1
|
Singh N, Lentine KL, Fleetwood VA, Woodside KJ, Odorico J, Axelrod D, Alhamad T, Maher K, Xiao H, Fridell J, Kukla A, Pavlakis M, Shokouh-Amiri HM, Zibari G, Cooper M, Parsons RF. Indications, Techniques, and Barriers for Pancreas Transplant Biopsy: A Consensus Perspective From a Survey of US Centers. Transplantation 2024:00007890-990000000-00688. [PMID: 38467588 DOI: 10.1097/tp.0000000000004960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
BACKGROUND Pancreas transplant biopsy practices for the diagnosis of rejection or other pathologies are not well described. METHODS We conducted a survey of staff at US pancreas transplant programs (March 22, 2022, to August 22, 2022) to assess current program practices and perceptions about the utility and challenges in the performance and interpretation of pancreas allograft biopsies. RESULTS Respondents represented 65% (76/117) of active adult pancreas transplant programs, capturing 66% of recent pancreas transplant volume in the United States. Participants were most often nephrologists (52%), followed by surgeons (46%), and other staff (4%). Pancreas allograft biopsies were performed mostly by interventional radiologists (74%), followed by surgeons (11%), nephrologists (8%), and gastroenterologists (1%). Limitations in the radiologist's or biopsy performer's comfort level or expertise to safely perform a biopsy, or to obtain sufficient/adequate samples were the two most common challenges with pancreas transplant biopsies. Pancreas transplant biopsies were read by local pathologists at a majority (86%) of centers. Challenges reported with pancreas biopsy interpretation included poor reliability, lack of reporting of C4d staining, lack of reporting of rejection grading, and inconclusive interpretation of the biopsy. Staff at a third of responding programs (34%) stated that they rarely or never perform pancreas allograft biopsies and treat presumed rejection empirically. CONCLUSIONS This national survey identified significant variation in clinical practices related to pancreas allograft biopsies and potential barriers to pancreas transplant utilization across the United States. Consideration of strategies to improve program experience with percutaneous pancreas biopsy and to support optimal management of pancreas allograft rejection informed by histology is warranted.
Collapse
Affiliation(s)
| | - Krista L Lentine
- Saint Louis University Transplant Center, SSM Health Saint Louis University Hospital, Saint Louis, MO
| | - Vidya A Fleetwood
- Saint Louis University Transplant Center, SSM Health Saint Louis University Hospital, Saint Louis, MO
| | | | | | | | - Tarek Alhamad
- Washington University School of Medicine, St. Louis, MO
| | - Kennan Maher
- Saint Louis University Transplant Center, SSM Health Saint Louis University Hospital, Saint Louis, MO
| | - Huiling Xiao
- Saint Louis University Transplant Center, SSM Health Saint Louis University Hospital, Saint Louis, MO
| | | | | | | | | | - Gazi Zibari
- Willis-Knighton Health System, Shreveport, LA
| | | | | |
Collapse
|
2
|
Kute VB, Fleetwood VA, Chauhan S, Meshram HS, Caliskan Y, Varma C, Yazıcı H, Oto ÖA, Lentine KL. Kidney paired donation in developing countries: A global perspective. Curr Transplant Rep 2023; 10:117-125. [PMID: 37720696 PMCID: PMC10501157 DOI: 10.1007/s40472-023-00401-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Purpose of review We review the key principles of kidney paired donation (KPD) and discuss the status and unique considerations for KPD in developing countries. Recent findings Despite the advantages of KPD programs, they remain rare among developing nations, and the programs that exist have many differences with those of in developed countries. There is a paucity of literature and lack of published data on KPD from most of the developing nations. Expanding KPD programs may require the adoption of features and innovations of successful KPD programs. Cooperation with national and international societies should be encouraged to ensure endorsement and sharing of best practices. Summary KPD is in the initial stages or has not yet started in the majority of the emerging nations. But the logistics and strategies required to implement KPD in developing nations differ from other parts of the world. By learning from the KPD experience in developing countries and adapting to their unique needs, it should be possible to expand access to KPD to allow more transplants to happen for patients in need world-wide.
