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Robinson TP, Milgrom DP, Nagaraju S, Goggins WC, Samy KP, Koniaris LG. Bilateral Renal Auto-Transplantation for Retroperitoneal Sarcomas: Is It Underutilized? Curr Oncol 2023; 30:7620-7626. [PMID: 37623033 PMCID: PMC10453660 DOI: 10.3390/curroncol30080552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 08/26/2023] Open
Abstract
Sarcomas are a rare tumor of mesenchymal origin. The liposarcoma is the most common sarcoma of the retroperitoneum. Liposarcomas are typically low grade, and present at an advanced stage and a large size. We report a case of a large retroperitoneal liposarcoma, approximately 50 kg, encasing both kidneys, which was managed via a two-stage resection and staged renal auto-transplantation into the intra-peritoneal pelvis. The patient maintained normal renal function throughout, and remains disease free two years post-resection. Renal auto-transplantation with pelvic placement may facilitate improved margin-free resection. Renal relocation may allow the use of curative-intent ablative therapies such as radiofrequency ablation and radiation in cases of retroperitoneal recurrence.
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Affiliation(s)
- Tyler P. Robinson
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Daniel P. Milgrom
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Providence Saint John’s Cancer Institute, Santa Monica, CA 90404, USA
| | - Santosh Nagaraju
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Renal Transplant Division, Charleston Area Medical Center, Charleston, WV 25301, USA
| | - William C. Goggins
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Kannan P. Samy
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Department of Surgery, Duke University Medical Center, Durham, NC 27707, USA
| | - Leonidas G. Koniaris
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Department of Surgery, Oregon Health and Science University, Portland, OR 97239, USA
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Devaud NA, Butte JM, De la Maza JC, von Mühlenbrock Hugo S, Cardona K. Complex Vascular Resections for Retroperitoneal Soft Tissue Sarcoma. Curr Oncol 2023; 30:3500-3515. [PMID: 36975479 PMCID: PMC10047166 DOI: 10.3390/curroncol30030266] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/09/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
Retroperitoneal sarcomas (RPSs) are locally aggressive tumors that can compromise major vessels of the retroperitoneum including the inferior vena cava, aorta, or main tributary vessels. Vascular involvement can be secondary to the tumor's infiltrating growth pattern or primary vascular origin. Surgery is still the mainstay for curing this disease, and resection of RPSs may include major vascular resections to secure adequate oncologic results. Our improved knowledge in the tumor biology of RPSs, in conjunction with the growing surgical expertise in both sarcoma and vascular surgical techniques, has allowed for major vascular reconstructions within multi-visceral resections for RPSs with good perioperative results. This complex surgical approach may include the combined work of various surgical subspecialties.
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Affiliation(s)
- Nicolas A Devaud
- Sarcoma Surgery Unit, Instituto Oncologico Fundación Arturo Lopez Perez (Falp), Santiago 7500691, Chile
| | - Jean M Butte
- Sarcoma Surgery Unit, Instituto Oncologico Fundación Arturo Lopez Perez (Falp), Santiago 7500691, Chile
| | - Juan C De la Maza
- Vascular Surgery Unit, Instituto Oncologico Fundación Arturo Lopez Perez (Falp), Santiago 7500691, Chile
| | | | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA 30307, USA
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3
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Auto-intestine transplantation for pancreatic tumors with mesenteric root involvement: a systematic review and survival-based analysis. JOURNAL OF PANCREATOLOGY 2021. [DOI: 10.1097/jp9.0000000000000081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Ex Vivo Resection and Autotransplantation for Conventionally Unresectable Tumors - An 11-year Single Center Experience. Ann Surg 2020; 272:766-772. [PMID: 32833756 DOI: 10.1097/sla.0000000000004270] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Ex vivo surgery may provide a chance at R0 resection for conventionally unresectable tumors. However, long-term outcomes have not been well documented. In this study, we analyze our 11-year outcomes to define its role. STUDY DESIGN We retrospectively analyzed 46 consecutive patients who underwent ex vivo surgery at our institution 2008-2019. RESULTS