjorg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, United States of America
| | - Bachar F Chaya
- Hansjorg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, United States of America
| | - Piul S Rabbani
- Hansjorg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, United States of America
| | - Catherine P Lu
- Hansjorg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, United States of America
| | - Daniel J Ceradini
- Hansjorg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, United States of America
| | - Bruce E Gelb
- Department of Surgery, NYU Grossman School of Medicine, New York, NY, United States of America
| | - Eduardo D Rodriguez
- Hansjorg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, United States of America
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Maklad M, Mazariegos G, Ganoza A. Pediatric intestine and multivisceral transplant. Curr Opin Organ Transplant 2023; 28:316-325. [PMID: 37418582 DOI: 10.1097/mot.0000000000001082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
Abstract
PURPOSE OF REVIEW Intestinal and multivisceral transplantation (ITx, MVTx) is the cornerstone in treatment of irreversible intestinal failure (IF) and complications related to parenteral nutrition. This review aims to highlight the unique aspects of the subject in pediatrics. RECENT FINDINGS Etiology of intestinal failure (IF) in children shares some similarity with adults but several unique considerations when being evaluated for transplantation will be discussed. Owing to significant advancement in IF management and home parenteral nutrition (PN), indication criteria for pediatric transplantation continues to be updated. Outcomes have continued to improve with current long-term patient and graft survival in multicenter registry reports reported at 66.1% and 48.8% at 5 years, respectively. Pediatric specific surgical challenges such abdominal closure, post transplantation outcomes, and quality of life are discussed in this review. SUMMARY ITx and MVTx remain lifesaving treatment for many children with IF. However long-term graft function is still a major challenge.
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Affiliation(s)
- Mohamed Maklad
- Hillman Center for Pediatric Transplantation, Thomas E. Starzl Transplantation Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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6
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Haykal S, Juvet S, Chan AW, O’Neill A, Pal P, Cypel M, Keshavjee S. Assessment of Acute Rejection in a Lung Transplant Recipient Using a Sentinel Skin Flap. Transpl Int 2023; 36:11166. [PMID: 37077407 PMCID: PMC10106558 DOI: 10.3389/ti.2023.11166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 03/21/2023] [Indexed: 04/05/2023]
Affiliation(s)
- Siba Haykal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University Healthy Network, Toronto, ON, Canada
- *Correspondence: Siba Haykal,
| | - Stephen Juvet
- Division of Medicine, Division of Respirology, University Healthy Network, Toronto, ON, Canada
| | - An-Wen Chan
- Department of Dermatology, University Healthy Network, Toronto, ON, Canada
| | - Anne O’Neill
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University Healthy Network, Toronto, ON, Canada
| | - Prodipto Pal
- Department of Pathology, University Healthy Network, Toronto, ON, Canada
| | - Marcelo Cypel
- Division of Thoracic Surgery, Department of Surgery, University Healthy Network, Toronto, ON, Canada
| | - Shaf Keshavjee
- Division of Thoracic Surgery, Department of Surgery, University Healthy Network, Toronto, ON, Canada
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Abstract
PURPOSE OF REVIEW Achieving abdominal wall closure after intestinal transplantation (ITx) is one of the crucial surgical challenges. This problem is present in 25-50% of all transplants due to reduction in abdominal domain, fistulae and extensive adhesions due to previous surgeries. Failure to achieve closure is an independent risk factor for mortality and graft loss. The aim of this paper is to summarize the current options to achieve this. RECENT FINDINGS Successful closure of the abdomen requires a tension-free repair. Primary closure of the fascia can be reinforced with synthetic or biological mesh. For more complex fascial defects bridging mesh, nonvascularised or vascularised rectus fascia can be utilised. If all components of the abdominal wall are affected, then a full-thickness abdominal wall transplantation may be necessary. SUMMARY A variety of successful techniques have been described by different groups to enable abdominal wall closure after ITx. Emerging developments in preoperative imaging, reconstructive surgery and immunology have expanded the surgical toolkit available. Crucial is a tailor-made approach whereby patients with expected closure issues are identified prior to surgery and the simplest technique is chosen.