Collapse
Affiliation(s)
- Vivek B Kute
- Department of Nephrology and Transplantation, Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences, Ahmedabad, India
| | - Vidya A. Fleetwood
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Sanshriti Chauhan
- Department of Nephrology and Transplantation, Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences, Ahmedabad, India
| | - Hari Shankar Meshram
- Department of Nephrology and Transplantation, Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences, Ahmedabad, India
| | - Yasar Caliskan
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Chintalapati Varma
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Halil Yazıcı
- Division of Nephrology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Özgür Akın Oto
- Division of Nephrology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO, USA
| |
Collapse
|
3
|
Fleetwood VA, Caliskan Y, Rub FAA, Axelrod D, Lentine KL. Maximizing opportunities for kidney transplantation in older adults. Curr Opin Nephrol Hypertens 2023; 32:204-211. [PMID: 36633323 DOI: 10.1097/mnh.0000000000000871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW To summarize the current state of evidence related to the outcomes of older adults who need and receive kidney transplants, and strategies to facilitate appropriate transplant access in this at-risk group. RECENT FINDINGS Older adults are a rapidly growing subgroup of the kidney transplant waitlist. Compared to younger adults, older kidney transplant recipients have increased mortality after kidney transplant and lower death-censored graft survival. In determining suitability for transplantation in older patients, clinicians must balance procedural and immunosuppression-related risk with incremental survival when compared with dialysis. To appropriately increase access to transplantation in this population, clinicians and policy makers consider candidates' chronological age and frailty, as well as the quality of and waiting time for a donated allograft. Given risk of deterioration prior to transplant, candidates should be rapidly evaluated, listed, and transplanted using living donor and or less than ideal deceased donor organs when available. SUMMARY Access to transplantation for older adults can be increased through targeted interventions to address frailty and reduce waiting times through optimized organ use. Focused study and educational interventions for patients and providers are needed to improve the outcomes of this vulnerable group.
Collapse
Affiliation(s)
- Vidya A Fleetwood
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
| | - Yasar Caliskan
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
| | - Fadee Abu Al Rub
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
| | | | - Krista L Lentine
- Saint Louis University Center for Abdominal Transplantation, SSM-Saint Louis University Hospital
| |
Collapse
|
4
|
Fleetwood VA, Falls C, Ohman J, Aziz A, Stalter L, Leverson G, Welch B, Kaufman DB, Al-Adra DP, Odorico JS. Post-pancreatic transplant enteric leaks: The role of the salvage operation. Am J Transplant 2022; 22:2052-2063. [PMID: 35593379 DOI: 10.1111/ajt.17094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 05/12/2022] [Accepted: 05/12/2022] [Indexed: 01/25/2023]
Abstract
Enteric drainage in pancreas transplantation is complicated by an enteric leak in 5%-8%, frequently necessitating pancreatectomy. Pancreatic salvage outcomes are not well studied. Risk factors for enteric leak were examined and outcomes of attempted graft salvage were compared to immediate pancreatectomy. Pancreas transplants performed between 1995 and 2018 were reviewed. Donor, recipient, and organ variables including demographics, donor type, ischemic time, kidney donor profile index, and pancreas donor risk index were analyzed. Among 1153 patients, 33 experienced enteric leaks (2.9%). Donors of allografts that developed leak were older (37.9y vs. 29.0y, p = .001), had higher KDPI (37% vs. 24%, p < .001), higher pancreas donor risk index (1.83 vs. 1.32, p < .001), and longer cold ischemic time (16.5 vs. 14.8 h, p = .03). Intra-abdominal abscess and higher blood loss decreased the chance of successful salvage. Enteric leak increased 6-month graft loss risk (HR 13.9[CI 8.5-22.9], p < .001). However, 50% (n = 12) of allografts undergoing attempted salvage survived long-term. After 6 months of pancreas graft survival, salvage and non-leak groups had similar 5-year graft survival (82.5% vs. 81.5%) and mortality (90.9% vs. 93.5%). Enteric leaks remain a challenging complication. Pancreatic allograft salvage can be attempted in suitable patients and accomplished in 50% of cases without significantly increased graft failure or mortality risk.