The types of tumors were: carcinoma (n = 20), sarcoma (n = 20) and benign to low grade tumor (n = 6). The type of ex vivo surgery was chosen based on tumor location and vascular involvement. The most commonly performed procedure was ex vivo hepatectomy (n = 18), followed by ex vivo resection and intestinal autotransplantation (n = 12), ex vivo Whipple procedure and liver autotransplantation (n = 8) and multivisceral ex vivo procedure (n = 7). Twenty-three patients (50%) are currently alive with median follow-up of 4.0-years (11 months-11.8 years). The overall survival was 70%/59%/52%, at 1-/3-/5-years, respectively. Patient survival for benign to low grade tumors, sarcoma, and carcinoma was 100%/100%/100%, 65%/60%/50%, and 65%/45%/40%, at 1-/3-/5-years, respectively. Ninety-one percent patients had R0 resection, and 57% had no recurrence to date with median follow-up of 3.1-years. Two patients (4.3%) died within 30 days due to sepsis and gastroduodenal artety (GDA) stump blowout. Two additional patients died between 30 and 90 days due to sepsis. Perioperative mortality in the last 23 consecutive cases was limited to 1 patient who died of sepsis between 30 and 90 days. CONCLUSIONS For a selected group of patients with conventionally unresectable tumors, ex vivo surgery can offer effective surgical removal with a reasonably low perioperative mortality at experienced centers.
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Perioperative Complications and Outcomes after Intestinal Autotransplantation for Neoplasms Involving the Superior Mesenteric Artery. J Gastrointest Surg 2020; 24:650-658. [PMID: 30937708 DOI: 10.1007/s11605-019-04204-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/08/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Intestinal autotransplantation (IATx) is a novel surgical technique for neoplasms arising from the pancreas, duodenum, mesentery, or retroperitoneum with involvement of the superior mesenteric artery (SMA). The value of this aggressive procedure remains to be defined. We describe its surgical indications, postoperative complications, and clinical outcomes after IATx. METHODS Fifteen patients aged 20 to 67 years (mean 44.9 years) underwent IATx in our program from January 2011 to January 2018. In all patients, selection and harvesting of a healthy bowel autograft were initially carried out, and an extended en bloc resection of neoplasms was performed afterward. RESULTS Of the 15 patients, there was one early death from a pancreatic leak and two late deaths either from disease recurrence or sudden cardiac arrest. Ten patients developed 23 postoperative complications. Of these, one patient lost his bowel autograft due to arterial thrombosis 48 h later. Delayed gastric emptying, pleural effusions, pancreatic fistula, and relaparotomy were the most common complications. In our series, four of nine patients with invasive malignant neoplasms had evidence of disease recurrence at 13, 13, 16, and 18 months after IATx. At a median follow-up of 29.9 months, 11 patients undergoing successful IATx remained alive with a well-functioning bowel graft. CONCLUSION Our results indicate that IATx is technically feasible with acceptable perioperative morbidity and mortality. This procedure should be considered in selected patients presenting with locally invasive neoplasms involving the SMA.
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Hibi T, Sapisochin G. What is transplant oncology? Surgery 2018; 165:281-285. [PMID: 30471780 DOI: 10.1016/j.surg.2018.10.024] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 10/11/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Taizo Hibi
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan.
| | - Gonzalo Sapisochin
- Multi-Organ Transplant and Hepato-Pancreato-Biliary Surgical Oncology, University Health Network, University of Toronto, Toronto, Canada
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Hwang R, Liou P, Kato T. Ex vivo liver resection and autotransplantation: An emerging option in selected indications. J Hepatol 2018; 69:1002-1003. [PMID: 30243765 DOI: 10.1016/j.jhep.2018.09.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/07/2018] [Accepted: 09/07/2018] [Indexed: 12/04/2022]
Affiliation(s)
- Regina Hwang
- Center for Liver Disease and Transplantation, Columbia University College of Physicians and Surgeons, New York, United States
| | - Peter Liou
- Center for Liver Disease and Transplantation, Columbia University College of Physicians and Surgeons, New York, United States
| | - Tomoaki Kato
- Center for Liver Disease and Transplantation, Columbia University College of Physicians and Surgeons, New York, United States.