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Affiliation(s)
- Irum Amin
- Department of Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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8
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Bustos VP, Escandón JM, Santamaría E, Ciudad P, Forte AJ, Hernandez-Alejandro R, Leckenby JI, Langstein HN, Manrique OJ. Abdominal Wall Vascularized Composite Allotransplantation: A Scoping Review. J Reconstr Microsurg 2021; 38:481-490. [PMID: 34905782 DOI: 10.1055/s-0041-1740121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Abdominal wall vascularized composite allotransplantation (AW-VCA) is a novel reconstructive technique used for large abdominal wall defects in combination with intestinal transplantation (ITx) or multivisceral abdominal transplantation (MVTx). Since the introduction of this procedure, several studies have been published reporting their experience. This study aims to present a scoping review looking at all available evidence-based medicine information to understand the most current surgical techniques and clinical outcomes. METHODS This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) extension for scoping reviews checklist. A comprehensive research strategy of several databases was conducted. RESULTS A total of 31 studies were included in this review, which comprised animal, cadaveric, and human studies. In human studies, four surgical techniques with high flap survival rates and low complication rates were found. In cadaveric studies, it was shown that the use of iliofemoral cuff-based flaps provided adequate tissue perfusion to the abdominal wall graft. Also, the use of thoracolumbar nerves have been described to provide functionality to the AW-VCA and prevent long-term muscle atrophy. CONCLUSION AW-VCA is a safe and efficient alternative for patients with large and complex abdominal wall defects. The future holds a promising evolution of a functional AW-VCA, though surgeons must face and overcome the challenge of distorted anatomy frequently present in this population. Forthcoming studies with a better level of evidence are required to evaluate functionality and differences between surgical techniques.
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Affiliation(s)
- Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Eric Santamaría
- Department of Plastic and Reconstructive Surgery, Hospital General Dr. Manuel Gea Gonzalez, National Cancer Institute, Mexico City, Mexico
| | - Pedro Ciudad
- Department of Plastic, Reconstructive, and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Antonio J Forte
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Jacksonville, Florida
| | - Roberto Hernandez-Alejandro
- Division of Abdominal Transplantation and Hepatobiliaty Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Jonathan I Leckenby
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Howard N Langstein
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
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Abstract
AbstractPurpose of ReviewSkin provides a window into the health of an individual. Using transplanted skin as a monitor can provide a powerful tool for surveillance of rejection in a transplant. The purpose of this review is to provide relevant background to the role of skin in vascularized transplantation medicine.Recent FindingsDiscrete populations of T memory cells provide distributed immune protection in skin, and cycle between skin, lymph nodes, and blood. Skin-resident TREGcells proliferate in response to inflammation and contribute to long-term VCA survival in small animal models. Early clinical studies show sentinel flap rejection to correlate well with facial VCA skin rejection, and abdominal wall rejection demonstrates concordance with visceral rejection, but further studies are required.SummaryThis review focuses on the immunology of skin, skin rejection in vascularized composite allografts, and the recent advances in monitoring the health of transplanted tissues using distant “sentinel” flaps.
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Abstract
Abstract
Purpose of Review
This article aims to review published outcomes associated with full-thickness vascularized abdominal wall transplantation, with particular emphasis on advances in the field in the last 3 years.
Recent Findings
Forty-six full-thickness vascularized abdominal wall transplants have been performed in 44 patients worldwide. Approximately 35% of abdominal wall transplant recipients will experience at least one episode of acute rejection in the first year after transplant, compared with rejection rates of 87.8% and 72.7% for hand and face transplant respectively. Recent evidence suggests that combining a skin containing abdominal wall transplant with an intestinal transplant does not appear to increase sensitization or de novo donor-specific antibody formation.
Summary
Published data suggests that abdominal wall transplantation is an effective safe solution to achieve primary closure of the abdomen after intestinal or multivisceral transplant. However, better data is needed to confirm observations made and to determine long-term outcomes, requiring standardized data collection and reporting and collaboration between the small number of active transplant centres around the world.