Collapse
Affiliation(s)
- Vidya A Fleetwood
- Center for Abdominal Transplantation, Saint Louis University, St. Louis, Missouri, USA.,Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Cody Falls
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jakob Ohman
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Antony Aziz
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Lily Stalter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Glen Leverson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Bridget Welch
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Dixon B Kaufman
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - David P Al-Adra
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jon S Odorico
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| |
Collapse
|
5
|
Lentine KL, Fleetwood VA, Caliskan Y, Randall H, Wellen JR, Lichtenberger M, Dedert C, Rothweiler R, Marklin G, Brockmeier D, Schnitzler MA, Husain SA, Mohan S, Kasiske BL, Cooper M, Mannon RB, Axelrod DA. Deceased Donor Procurement Biopsy Practices, Interpretation, and Histology-Based Decision Making: A Survey of U.S. Transplant Centers. Kidney Int Rep 2022; 7:1268-1277. [PMID: 35685316 PMCID: PMC9171615 DOI: 10.1016/j.ekir.2022.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/13/2022] [Accepted: 03/21/2022] [Indexed: 10/31/2022] Open
Abstract
Introduction Methods Results Conclusion
Collapse
|
6
|
Fleetwood VA, Mannon RB, Lentine KL. The Agony and the Ecstasy: Stories from Organ Transplant Recipients. Narrat Inq Bioeth 2022; 12:147-152. [PMID: 36373535 DOI: 10.1353/nib.2022.0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Transplantation affords recipients of a donated organ a second chance at life. However, the gift of life can incur impactful costs to the donor, the recipient, and their caregivers. In this collection of stories, thirteen authors explore their journey to transplantation and afterward-from physical pain and deconditioning; to navigating well-intentioned but rigid clinicians; to developing a greater appreciation of life, their community, and their abilities. We explore the recurring themes woven throughout the stories, including the solemn responsibility of accepting an organ, the challenges of living a new life with a body and mind changed by transplantation, the difficulty of preserving one's sense of self when one's clinicians are dominantly focused on the organ, and the spectrum of gifts that organ donation and transplantation provide.
Collapse
|
7
|
Kute VB, Fleetwood VA, Meshram HS, Guenette A, Lentine KL. Use of Organs from SARS-CoV-2 Infected Donors: Is It Safe? A Contemporary Review. Curr Transplant Rep 2021; 8:281-292. [PMID: 34722116 PMCID: PMC8546195 DOI: 10.1007/s40472-021-00343-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW As the prevalence of individuals with recovered coronavirus disease 2019 (COVID-19) increases, determining if and when organs from these donors can be safely used is an important priority. We examined current knowledge of outcomes of transplant using donors with recovered COVID-19. RECENT FINDINGS A literature search of PubMed and Google scholar databases was conducted to identify articles with terms "SARS-CoV2," "COVID-19," "donor recovered," and "transplantation" published through 08/10/2021. We identified 25 reports detailing 94 recipients of both abdominal and thoracic transplants from donors with both prior and active COVID-19 infection. Rates of transmission to the recipient and of transplanted organ dysfunction were low among reports of donors with prior COVID-19 infection. End organ dysfunction and transmission were more common with active infection, although few reports are available. Standardized reporting is needed to better assess the impact of donor symptomatology, cycle thresholds, and individual recipient risk factors on postoperative outcomes. SUMMARY Available reports suggest that transplantation from COVID-19 donors may be feasible and safe, at least in short term follow-up. Nevertheless, there is a need for standardized testing and management protocols which should be tailored for available resources. While increased availability of COVID-19 vaccinations will mitigate risks of donor-derived COVID-19 and simplify management, continued vigilance is warranted during the ongoing public health emergency.
Collapse
Affiliation(s)
- Vivek B. Kute
- Department of Nephrology, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Civil Hospital Campus, Asarwa, Ahmedabad, India
| | - Vidya A. Fleetwood
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO USA
| | - Hari Shankar Meshram
- Department of Nephrology, Institute of Kidney Diseases and Research Center, Dr HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Civil Hospital Campus, Asarwa, Ahmedabad, India
| | - Alexis Guenette
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO USA
| | - Krista L. Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, Saint Louis, MO USA
| |
Collapse
|
8
|
Fleetwood VA, Maher K, Satish S, Varma CR, Nazzal M, Randall H, Al-Adra DP, Caliskan Y, Bastani B, Rub FAA, Lentine KL. Clinician and patient attitudes toward use of organs from hepatitis C viremic donors and their impact on acceptance: A contemporary review. Clin Transplant 2021; 35:e14519. [PMID: 34672392 DOI: 10.1111/ctr.14519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/10/2021] [Accepted: 10/15/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The use of Hepatitis C (HCV) NAT positive allografts remains unusual and is clustered at few centers. We conducted a contemporary literature review to assess whether patient and clinician attitudes toward viremic organs impact acceptance. METHODS Databases including PubMed, MEDLINE, and SCOPUS databases were reviewed to identify studies focused on evaluating patient and provider perceptions of HCV NAT positive organ use within the DAA era (January 2015-April 2021). Search included MeSH terms related to Hepatitis C, transplantation, and patient and clinician attitudes. Two investigators extracted study characteristics including information on willingness to accept viremic organs, HCV-specific outcomes knowledge, HCV-specific concerns, and factors that contributed to acceptance or non-acceptance. RESULTS Eight studies met all inclusion criteria. These included three pretransplant patient-directed studies, two post-transplant patient-directed studies, one pre- and post-transplant patient-directed study, and two clinician-directed studies. Common themes identified were concerns regarding HCV cure rates, viremic organ quality, DAA cost, stigma, and the possibility of HCV transmission to household members. The perception of decreased waitlist time was associated with viremic organ acceptance. Physician trust played a mixed role in acceptance patterns. CONCLUSIONS Knowledge of high cure rates, shorter waitlist times, and higher organ quality appear to have the highest impact on organ acceptance.