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8
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Clift AK, Frilling A. Liver transplantation and multivisceral transplantation in the management of patients with advanced neuroendocrine tumours. World J Gastroenterol 2018; 24:2152-2162. [PMID: 29853733 PMCID: PMC5974577 DOI: 10.3748/wjg.v24.i20.2152] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/03/2018] [Accepted: 05/18/2018] [Indexed: 02/06/2023] Open
Abstract
Orthotopic liver transplantation (OLT) represents a generally accepted albeit somewhat controversially discussed therapeutic strategy in highly selected patients with non-resectable hepatic metastases from neuroendocrine tumours (NET). Whilst there are some exclusion criteria, these are not universally followed, and the optimal set of inclusion parameters for deeming patients eligible has not yet been elucidated. This is due to heterogeneity in the study populations, as well differing approaches employed and also divergences in selection criteria between centres. Recent data have suggested that OLT may represent the most efficacious approach in terms of overall and disease-free survival to the management of NET metastatic to the liver when conducted in accordance with the modified Milan criteria. Therefore, a consensus set of selection criteria requires definition to facilitate stringent and fair allocation of deceased-donor organs, as well as consideration for living-donor organs. In the context of classically non-resectable metastatic tumour bulk, multivisceral transplantation with or without the liver may also be indicated, yet experience is very limited. In this review, we discuss the diagnostic work-up of patients in whom the aforementioned transplantation approaches are being considered, critically analyse the published experience and also anticipate future developments in this field, including a discussion of immediate and longer-term research priorities.
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Affiliation(s)
- Ashley Kieran Clift
- Department of Surgery and Cancer, Imperial College London, London W12 0HS, United Kingdom
| | - Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, London W12 0HS, United Kingdom
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10
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Ware MJ, Nguyen LP, Law JJ, Krzykawska-Serda M, Taylor KM, Cao HST, Anderson AO, Pulikkathara M, Newton JM, Ho JC, Hwang R, Rajapakshe K, Coarfa C, Huang S, Edwards D, Curley SA, Corr SJ. A new mild hyperthermia device to treat vascular involvement in cancer surgery. Sci Rep 2017; 7:11299. [PMID: 28900126 PMCID: PMC5595878 DOI: 10.1038/s41598-017-10508-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 08/09/2017] [Indexed: 01/04/2023] Open
Abstract
Surgical margin status in cancer surgery represents an important oncologic parameter affecting overall prognosis. The risk of disease recurrence is minimized and survival often prolonged if margin-negative resection can be accomplished during cancer surgery. Unfortunately, negative margins are not always surgically achievable due to tumor invasion into adjacent tissues or involvement of critical vasculature. Herein, we present a novel intra-operative device created to facilitate a uniform and mild heating profile to cause hyperthermic destruction of vessel-encasing tumors while safeguarding the encased vessel. We use pancreatic ductal adenocarcinoma as an in vitro and an in vivo cancer model for these studies as it is a representative model of a tumor that commonly involves major mesenteric vessels. In vitro data suggests that mild hyperthermia (41-46 °C for ten minutes) is an optimal thermal dose to induce high levels of cancer cell death, alter cancer cell's proteomic profiles and eliminate cancer stem cells while preserving non-malignant cells. In vivo and in silico data supports the well-known phenomena of a vascular heat sink effect that causes high temperature differentials through tissues undergoing hyperthermia, however temperatures can be predicted and used as a tool for the surgeon to adjust thermal doses delivered for various tumor margins.