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Honeyman C, Stark HL, Fries CA, Gorantla VS, Davis MR, Giele H. Vascularised composite allotransplantation in solid organ transplant recipients: A systematic review. J Plast Reconstr Aesthet Surg 2020; 74:316-326. [PMID: 33036926 DOI: 10.1016/j.bjps.2020.08.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 03/16/2020] [Accepted: 08/20/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION A solid organ transplant (SOT) recipient, already taking immunosuppression, may represent the ideal candidate for vascularised composite allograft transplantation (VCA). However, concerns have been raised about the potential risk of SOT loss or the need for increased immunosuppression to sustain the VCA. This systematic review examines all published cases of SOT recipients who have received a VCA to establish associated morbidity and immunosuppression requirements. METHODS A systematic review was performed in accordance with the PRISMA guidelines. The PubMed, MEDLINE and EMBASE databases were searched for original articles published between January 1997 and May 2019. Only articles relating to patients who had received both a VCA and SOT with a reported follow up of greater than six months were included. RESULTS Fifteen articles were identified, including data from 39 VCAs in 37 patients. There was no increase in the number of SOT rejection episodes, complications such as post-transplant lymphoproliferative disorder or graft versus host disease, de novo donor specific HLA antibodies or short-term risks to the recipient when compared with SOT in isolation. One child required a sustained increase in their baseline immunosuppression following bilateral hand transplantation. CONCLUSIONS In this small heterogeneous cohort, the addition of a VCA to a SOT does not appear to increase the short-term risks to the SOT or the patient with comparable results to SOT in isolation. However, data are often poorly reported and longer-term follow up and uniform reporting of outcomes would be beneficial to more accurately assess the safety profile of combining VCA with SOT.
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Affiliation(s)
- Calum Honeyman
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Helen L Stark
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Charles A Fries
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Vijay S Gorantla
- Wake Forest Institute of Regenerative Medicine, Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | - Michael R Davis
- The United States Army Institute of Surgical Research, San Antonio, TX, USA
| | - Henk Giele
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Synchronous Abdominal Wall and Small-bowel Transplantation: A 1-year Follow-up. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2995. [PMID: 32802681 PMCID: PMC7413814 DOI: 10.1097/gox.0000000000002995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/03/2020] [Indexed: 11/26/2022]
Abstract
Abdominal wall-vascularized composite allotransplantation (AW-VCA) has evolved as a technically feasible but challenging option in the rare event of abdominal wall reconstruction in patients whose abdomen cannot be closed by applying conventional methods. The authors conducted the first synchronous child-to-adult recipient AW-VCA using an arteriovenous loop technique. This article presents a 1-year follow-up of the patient's postoperative course. Frequent skin biopsies were performed in accordance with Duke Institutional Review Board protocol, with 3 episodes of rejection treated with high-dose steroids and Thymoglobulin (Genzyme Corp, Cambridge, Mass.). The patient developed an opportunistic fungal brain abscess secondary to immunosuppression, which led to temporary upper extremity weakness. Future considerations for AW-VCA include a modified surgical technique involving utilization of donor vein graft for arteriovenous loop formation. In addition, reduction in postoperative biopsy schedule and changes in immunosuppression regimen may lead to improved outcomes and prevent unnecessary high-dose immunosuppression.
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14
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Safe and Successful Treatment of Acute Cellular Rejection of an Intestine and Abdominal Wall Transplant With Vedolizumab. Transplant Direct 2020; 6:e527. [PMID: 32095513 PMCID: PMC7004630 DOI: 10.1097/txd.0000000000000973] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/15/2019] [Accepted: 11/20/2019] [Indexed: 01/02/2023] Open
Abstract
Graft survival rates after intestinal transplantation (ITx) are still the lowest in comparison to other solid organ transplants. One of the main reasons is the frequent occurrence of acute cellular rejection (ACR). Vedolizumab is an antibody against α4β7+ integrin involved in gut-homing of T cells which has been approved for inflammatory bowel diseases (IBD). We report its off-label use to treat ACR after ITx.
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Abstract
"The intestinal transplantation is reserved for patients with life-threatening complications of permanent intestinal failure or underlying gastrointestinal disease. The choice of the allograft for a particular patient depends on several factors and the presence of concurrent organ failure, and availability of the donor organs, and specialized care. Combined liver and intestinal transplant allows for patients who have parenteral nutrition-associated liver disease a possibility of improved quality of life and nutrition as well as survival. Intestinal transplantation has made giant strides over the past few decades to the present era where current graft survivals are comparable with other solid organ transplants."
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Affiliation(s)
- Arshad B Kahn
- Altru Health System, 715 Delmore Drive, Roseau, MN 56751, USA
| | - Kiara A Tulla
- Department of Surgery, University of Illinois at Chicago, 840 South Wood Street, 376 CSN, M/C 958, Chicago, IL 60612, USA
| | - Ivo G Tzvetanov
- Division of Transplantation, Department of Surgery, University of Illinois at Chicago, 840 South Wood Street, Suite 402, Chicago, IL 60612, USA.