Collapse
Affiliation(s)
- Vidya A Fleetwood
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Kennan Maher
- School of Public Health and Epidemiology, Saint Louis University, St Louis, Missouri, USA
| | - Sangeeta Satish
- School of Medicine, Saint Louis University, St. Louis, Missouri, USA
| | - C Rathna Varma
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Mustafa Nazzal
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Henry Randall
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - David P Al-Adra
- Division of Transplant Surgery, Department of General Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Yasar Caliskan
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Bahar Bastani
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Fadee Abu Al Rub
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| | - Krista L Lentine
- Center for Abdominal Transplantation, Saint Louis University School of Medicine, St. Louis, Missouri, USA
| |
Collapse
|
9
|
Fleetwood VA, Janek K, Leverson G, Welch B, Yankol Y, Foley D, Mezrich J, D'Alessandro A, Fernandez L, Al-Adra DP. Predicting the Safe Use of Deceased After Circulatory Death Liver Allografts in Primary Sclerosing Cholangitis. EXP CLIN TRANSPLANT 2021; 19:563-569. [PMID: 33952182 DOI: 10.6002/ect.2020.0387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The use of deceased after circulatory death liver allografts in patients with primary sclerosing cholangitis is controversial, given the increased risk of graft complications in patients with primary sclerosing cholangitis. We hypothesized that transplant of deceased after circulatory death livers into recipients with primary sclerosing cholangitis when appropriately selected using the UK deceased after circulatory death scoring system is not associated with increased graft failure and mortality. MATERIALS AND METHODS We analyzed 99 229 transplants (between January 2001 and December 2018) from the Organ Procurement and Transplantation Network database. Deceased after circulatory death transplants were stratified by the UK scoring system as low risk or high risk. We identified 3958 patients with primary sclerosing cholangitis who received deceased after brain death transplant and 95 patients with primary sclerosing cholangitis who received deceased after circulatory death transplant. RESULTS As expected, 5-year graft survival was lower in the circulatory death recipient group (69.0% vs 78.4%; P = .02). However, 5-year graft survival was significantly lower in the high-risk versus low-risk UK scoring system group (60.0% vs 75.4%; P = .02), with rate in the low-risk group similar to the brain death recipient group (78.4% vs 75.4%; P = .52). On multivariate analysis, the high-risk group had significantly increased risk of graft loss (hazard ratio of 1.92; P = .01). However, the low-risk group had equivalent graft survival to the brain death recipient group (hazard ratio of 1.23; P = .31). CONCLUSIONS Graft failure was higher in patients with primary sclerosing cholangitis who received livers from deceased after circulatory death donors; however, the risk of graft loss was abrogated using appropriately matched donor and recipient combinations.