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Affiliation(s)
- Matthew J Ware
- Department of Surgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Lam P Nguyen
- Department of Surgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Justin J Law
- Department of Surgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Martyna Krzykawska-Serda
- Department of Surgery, Baylor College of Medicine, Houston, TX, 77030, USA
- Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Gronostajowa 7 St., Kraków, 30-387, Poland
| | - Kimberly M Taylor
- Department of Surgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Hop S Tran Cao
- Department of Surgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Andrew O Anderson
- Department of Surgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | | | - Jared M Newton
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX, 77030, USA
- Interdepartmental program in Translational Biology and Molecular Medicine, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Jason C Ho
- Department of Surgery, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Rosa Hwang
- Department of Surgical oncology, MD Anderson, Houston, Texas, 77030, USA
| | - Kimal Rajapakshe
- Department of Molecular and Cell Biology, Baylor College of Medicine, Houston, Texas, 77030, USA
| | - Cristian Coarfa
- Department of Molecular and Cell Biology, Baylor College of Medicine, Houston, Texas, 77030, USA
| | - Shixia Huang
- Department of Molecular and Cell Biology, Baylor College of Medicine, Houston, Texas, 77030, USA
| | - Dean Edwards
- Department of Molecular and Cell Biology, Baylor College of Medicine, Houston, Texas, 77030, USA
| | - Steven A Curley
- Department of Surgery, Baylor College of Medicine, Houston, TX, 77030, USA.
- Department of Mechanical Engineering and Materials Science, Rice University, Houston, TX, 77005, USA.
| | - Stuart J Corr
- Department of Surgery, Baylor College of Medicine, Houston, TX, 77030, USA.
- Department of Chemistry, Rice University, Houston, TX, 77030, USA.
- Department of Biomedical Engineering, University of Houston, Houston, 77204, TX, USA.
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11
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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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Abstract
Most abdominal neoplasms involving the root of the superior mesenteric artery and/or celiac artery are difficult to manage with conventional operative techniques because of limited intestinal ischemia times and poor accessibility to the tumor region. Ex vivo surgery followed by intestinal autotransplantation (IATx) is a relatively novel surgical strategy to offer chances for complete resection in such hopeless circumstances. This review aims to assess potential surgical indications, operative techniques and clinical outcomes after IATx. Currently the main indications reported for IATx broadly include pancreatic, mesenteric and retroperitoneal neoplasms closely involving the superior mesenteric vessels. The preliminary results show that radical resection can be effectively achieved in carefully selective patients. Although perioperative morbidity and mortality are relatively high, there are several long-term survivors, particularly after complete resection of benign and low-grade tumor. Early tumor recurrence, however, remains a major problem in patients with high-grade tumor, particularly pancreatic ductal carcinoma. In conclusion, IATx allows patients with selected abdominal neoplasms involving the major mesenteric vessels to be completely resected. However, this aggressive approach is associated with a considerable operative risk, and should only be performed at experienced centers. Additional and adjunctive treatment therapies are required to improve the efficacy of this treatment.