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16
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Cassar N, Cortes-Cerisuelo M, Bambridge C, Ali A, Heaton N, Vilca-Melendez H. The difficult abdominal closure after paediatric intestinal transplantation: Use of abdominal rectus muscle fascia and literature review. Pediatr Transplant 2019; 23:e13473. [PMID: 31124589 DOI: 10.1111/petr.13473] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 02/19/2019] [Accepted: 04/09/2019] [Indexed: 12/19/2022]
Abstract
Primary abdominal wall closure after intestinal and multivisceral transplantation may not be possible because of loss of abdominal domain and/or graft size/abdominal cavity mismatch. Traditional closure techniques for the open abdomen may not be valid in these circumstances because of severe scarring of the abdominal wall from multiple previous surgeries in this particular group of patients. We present our initial experience with the use of non-vascularized abdominal rectus muscle fascia in two patients who underwent deceased donation and living-related combined liver and small bowel transplantation, respectively, and who could not be closed primarily. The donor fascia was attached to the recipient fascia in both patients. In either case, there was not enough skin cover for closure, the wound was left open, and a negative pressure dressing was applied. In both cases, over a period of 6 months after placement of the non-vascularized abdominal rectus muscle fascia, the wound contracted, granulation tissue gradually covered the wound, and healing occurred, giving an intact abdominal wall. The abdominal rectus muscle fascia from a deceased donor can be used in a definite procedure for closure of the abdominal wall either at the time of transplant or later when a suitable rectus muscle fascia graft becomes available.
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Affiliation(s)
- Noel Cassar
- Institute of Liver Studies, King's Healthcare Partners Denmark Hill Site, London, UK
| | | | - Carly Bambridge
- Institute of Liver Studies, King's Healthcare Partners Denmark Hill Site, London, UK
| | - Amir Ali
- Institute of Liver Studies, King's Healthcare Partners Denmark Hill Site, London, UK
| | - Nigel Heaton
- Institute of Liver Studies, King's Healthcare Partners Denmark Hill Site, London, UK
| | - Hector Vilca-Melendez
- Institute of Liver Studies, King's Healthcare Partners Denmark Hill Site, London, UK
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17
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Abdominal wall transplantation in organ transplantation: Our experience. Cir Esp 2019; 97:247-253. [PMID: 30948213 DOI: 10.1016/j.ciresp.2019.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/26/2019] [Accepted: 03/01/2019] [Indexed: 12/21/2022]
Abstract
Abdominal wall transplantation has been consolidated as an alternative to primary abdominal wall closure in intestinal and multiple organ transplant recipients. Given that it is feasible to obtain the visceral graft and the abdominal wall graft from the same donor, abdominal wall transplantation could offer satisfactory outcomes and be easily coordinated. Non-vascularized fascia is one of the alternatives for abdominal wall closure in transplantation. We report two cases of non-vascularized fascia transplantation in intestinal and multivisceral transplants, respectively. Both donors were young (23 and 18 years old). Both recipients had endured multiple previous surgeries, and no surgical alternatives for primary wall repair could be offered. In both cases, a complete abdominal wall flap was retrieved from the donor, however, due to the characteristics of the recipient's abdominal wall defect, only non-vascularized fascia was used after removing skin and subcutaneous cellular tissue from the graft. Abdominal wall transplantation is an option to consider for abdominal wall closure in patients with multiple previous surgeries and no alternatives for primary wall repair.
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18
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Honeyman C, Fries CA. Vascularised Composite Allotransplantation – Basic Science and Clinical Applications. ACTA ACUST UNITED AC 2019. [DOI: 10.29337/ijops.28] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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19
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Abstract
The evolution and success of intestinal and multi-visceral transplantation over the past 20 years have raised the issue of difficult or even impossible abdominal closure, a topic rarely encountered in other fields of transplantation. Different techniques have been proposed to address this topic. The choice depends on the transplant team's expertise and/or the availability of a plastic surgery service. Abdominal wall transplant is a type of composite tissue allograft that can be utilized to reconstitute the abdominal domains of patients who undergo intestinal transplant, and the results are encouraging. It is an effective option to achieve primary abdominal closure after intestinal transplant. In its full-thickness form, it may be useful for monitoring rejection or viability of visceral organs. Our aim is to review the role of abdominal wall transplant in achieving tension-free closure of the abdomen.