Collapse
Affiliation(s)
- Vidya A Fleetwood
- From the Division of Transplant Surgery, Department of General Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Abstract
The objective of the study was to determine the long-term stricture rate of hepaticojejunostiomy (HJ) performed for benign disease, to compare stricture rates for transplant patients and non-transplant patients, and to compare the success rates of procedural and surgical treatment options. Hospital charts of 135 consecutive patients undergoing HJ between 1998 and 2016 were analyzed retrospectively. The primary outcome was stricture formation. Secondary outcomes were time to stricture diagnosis and success rates of various interventions. The anastomotic stricture rate was 13.3 per cent (18). The mean follow-up period was 4.3 years. The mean time to stricture diagnosis was 2.3 years. Stricture rates were similar between the transplant (19.2%) and nontransplant, non-Whipple group (13%). Strictures were treated with radiological intervention with a 44.4 per cent success rate; each required multiple interventions. Mortality from liver disease after failure of nonoperative management of HJ strictures reached 30 per cent (3). Five of ten patients who failed radiological intervention underwent HJ revision; the success rate was 80 per cent. Anastomotic strictures of HJ performed for benign disease occur in 13 per cent of patients and typically develop within 2.5 years postoperatively. Yet, given the dangerous sequelae of chronic biliary obstruction and potential delay in presentation, a follow-up is recommended for up to 10 years. When strictures occur, HJ revision should be considered early, after two failed radiological interventions.
Collapse
Affiliation(s)
| | - John J. Klein
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | | | - Martin Hertl
- Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Edie Y. Chan
- Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| |
Collapse
|
11
|
Zielsdorf SM, Klein JJ, Fleetwood VA, Hertl M, Chan EY. Hepaticojejunostomy for Benign Disease: Long-Term Stricture Rate and Management. Am Surg 2019; 85:1350-1353. [PMID: 31908217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The objective of the study was to determine the long-term stricture rate of hepaticojejunostiomy (HJ) performed for benign disease, to compare stricture rates for transplant patients and nontransplant patients, and to compare the success rates of procedural and surgical treatment options. Hospital charts of 135 consecutive patients undergoing HJ between 1998 and 2016 were analyzed retrospectively. The primary outcome was stricture formation. Secondary outcomes were time to stricture diagnosis and success rates of various interventions. The anastomotic stricture rate was 13.3 per cent (18). The mean follow-up period was 4.3 years. The mean time to stricture diagnosis was 2.3 years. Stricture rates were similar between the transplant (19.2%) and nontransplant, non-Whipple group (13%). Strictures were treated with radiological intervention with a 44.4 per cent success rate; each required multiple interventions. Mortality from liver disease after failure of nonoperative management of HJ strictures reached 30 per cent (3). Five of ten patients who failed radiological intervention underwent HJ revision; the success rate was 80 per cent. Anastomotic strictures of HJ performed for benign disease occur in 13 per cent of patients and typically develop within 2.5 years postoperatively. Yet, given the dangerous sequelae of chronic biliary obstruction and potential delay in presentation, a follow-up is recommended for up to 10 years. When strictures occur, HJ revision should be considered early, after two failed radiological interventions.
Collapse
Affiliation(s)
- Shannon M Zielsdorf
- From the *Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - John J Klein
- From the *Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Vidya A Fleetwood
- †Department of Surgery, University of Wisconsin, Madison, Wisconsin; and
| | - Martin Hertl
- ‡Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Edie Y Chan
- ‡Division of Abdominal Transplantation, Department of Surgery, Rush University Medical Center, Chicago, Illinois
| |
Collapse
|
12
|
Affiliation(s)
- John D. Cull
- Department of Surgery Greenville Health System Greenville, South Carolina
| | - Vidya A. Fleetwood
- Department of Surgery Greenville Health System Greenville, South Carolina
| | - Benjamin Manning
- Department of Surgery Greenville Health System Greenville, South Carolina
| | - Edie Y. Chan
- Department of Surgery Greenville Health System Greenville, South Carolina
| |
Collapse
|
13
|
Cull JD, Fleetwood VA, Manning B, Chan EY. Healthcare Workers' Attitude toward Organ Donation at Two Level 1 Urban Trauma. Am Surg 2017; 83:e389-e391. [PMID: 30454364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- John D Cull
- Department of Surgery, Greenville Health System, Greenville, South Carolina, USA