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Affiliation(s)
- Guosheng Wu
- Xijing Hospital of Digestive Diseases, The Fourth Military Medical University, Xi'an, Shaanxi, China
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Bharadwaj S, Tandon P, Gohel TD, Brown J, Steiger E, Kirby DF, Khanna A, Abu-Elmagd K. Current status of intestinal and multivisceral transplantation. Gastroenterol Rep (Oxf) 2017; 5:20-28. [PMID: 28130374 PMCID: PMC5444259 DOI: 10.1093/gastro/gow045] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Clinical-nutritional autonomy is the ultimate goal of patients with intestinal failure (IF). Traditionally, patients with IF have been relegated to lifelong parenteral nutrition (PN) once surgical and medical rehabilitation attempts at intestinal adaptation have failed. Over the past two decades, however, outcome improvements in intestinal transplantation have added another dimension to the therapeutic armamentarium in the field of gut rehabilitation. This has become possible through relentless efforts in the standardization of surgical techniques, advancements in immunosuppressive therapies and induction protocols and improvement in postoperative patient care. Four types of intestinal transplants include isolated small bowel transplant, liver-small bowel transplant, multivisceral transplant and modified multivisceral transplant. Current guidelines restrict intestinal transplantation to patients who have had significant complications from PN including liver failure and repeated infections. From an experimental stage to the currently established therapeutic modality for patients with advanced IF, outcome improvements have also been possible due to the introduction of tacrolimus in the early 1990s. Studies have shown that intestinal transplant is cost-effective within 1-3 years of graft survival compared with PN. Improved survival and quality of life as well as resumption of an oral diet should enable intestinal transplantation to be an important option for patients with IF in addition to continued rehabilitation. Future research should focus on detecting biomarkers of early rejection, enhanced immunosuppression protocols, improved postoperative care and early referral to transplant centers.
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Affiliation(s)
- Shishira Bharadwaj
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Parul Tandon
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tushar D Gohel
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jill Brown
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ezra Steiger
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Donald F Kirby
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ajai Khanna
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kareem Abu-Elmagd
- Center for Gut Rehabilitation and Transplantation, the Cleveland Clinic Foundation, Cleveland, OH, USA
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14
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Hashimoto K, Costa G, Khanna A, Fujiki M, Quintini C, Abu-Elmagd K. Recent Advances in Intestinal and Multivisceral Transplantation. Adv Surg 2016; 49:31-63. [PMID: 26299489 DOI: 10.1016/j.yasu.2015.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Koji Hashimoto
- Center for Gut Rehabilitation and Transplantation, Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Guilherme Costa
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15261, USA
| | - Ajai Khanna
- Center for Gut Rehabilitation and Transplantation, Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Masato Fujiki
- Center for Gut Rehabilitation and Transplantation, Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Cristiano Quintini
- Center for Gut Rehabilitation and Transplantation, Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Kareem Abu-Elmagd
- Center for Gut Rehabilitation and Transplantation, Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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15
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Wu G, Zhao Q, Wang W, Shi H, Wang M, Zhang J, Li Z, Fan D. Clinical and nutritional outcomes after intestinal autotransplantation. Surgery 2016; 159:1668-1676. [DOI: 10.1016/j.surg.2016.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 12/28/2015] [Accepted: 01/12/2016] [Indexed: 02/07/2023]
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16
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Liver transplantation for hepatobiliary malignancies: a new era of "Transplant Oncology" has begun. Surg Today 2016; 47:403-415. [PMID: 27130463 DOI: 10.1007/s00595-016-1337-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 04/06/2016] [Indexed: 01/10/2023]
Abstract
The indications of liver transplantation for hepatobiliary malignancies have been carefully expanded in a stepwise fashion, despite the fundamental limitations in oncological, immunological, and technical aspects. A new era of "Transplant Oncology," the fusion of transplant surgery and surgical oncology, has begun, and we stand at the dawn of a paradigm shift in multidisciplinary cancer treatment. For hepatocellular carcinoma, new strategies have been undertaken to select recipients based on biological and dynamic markers instead of conventional morphological and static parameters, opening the doors for a more deliberate expansion of the Milan criteria and locoregional therapies before liver transplantation. Neoadjuvant chemoradiation therapy followed by liver transplantation for unresectable perihilar cholangiocarcinoma developed by the Mayo Clinic provided excellent outcomes in a US multicenter study; however, the surgical indications are not necessarily universal and await international validation. Similarly, an aggressive multidisciplinary approach has been applied for other tumors, including intrahepatic cholangiocarcinoma, hepatoblastoma, liver metastases from colorectal and neuroendocrine primary and gastrointestinal stromal tumors as well as rare tumors, such as hepatic undifferentiated embryonal sarcoma and infantile choriocarcinoma. In conclusion, liver transplantation is an important option for hepatobiliary malignancies; however, prospective studies are urgently needed to ensure the appropriate patient selection, organ allocation and living donation policies, and administration of antineoplastic immunosuppression.