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Affiliation(s)
- Seong Hyuk Park
- From the Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Korea
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20
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Molitor M, Oliverius M, Sukop A. Abdominal wall allotransplantation. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2018; 162:184-189. [PMID: 30209436 DOI: 10.5507/bp.2018.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/27/2018] [Indexed: 11/23/2022] Open
Abstract
Allotransplantation of vascularized composite tissue is a new field of transplantation surgery. One application of this technique is abdominal wall transplantation used as a supplementary procedure to the transplantation of visceral organs in patients with abdominal compartment deficits. As abdominal wall closure problems are experienced in around 30-40% of such patients, peer reviewed conclusions on the viability of various options, are important for an informed choice of possible procedures. This review focuses on the abdominal wall allotransplantion procedure. Our search provided 35 appropriate references which we used to support our findings as follows: abdominal wall transplantation was performed in 33 patients at seven centres. Of these, 30 had a full thickness abdominal wall transplanted from the same donor, 3 from a second donor. Three had visceral organ transplants and in addition, the posterior sheet of the rectus muscle fascia. In summary, our findings were that abdominal wall allotransplantation does not jeopardize the outcome of visceral organs transplantation. There is no higher risk of complications or rejection of the visceral organs. There have been no fatalities as a direct result of complications due to abdominal wall transplantation. Finally, the transplanted abdominal wall may provide an early warning of rejection before diagnostic tests on the bowel are symptomatic.
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Affiliation(s)
- Martin Molitor
- Department of Plastic Surgery Hospital na Bulovce and 1 st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Martin Oliverius
- Department of General Surgery, 3 rd Faculty of Medicine, Charles University and Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Andrej Sukop
- Department of Plastic Surgery, 3 rd Faculty of Medicine, Charles University and Hospital Kralovske Vinohrady, Prague, Czech Republic
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21
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Kollar B, Tasigiorgos S, Dorante MI, Carty MJ, Talbot SG, Pomahac B. Innovations in reconstructive microsurgery: Reconstructive transplantation. J Surg Oncol 2018; 118:800-806. [PMID: 30098294 DOI: 10.1002/jso.25147] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/04/2018] [Indexed: 12/17/2022]
Abstract
In the past 20 years, reconstructive transplantation (RT) has emerged as a viable reconstructive option for carefully selected patients. More than 100 upper extremity and 40 face transplants have been performed worldwide to date. Concomitantly, the portfolio of reconstructive transplantation has been extended by additional procedures such as lower extremities, abdominal wall, neck, uterus, genitourinary, and pediatric transplants. In the present review article, we aim to summarize the current state of knowledge about this exciting field.
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Affiliation(s)
- Branislav Kollar
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sotirios Tasigiorgos
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Miguel I Dorante
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthew J Carty
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Simon G Talbot
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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22
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Weissenbacher A, Vrakas G, Chen M, Reddy S, Allan P, Giele H, Barnardo MC, Vaidya A, Friend PJ, Fuggle SV. De novo
donor-specific HLA antibodies after combined intestinal and vascularized composite allotransplantation - a retrospective study. Transpl Int 2017; 31:398-407. [DOI: 10.1111/tri.13096] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/24/2017] [Accepted: 11/12/2017] [Indexed: 12/26/2022]
Affiliation(s)
- Annemarie Weissenbacher
- Oxford Transplant Centre; Nuffield Department of Surgical Sciences; Oxford University Hospitals; Churchill Hospital Oxford, UK
- Department of Visceral; Transplant and Thoracic Surgery; Innsbruck Medical University Innsbruck, Austria
| | - Georgios Vrakas
- Oxford Transplant Centre; Nuffield Department of Surgical Sciences; Oxford University Hospitals; Churchill Hospital Oxford, UK
| | - Mian Chen
- Oxford Transplant Centre; Nuffield Department of Surgical Sciences; Oxford University Hospitals; Churchill Hospital Oxford, UK
| | - Srikanth Reddy