| | | | | | | |
Collapse
|
14
|
Affiliation(s)
- Vidya A. Fleetwood
- Department of General Surgery Rush University Medical Center Chicago, Illinois
| | - Lindsay Petersen
- Department of General Surgery Rush University Medical Center Chicago, Illinois
| | - Keith W. Millikan
- Department of General Surgery Rush University Medical Center Chicago, Illinois
| |
Collapse
|
15
|
Fleetwood VA, Petersen L, Millikan KW. Gastric Adenocarcinoma Presenting after Revisional Roux-en-Y Gastric Bypass. Am Surg 2016; 82:e186-e187. [PMID: 27657561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Vidya A Fleetwood
- Department of General Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | | |
Collapse
|
16
|
Fleetwood VA, Kubasiak JC, Janssen I, Myers JA, Millikan KW, Deziel DJ, Luu MB. Primary Anastomosis versus Ostomy after Colon Resection during Debulking of Ovarian Carcinomatosis: A NSQIP Analysis. Am Surg 2016. [DOI: 10.1177/000313481608200413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ovarian carcinomatosis poses a dilemma for the surgeon. When resecting colon for tumor invasion, one must decide between diversion and primary anastomosis (PA). We examined the National Surgical Quality Improvement Program to determine whether PA associated with more complications than ostomy. The National Surgical Quality Improvement Program dataset was queried for patients with ovarian carcinomatosis between 2007 and 2012. Current Procedural Terminology codes were used to further identify patients undergoing colectomy with PA or ostomy. Logistic regression was used to evaluate 30-day morbidity and mortality. The 1013 ovarian carcinomatosis patients who underwent elective colon surgery were divided into primary repair (n = 453, 43.5%) or ostomy (n = 586, 56.5%) groups. Preoperative demographics were similar; however, ostomy patients had more severe preoperative laboratory derangements. The 30-day mortality and postoperative transfusion requirements were higher in the ostomy group. On multivariate analysis controlling for confounders, the differences were no longer significant. In conclusion, 30-day mortality and postoperative complications were increased in the ostomy group. Given the laboratory derangements in this group, this may reflect tendency to allocate ostomies to more ill patients. Primary repair in a selected population does not worsen outcomes. Prospective evaluation would help determine the impact of PA in the ovarian carcinomatosis population.
Collapse
Affiliation(s)
- Vidya A. Fleetwood
- Department of General Surgery, Rush University Medical Center, Chicago, Illinois
| | - John C. Kubasiak
- Department of General Surgery, Rush University Medical Center, Chicago, Illinois
| | - Imke Janssen
- Department of General Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jonathan A. Myers
- Department of General Surgery, Rush University Medical Center, Chicago, Illinois
| | - Keith W. Millikan
- Department of General Surgery, Rush University Medical Center, Chicago, Illinois
| | - Daniel J. Deziel
- Department of General Surgery, Rush University Medical Center, Chicago, Illinois
| | - Minh B. Luu
- Department of General Surgery, Rush University Medical Center, Chicago, Illinois
| |
Collapse
|
17
|
Fleetwood VA, Kubasiak JC, Janssen I, Myers JA, Millikan KW, Deziel DJ, Luu MB. Primary Anastomosis versus Ostomy after Colon Resection during Debulking of Ovarian Carcinomatosis: A NSQIP Analysis. Am Surg 2016; 82:302-307. [PMID: 27097621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Ovarian carcinomatosis poses a dilemma for the surgeon. When resecting colon for tumor invasion, one must decide between diversion and primary anastomosis (PA). We examined the National Surgical Quality Improvement Program to determine whether PA associated with more complications than ostomy. The National Surgical Quality Improvement Program dataset was queried for patients with ovarian carcinomatosis between 2007 and 2012. Current Procedural Terminology codes were used to further identify patients undergoing colectomy with PA or ostomy. Logistic regression was used to evaluate 30-day morbidity and mortality. The 1013 ovarian carcinomatosis patients who underwent elective colon surgery were divided into primary repair (n = 453, 43.5%) or ostomy (n = 586, 56.5%) groups. Preoperative demographics were similar; however, ostomy patients had more severe preoperative laboratory derangements. The 30-day mortality and postoperative transfusion requirements were higher in the ostomy group. On multivariate analysis controlling for confounders, the differences were no longer significant. In conclusion, 30-day mortality and postoperative complications were increased in the ostomy group. Given the laboratory derangements in this group, this may reflect tendency to allocate ostomies to more ill patients. Primary repair in a selected population does not worsen outcomes. Prospective evaluation would help determine the impact of PA in the ovarian carcinomatosis population.