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Intestinal autotransplantation for neoplasms originating in the pancreatic head with involvement of the superior mesenteric artery. Langenbecks Arch Surg 2016; 401:1249-1257. [DOI: 10.1007/s00423-016-1437-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 04/14/2016] [Indexed: 12/22/2022]
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Matsuoka N, Weiner JI, Griesemer AD, Samstein BB, Zhao Y, Emond JC, Kato T. Ex vivo pancreaticoduodenectomy and liver autotransplantation for pancreatic head tumor with extensive involvement of the hepatoduodenal ligament. Liver Transpl 2015; 21:1553-6. [PMID: 26289503 DOI: 10.1002/lt.24229] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 08/02/2015] [Accepted: 08/10/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Nobuhide Matsuoka
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Joshua I Weiner
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Adam D Griesemer
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Benjamin B Samstein
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Yejun Zhao
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Jean C Emond
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Tomoaki Kato
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY
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Frilling A, Giele H, Vrakas G, Reddy S, Macedo R, Al-Nahhas A, Wasan H, Clift AK, Gondolesi GE, Vianna RM, Friend P, Vaidya A. Modified liver-free multivisceral transplantation for a metastatic small bowel neuroendocrine tumor: a case report. Transplant Proc 2015; 47:858-62. [PMID: 25689880 DOI: 10.1016/j.transproceed.2015.01.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 01/14/2015] [Indexed: 12/17/2022]
Abstract
Neuroendocrine tumors originating from the small bowel frequently metastasize to the lymph nodes and/or liver. Although surgical extirpation of the primary tumor and locoregional metastases epitomizes the management of patients with such tumors, this is not always possible with conventional surgical techniques. Nonresectable, slow-growing tumors involving the mesenteric root represent a generally accepted indication for deceased donor intestinal and multivisceral transplantation. Furthermore, vascularized sentinel forearm flaps offer opportunities for monitoring graft rejection and tailoring immunosuppression regimens. Here, we report the first documented case of modified liver-free multivisceral transplantation preceded by neoadjuvant 177-lutetium peptide receptor radionuclide therapy in a patient with a small bowel neuroendocrine tumor and extensive lymph node metastases in the mesenterium. At a follow-up of 21 months the patient is biochemically and radiologically disease-free.
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Affiliation(s)
- A Frilling
- Department of Surgery and Cancer, Imperial College London, United Kingdom.
| | - H Giele
- Department of Plastic and Reconstructive Surgery, Oxford University NHS Trust, Oxford, United Kingdom
| | - G Vrakas
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, United Kingdom
| | - S Reddy
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, United Kingdom
| | - R Macedo
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, United Kingdom
| | - A Al-Nahhas
- Department of Nuclear Medicine, Imperial College London, United Kingdom
| | - H Wasan
- Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - A K Clift
- School of Medicine, Imperial College London, United Kingdom
| | - G E Gondolesi
- Instituto de Trasplante Multiorgánico, Fundación Favaloro, Buenos Aires, Argentina
| | - R M Vianna
- Miami Transplant Institute, University of Miami/Jackson Memorial Hospital, Miami, Fla., United States
| | - P Friend
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, United Kingdom
| | - A Vaidya
- Oxford Transplant Centre, Oxford University NHS Trust, Oxford, United Kingdom
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20
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Abu-Elmagd K. The concept of gut rehabilitation and the future of visceral transplantation. Nat Rev Gastroenterol Hepatol 2015; 12:108-20. [PMID: 25601664 DOI: 10.1038/nrgastro.2014.216] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the 1990s, the introduction of visceral transplantation fuelled interest in other innovative therapeutic modalities for gut rehabilitation. Ethanol lock and omega-3 lipid formulations were introduced to reduce the risks associated with total parenteral nutrition (TPN). Autologous surgical reconstruction and bowel lengthening have been increasingly utilized for patients with complex abdominal pathology and short-bowel syndrome. Glucagon-like peptide 2 analogue, along with growth hormone, are available to enhance gut adaptation and achieve nutritional autonomy. Intestinal transplantation continues to be limited to a rescue therapy for patients with TPN