- Oxford Transplant Centre; Nuffield Department of Surgical Sciences; Oxford University Hospitals; Churchill Hospital Oxford, UK
| | - Philip Allan
- Oxford Transplant Centre; Nuffield Department of Surgical Sciences; Oxford University Hospitals; Churchill Hospital Oxford, UK
- Translational Gastroenterology Unit; John Radcliffe Hospital; Oxford UK
| | - Henk Giele
- Department of Plastic and Reconstructive Surgery; John Radcliffe Hospital; Oxford UK
| | - Martin C.N.M Barnardo
- Oxford Transplant Centre; Nuffield Department of Surgical Sciences; Oxford University Hospitals; Churchill Hospital Oxford, UK
| | - Anil Vaidya
- Transplant Department; Apollo Hospitals Enterprise; Chennai India
| | - Peter J. Friend
- Oxford Transplant Centre; Nuffield Department of Surgical Sciences; Oxford University Hospitals; Churchill Hospital Oxford, UK
| | - Susan V. Fuggle
- Oxford Transplant Centre; Nuffield Department of Surgical Sciences; Oxford University Hospitals; Churchill Hospital Oxford, UK
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23
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Abstract
PURPOSE OF REVIEW Abdominal wall transplantation is a technique used to achieve abdominal closure after intestinal and multivisceral transplantation. This review focuses on whether there are additional benefits for the skin component as an immune-monitoring tool. RECENT FINDINGS The largest series of abdominal wall transplants has recently been published. Alongside the physiological advantage gained in abdominal closure, the authors describe the immunological insight that the skin component can provide and how this contributes to the management of patients. The skin appears to develop a rash with early rejection, which facilitates early systemic treatment before significant visceral rejection occurs. It can also help in cases in which there is diagnostic doubt regarding the cause of bowel dysfunction such as in instances of intestinal infection. Despite the additional immunological burden of donor tissue, there appears to be no requirement for increased immunosuppressive therapy. SUMMARY The technical and immunological feasibility of abdominal wall transplantation has now been demonstrated by several centres. Skin transplanted as part of the abdominal wall or as a separate vascularized sentinel skin flap may aid in the diagnosis of rejection. This has the potential to improve graft survival and reduce immunosuppressive morbidity.
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24
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Farinelli P, Rubio J, Padín J, Rumbo C, Solar H, Ramisch D, Gondolesi G. Use of Nonvascularized Abdominal Rectus Fascia After Liver, Small Bowel, and Multiorgan Transplantation: Long-Term Follow-up of a Single-Center Series. Transplant Proc 2017; 49:1810-1814. [DOI: 10.1016/j.transproceed.2017.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/13/2017] [Indexed: 12/17/2022]
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25
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Lauro A, Vaidya A. Role of “reduced-size” liver/bowel grafts in the “abdominal wall transplantation” era. World J Gastrointest Surg 2017; 9:186-192. [PMID: 29081901 PMCID: PMC5633532 DOI: 10.4240/wjgs.v9.i9.186] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/24/2017] [Accepted: 07/10/2017] [Indexed: 02/06/2023] Open
Abstract
The evolution of multi-visceral and isolated intestinal transplant techniques over the last 3 decades has highlighted the technical challenges related to the closure of the abdomen at the end of the procedure. Two key factors that contribute to this challenge include: (1) Volume/edema of donor graft; and (2) loss of abdominal domain in the recipient. Not being able to close the abdominal wall leads to a variety of complications and morbidity that range from complex ventral hernias to bowel perforation. At the end of the 90’s this challenge was overcome by graft reduction during the donor operation or bench table procedure (especially reducing liver and small intestine), as well as techniques to increase the volume of abdominal cavity by pre-operative expansion devices. Recent reports from a few groups have demonstrated the ability of transplanting a full-thickness, vascularized abdominal wall from the same donor. Thus, a spectrum of techniques have co-evolved with multi-visceral and intestinal transplantation, ranging from graft reduction to enlarging the volume of the abdominal cavity. None of these techniques are free from complications, however in large-volume centers the combinations of both (graft reduction and abdominal widening, sometimes used in the same patient) could decrease the adverse events related to recipient’s closure, allowing a faster recovery. The quest for a solution to this unique challenge has led to the proposal and implementation of innovative solutions to enlarge the abdominal cavity.