Collapse
Affiliation(s)
- Vidya A Fleetwood
- Department of General Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | | | | | | | | | | |
Collapse
|
18
|
Fleetwood VA, Harris JC, Luu MB. Cutaneous angiosarcoma metastatic to small bowel with nodal involvement. Gastroenterol Hepatol Bed Bench 2016; 9:340-342. [PMID: 27895862 PMCID: PMC5118861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A 77-year-old male with a history of metastatic scalp angiosarcoma presented with intractable gastrointestinal bleeding from a jejunal mass detected on capsule endoscopy. He underwent laparoscopic-assisted resection of the mass. Intraoperatively, an isolated small bowel mass with bulky lymphadenopathy was seen and resected en bloc. Pathology showed a 6.8cm high-grade metastatic angiosarcoma with nodal involvement and negative margins. Angiosarcoma is a sarcoma with a grim prognosis. The incidence is 2% of all soft tissue sarcomas; cutaneous lesions comprise 27% of manifestations and usually appear on head and neck. Risk factors include lymphedema, neurofibromatosis, vinyl chloride, arsenic, and anabolic steroids. Overall 5-year survival is 30-35% and is higher in patients younger than 60, those without metastasis, tumors less than 5 cm, and favorable histology. Angiosarcoma metastasis to small bowel is rare but nodal involvement is even more unusual, reported only three times in the literature. This case is the first with nodal involvement to present at a resectable stage. To diagnose disease when still at a resectable stage, a high index of suspicion must be maintained with any gastrointestinal symptoms in a patient with a history of angiosarcoma. Laparoscopic-assisted resection is safe for the resection of small bowel angiosarcoma.
Collapse
|
19
|
Fleetwood VA, Hertl M, Chan EY. Liver Transplantation to the Active Smoker: Transplant Provider Opinions and How They Have Changed : Transplantation in Smokers: A Survey. J Gastrointest Surg 2015; 19:2223-7. [PMID: 26358276 DOI: 10.1007/s11605-015-2935-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 08/31/2015] [Indexed: 01/31/2023]
Abstract
Awareness of smoking complications in liver transplantation patients is increasing. No study in the past 15 years has addressed attitudes toward offering transplantation to smokers. Our aim was to determine smoking policies nationwide. We conducted a survey of liver transplantation centers. The seven-question survey was sent to medical and surgical directors of liver transplantation. Results were analyzed in R 3.1.1 using two-tailed t testing and ANOVA. Fifty one of 110 centers (46 %) responded. Volume transplanted annually ranged from 10 to 190. Most respondents acknowledged a policy on smoking (38/51, 75 %). Most centers with policies required cessation (32/38, 84 %). All other centers did encourage attempts at cessation (19/19, 100 %). Whether smoking cessation was required differed by region (p = 0.02). Southern programs more commonly required smoking cessation (87.5 vs. 38.4 %, p < 0.001). The highest rates of smoking cessation were noted in the Southwest (90.0 %) and the lowest in the Northeast (26.2 %). There was a trend toward requiring cessation in larger-volume centers. Most respondents had a tobacco policy and tended to require abstinence; however, ultimately centers were divided on requiring cessation. Regional differences were noted, with the South more commonly requiring cessation. Our results indicate lack of consensus among transplantation centers regarding access of smokers to liver transplantation.
Collapse
Affiliation(s)
- Vidya A Fleetwood
- Department of General Surgery, Rush University Medical Center, 1653W. Congress Parkway Jelke Bldg Suite 792, Chicago, IL, 60612, USA. .,, 1653W. Congress Parkway, Jelke Bldg Suite 878, Chicago, IL, 60612, USA.