failure. Nonetheless, survival outcomes have substantially improved with advances in surgical techniques, immunosuppressive strategies and postoperative management. Furthermore, both nutritional autonomy and quality of life can be restored for more than two decades in most survivors, with social support and inclusion of the liver being favourable predictors of long-term outcome. One of the current challenges is the discovery of biomarkers to diagnose early rejection and further improve liver-free allograft survival. Currently, chronic rejection with persistence of preformed and development of de novo donor-specific antibodies is a major barrier to long-term graft function; this issue might be overcome with innovative immunological and tolerogenic strategies. This Review discusses advances in the field of gut rehabilitation, including intestinal transplantation, and highlights future challenges. With the growing interest in individualized medicine and the value of health care, a novel management algorithm is proposed to optimize patient care through an integrated multidisciplinary team approach.
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Affiliation(s)
- Kareem Abu-Elmagd
- Transplant Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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21
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Miyazaki M. Combined vascular resection and reconstruction during hepatobiliary and pancreatic cancer surgery. Br J Surg 2014; 102:1-3. [PMID: 25142724 DOI: 10.1002/bjs.9618] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2014] [Indexed: 11/06/2022]
Abstract
Prospective studies needed at high-volume centres
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Affiliation(s)
- M Miyazaki
- Department of General Surgery, Chiba University, 1-8-1, Inohana, Chuoh-ku, Chiba, 260-0856 Japan.
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22
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Hibi T, Shinoda M, Itano O, Kitagawa Y. Current status of the organ replacement approach for malignancies and an overture for organ bioengineering and regenerative medicine. Organogenesis 2014; 10:241-9. [PMID: 24836922 DOI: 10.4161/org.29245] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Significant achievements in the organ replacement approach for malignancies over the last 2 decades opened new horizons, and the age of "Transplant Oncology" has dawned. The indications of liver transplantation for malignancies have been carefully expanded by a strict patient selection to assure comparable outcomes with non-malignant diseases. Currently, the Milan criteria, gold standard for hepatocellular carcinoma, are being challenged by high-volume centers worldwide. Neoadjuvant chemoradiation therapy and liver transplantation for unresectable hilar cholangiocarcinoma has been successful in specialized institutions. For other primary and metastatic liver tumors, clinical evidence to establish standardized criteria is lacking. Intestinal and multivisceral transplantation is an option for low-grade neoplasms deemed unresectable by conventional surgery. However, the procedure itself is in the adolescent stage. Solid organ transplantation for malignancies inevitably suffers from "triple distress," i.e., oncological, immunological, and technical. Organ bioengineering and regenerative medicine should serve as the "triple threat" therapy and revolutionize "Transplant Oncology."
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Affiliation(s)
- Taizo Hibi
- Department of Surgery; Keio University School of Medicine; Tokyo, Japan
| | - Masahiro Shinoda
- Department of Surgery; Keio University School of Medicine; Tokyo, Japan
| | - Osamu Itano
- Department of Surgery; Keio University School of Medicine; Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery; Keio University School of Medicine; Tokyo, Japan
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23
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Vakili K, Kim HB. Partial esophageal transplantation is possible as part of a multivisceral graft. Am J Transplant 2014; 14:720-3. [PMID: 24447794 DOI: 10.1111/ajt.12623] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 12/10/2013] [Accepted: 12/10/2013] [Indexed: 01/25/2023]
Abstract
We report a case of a 9-year-old female with inflammatory myofibroblastic tumor (IMT), which involved the upper retroperitoneum, visceral vessels, stomach and distal esophagus. Complete resection of the tumor required a multivisceral (MV) transplant. Due to tumor involvement, resection of the distal third of recipient esophagus was necessary. Gastrointestinal continuity was subsequently established via esophagoesophagostomy to donor esophagus en bloc with a standard MV graft. After 1.9 years of follow-up, the patient has no symptoms of dysphagia or reflux. This case illustrates the feasibility of including the distal donor esophagus as part of an MV graft.