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Affiliation(s)
- Augusto Lauro
- Liver and Multiorgan Transplant Unit, St Orsola University Hospital, 40138 Bologna, Italy
| | - Anil Vaidya
- Department of Transplant Surgery, Oxford University Hospital, Oxford OX3 7LE, United Kingdom
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26
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Diagnostic Lessons from a Complex Case of Postintestinal Transplantation Enteropathy. Case Rep Transplant 2017; 2017:2498423. [PMID: 28845319 PMCID: PMC5563400 DOI: 10.1155/2017/2498423] [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: 03/18/2017] [Revised: 06/04/2017] [Accepted: 07/04/2017] [Indexed: 11/20/2022] Open
Abstract
Recent advances in the field of intestinal transplantation have been mitigated by the incidence of allograft rejection. In such events, early identification and appropriate timing of antirejection therapy are crucial in retaining graft function. We present the case of a patient who suffered severe postintestinal transplantation allograft enteropathy, primarily characterized by extensive mucosal ulcerations, and was refractory to all conventional therapy. This progressed as chronic rejection; however crucially this was not definitively diagnosed until allograft function had irreversibly diminished. We argue that the difficulties encountered in this case can be attributed to the inability of our current array of investigative studies and diagnostic guidelines to provide adequate clinical guidance. This case illustrates the importance of developing reliable and specific markers for guiding the diagnosis of rejection and the use of antirejection therapeutics in this rapidly evolving field of transplant surgery.
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27
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Clift AK, Giele H, Reddy S, Macedo R, Al-Nahhas A, Wasan HS, Gondolesi GE, Vianna RM, Friend P, Vaidya A, Frilling A. Neoadjuvant peptide receptor radionuclide therapy and modified multivisceral transplantation for an advanced small intestinal neuroendocrine neoplasm: an updated case report. Innov Surg Sci 2017; 2:247-253. [PMID: 31579758 PMCID: PMC6754026 DOI: 10.1515/iss-2017-0025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 08/02/2017] [Indexed: 01/12/2023] Open
Abstract
Small intestinal neuroendocrine neoplasms (SI-NEN) frequently metastasise to regional lymph nodes, and surgery is the mainstay of therapy for such patients. However, despite the possible use of advanced surgical techniques, the resection of both primary and locoregional diseases is not always attainable. Intestinal and multivisceral transplantation has been performed in a small number of patients with conventionally nonresectable, slow-growing tumours threatening the mesenteric root but has remained controversial. The use of donor skin in “sentinel flaps” in transplantation theoretically offers advantages in tailoring immunosuppression and monitoring for rejection. We represent (with extended follow-up) the first case of a patient with inoperable extensive mesenteric metastases from SI-NEN, who underwent neoadjuvant peptide receptor radionuclide therapy before a modified multivisceral transplant with a concomitant vascularised sentinel forearm flap. At 48 months after transplantation, our patient remained at full physical activity with no evidence of disease recurrence on either tumour biochemistry or radiological imaging.
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Affiliation(s)
- Ashley K Clift
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Henk Giele
- Department of Plastic and Reconstructive Surgery, Oxford University NHS Trust, Oxford, UK
| | - Srikanth Reddy
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, UK
| | - Rubens Macedo
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, UK
| | - Adil Al-Nahhas
- Department of Nuclear Medicine, Imperial College London, London, UK
| | - Harpreet S Wasan
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Gabriel E Gondolesi
- Instituto de Trasplante Multiorgano, Fundacion Favaloro, Buenos Aires, Argentina
| | - Rodrigo M Vianna
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Peter Friend
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, UK
| | - Anil Vaidya
- Department of Plastic and Reconstructive Surgery, Oxford University NHS Trust, Oxford, UK
| | - Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK,
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28
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Ali JM, Catarino P, Dunning J, Giele H, Vrakas G, Parmar J. Could Sentinel Skin Transplants Have Some Utility in Solid Organ Transplantation? Transplant Proc 2017; 48:2565-2570. [PMID: 27788782 DOI: 10.1016/j.transproceed.2016.06.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 06/06/2016] [Indexed: 12/20/2022]
Abstract
Accurate diagnosis of allograft rejection can be hazardous and challenging. A strategy that has emerged from experience with vascularized composite allografts (VCAs) is the use of sentinel skin transplants (SSTs)-portions of donor skin transplanted synchronously to an allograft. Work in nonhuman animal models and experience with VCAs suggest concordance between rejection occurring in the primary allograft and the SST, and that appearance of rejection in the SST may precede rejection in the primary allograft, permitting early therapeutic intervention that may improve outcomes with lower rates of chronic rejection. The encouraging findings reported in VCA transplantation raise the possibility that SST may also be useful in solid organ transplantation. Some evidence is provided by experience with abdominal wall transplantation in some intestinal and multivisceral transplant recipients. Results from those reports raise the possibility that rejection may manifest in the skin component before emergence in the intestinal allograft, providing a "lead time" during which treatment of rejection of the abdominal wall could prevent the emergence of intestinal rejection. It is plausible that these findings may be extrapolated to other solid organ allografts, especially those for which obtaining an accurate diagnosis of acute rejection can be hazardous and challenging, such as the lung or pancreas. However, more data are required to support widespread adoption of this technique.