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Affiliation(s)
- K Vakili
- Department of Surgery and Pediatric Transplant Center, Boston Children's Hospital, Boston, MA
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24
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Is there a role for transplantation in gynecologic oncology? Autotransplantation and other lessons. Int J Gynecol Cancer 2013; 23:413-6. [PMID: 23429484 DOI: 10.1097/igc.0b013e3182849d75] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We describe an exciting and novel surgical option, which may be used to treat formerly unresectable masses. This process is commonly referred to as autotransplantation (AuTn), and it combines the advances in transplant medicine and applies them to surgical oncology. The idea behind AuTn is the removal of the cancerous organ(s) to allow complete anatomic resection of the tumor mass, with consequent anastomotic reimplantation or AuTn of the now macroscopically tumor-free organ back into the patient. Autotransplantation has been used to remove large fibromatosis and desmoid tumors as well as malignant tumors. Our belief is that using lessons learned from the field of transplantation, AuTn can be applied in gynecologic oncology.
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25
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Erkan M, Hausmann S, Michalski CW, Schlitter AM, Fingerle AA, Dobritz M, Friess H, Kleeff J. How fibrosis influences imaging and surgical decisions in pancreatic cancer. Front Physiol 2012; 3:389. [PMID: 23060813 PMCID: PMC3462403 DOI: 10.3389/fphys.2012.00389] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 09/11/2012] [Indexed: 12/16/2022] Open
Abstract
Our understanding of pancreatic ductal adenocarcinoma (PDAC) is shifting away from a disease of malignant ductal cells-only, toward a complex system where tumor evolution is a result of interaction of cancer cells with their microenvironment. This change has led to intensification of research focusing on the fibrotic stroma of PDAC. Pancreatic stellate cells (PSCs) are the main fibroblastic cells of the pancreas which are responsible for producing the desmoplasia in chronic pancreatitis (CP) and PDAC. Clinically, the effect of desmoplasia is two-sided; on the negative side it is a hurdle in the diagnosis of PDAC because the fibrosis in cancer resembles that of CP. It is also believed that PSCs and pancreatic fibrosis are partially responsible for the therapy resistance in pancreatic cancer. On the positive side, a fibrotic pancreas is safer to operate on compared to a fatty and soft pancreas which is prone for postoperative pancreatic fistula. In this review the impact of pancreatic fibrosis on diagnosis of pancreatic cancer and surgical decisions are discussed from a clinical point of view.
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Affiliation(s)
- Mert Erkan
- Department of General Surgery, Klinikum rechts der Isar, Technische Universität München Munich, Germany
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Intestinal and multivisceral autotransplantation for tumors of the root of the mesentery: Long-term follow-up. Surgery 2012; 152:82-9. [PMID: 22386709 DOI: 10.1016/j.surg.2012.01.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 01/16/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To present the indications, techniques, short- and long-term outcomes after visceral exenteration, ex vivo resection, and intestinal/multivisceral autotransplantation. PATIENTS AND METHODS All patients who have undergone this procedure at our center were studied. Technique, postoperative complications, survival, tumor recurrence, and functional status were recorded. RESULTS Ten patients, 4 children and 6 adults, have undergone these procedures since January 1999. Seven patients are alive at 13-138 months later, 6 with functioning autografts and one after rescue with an allotransplantation. CONCLUSION Intestinal/multivisceral autotransplantation is a potentially valuable option for some otherwise unresectable neoplasms of the root of the mesentery.
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