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Affiliation(s)
- J M Ali
- Department of Cardiothoracic Transplantation, Papworth Hospital, Papworth Everard, Cambridge, United Kingdom.
| | - P Catarino
- Department of Cardiothoracic Transplantation, Papworth Hospital, Papworth Everard, Cambridge, United Kingdom
| | - J Dunning
- Department of Cardiothoracic Transplantation, Papworth Hospital, Papworth Everard, Cambridge, United Kingdom
| | - H Giele
- Department of Plastic and Reconstructive Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - G Vrakas
- Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - J Parmar
- Department of Cardiothoracic Transplantation, Papworth Hospital, Papworth Everard, Cambridge, United Kingdom
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29
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Abstract
PURPOSE OF REVIEW The purpose of this article is to review the existing literature on the current indications, surgical techniques, immunosuppressive therapy and outcomes following intestinal transplantation (ITx). RECENT FINDINGS Over recent years, ITx has become a more common operation with approximately 2500 procedures carried out worldwide by 2014. It is reserved for patients with intestinal failure and who have developed complications of home parenteral nutrition or who have a high risk of dying from their underlying disease. Recent advances such as the improvement in survival rates, not only for isolated small bowel transplants but also following inclusion of a liver graft in combined liver-small bowel transplant, and the utility of citrulline as a noninvasive biomarker to appreciate acute rejection herald an exciting shift in the field of ITx. SUMMARY With advancements in immunosuppressive drugs, induction regimens, standardization of surgical techniques and improved postoperative care, survival is increasing. In due course, it will most likely become as good as remaining on home parenteral nutrition and as such could become a viable first-line option.
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30
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Techniques for abdominal wall reconstruction in intestinal transplantation. Curr Opin Organ Transplant 2017; 22:135-141. [DOI: 10.1097/mot.0000000000000394] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Zerillo J, Kim S, Hill B, DeMaria S, Sakai T. Noteworthy Literature Published in 2016 for Abdominal Organ Transplant Anesthesiologists. Semin Cardiothorac Vasc Anesth 2017; 21:70-80. [PMID: 28107792 DOI: 10.1177/1089253216688538] [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: 11/15/2022]
Abstract
More than 400 peer-reviewed publications on the topic of pancreas transplantation, more than 400 on intestine transplantation, and more than 3000 on renal transplantation were published in 2016. This review will highlight the most pertinent literature for anesthesiologists caring for patients undergoing non-liver abdominal organ transplantation. This review is the second part in an annual series to review relevant contributions in the field of abdominal organ transplantation focusing on pancreas, intestine, and renal transplantation. We explore a myriad of topics, including outcomes determined by center size, novel assessment of intestine graft function, the effect of Zika virus on the transplant population, appropriate fluid management for renal transplantation, cardiovascular risk assessment in the transplant population, and several topics pertinent to optimizing patient and graft survival.
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Affiliation(s)
- Jeron Zerillo
- 1 Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sang Kim
- 1 Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bryan Hill
- 1 Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel DeMaria
- 1 Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tetsuro Sakai
- 2 University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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32
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Momeni A, Chang B, Levin LS. Technology and vascularized composite allotransplantation (VCA)-lessons learned from the first bilateral pediatric hand transplant. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2016; 27:161. [PMID: 27638100 DOI: 10.1007/s10856-016-5771-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 08/24/2016] [Indexed: 06/06/2023]
Abstract
The reconstructive principle of replacing "like with like" is best met with vascularized composite allotransplantation in which the components of an existing defect are "matched" to the greatest extent possible in a single stage restoration. Hand transplantation is a labor-intensive and time-intensive process and can be conceptualized into distinct phases that include (1) patient selection and preoperative preparation, (2) technical execution of the procedure, and (3) postoperative rehabilitation and follow-up. The advent of technological innovations, such as 3D printing technology, novel implant technology, as well as innovative imaging technology, such as functional magnetic resonance imaging have the potential of favorably affecting all phases of this process, thus contributing to improved outcomes. The use of these technologies in the world's first case of bilateral hand transplantation in a pediatric patient is discussed.
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Affiliation(s)
- Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University, 770 Welch Road, Suite 400, Palo Alto, CA, USA.
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA.
| | - Benjamin Chang
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - L Scott Levin
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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