| | - Martin Hertl
- Division of Transplantation Surgery, Rush University Medical Center, 1653W. Congress Parkway Jelke Bldg Suite 792, Chicago, IL, 60612, USA
| | - Edie Yee Chan
- Division of Transplantation Surgery, Rush University Medical Center, 1653W. Congress Parkway Jelke Bldg Suite 792, Chicago, IL, 60612, USA
| |
Collapse
|
20
|
Singer GA, Zielsdorf S, Fleetwood VA, Alvey N, Cohen E, Eswaran S, Shah N, Chan EY, Hertl M, Fayek SA. Limited hepatitis B immunoglobulin with potent nucleos(t)ide analogue is a cost-effective prophylaxis against hepatitis B virus after liver transplantation. Transplant Proc 2015; 47:478-84. [PMID: 25769595 DOI: 10.1016/j.transproceed.2014.11.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 11/19/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prophylaxis against hepatitis B virus (HBV) recurrence after orthotopic liver transplantation (OLT) includes lifelong hepatitis B immunoglobulin (HBIG) and oral antiviral agent(s). In the presence of high-genetic-barrier nucleos(t)ide analogues, the need for lifelong HBIG is questioned. We evaluated the safety and cost-effectiveness of a limited HBIG course. METHODS OLT from 2006 to 2013 were reviewed. Patients with pre-OLT hepatitis B virus surface antigen who received HBV prophylaxis with 2 HBIG doses (anhepatic and first post-operative day; 10,000 units/dose) and potent nucleos(t)ide analogues were included. The primary end point was HBV recurrence (HBV-DNA detection). RESULTS Thirteen patients (primary transplants) were included, median Model for End-Stage Liver Disease score was 18, and there was no fulminant failure; HBV-DNA was detected in 4 patients at OLT. After OLT, 10 patients received entecavir and/or tenofovir. Median follow-up was 23 months. One recurrence occurred (7.7%) at month 13 (HBV-DNA: 14 IU/mL); the graft maintained excellent function. This minimal viremic expression is related to hepatocellular carcinoma recurrence with neoplastic replication carrying integrated HBV-DNA; thus, there is no defined HBV viral recurrence. No graft loss or patient death was related to HBV recurrence. The 1-year patient and graft survival rate was 84.6%. Cost-savings in the first year was $178,100 per patient when compared with Food and Drug Administration-approved HBIG dosing. CONCLUSIONS In the era of potent oral nucleos(t)ide analogues, a limited HBIG course appears to be cost-effective in preventing HBV recurrence.
Collapse
Affiliation(s)
- G A Singer
- Department of Surgery, Section of Transplantation, Rush University Medical Center, Chicago, Illinois
| | - S Zielsdorf
- Department of Surgery, Section of Transplantation, Rush University Medical Center, Chicago, Illinois
| | - V A Fleetwood
- Department of Surgery, Section of Transplantation, Rush University Medical Center, Chicago, Illinois
| | - N Alvey
- Department of Pharmacy, Rush University Medical Center, Chicago, Illinois
| | - E Cohen
- Department of Medicine, Section of Hepatology, Rush University Medical Center, Chicago, Illinois
| | - S Eswaran
- Department of Medicine, Section of Hepatology, Rush University Medical Center, Chicago, Illinois
| | - N Shah
- Department of Medicine, Section of Hepatology, Rush University Medical Center, Chicago, Illinois
| | - E Y Chan
- Department of Surgery, Section of Transplantation, Rush University Medical Center, Chicago, Illinois
| | - M Hertl
- Department of Surgery, Section of Transplantation, Rush University Medical Center, Chicago, Illinois
| | - S A Fayek
- Department of Surgery, Section of Transplantation, Rush University Medical Center, Chicago, Illinois.
| |
Collapse
|
21
|
Fleetwood VA, Gross K, Alex GC, Cortina CS, Smolevitz JB, Sarvepalli S, Bakhsh SR, Myers JA, Singer MA, Orkin BA. Common side closure type but not stapler brand or oversewing influences side-to-side anastomotic leak rates. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.08.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
22
|
Fleetwood VA, Zielsdorf S, Eswaran S, Jakate S, Chan EY. Intra-abdominal desmoid tumor after liver transplantation: A case report. World J Transplant 2014; 4:148-152. [PMID: 25032104 PMCID: PMC4094950 DOI: 10.5500/wjt.v4.i2.148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 05/06/2014] [Accepted: 06/11/2014] [Indexed: 02/05/2023] Open
Abstract
We are reporting the first documented case of an abdominal desmoid tumor presenting primarily after liver transplantation. This tumor, well described in the literature as occurring both in conjunction with familial adenomatous polyposis as well as in the post-surgical patient, has never been noted after solid organ transplantation and was therefore not included in our differential upon presentation. Definitive diagnosis required the patient to undergo surgical excision and immunochemical staining of the mass for confirmation. A review of the literature showed no primary tumors after transplantation. In a population of patients who received a small bowel transplant after they developed short gut post radical resection of aggressive fibromatosis, only rare recurrences were seen. No connection of tumor development with immunosuppression or need to decrease immunosuppressant treatment has been demonstrated in these patients. Our case and the literature show the risk of this tumor presenting in the post-transplantation patient and the need for a high index of suspicion in patients who present with a complex mass after transplantation to prevent progression of the disease beyond a resectable lesion. Results of a thorough search of the literature are detailed and the medical and surgical management of both resectable and unresectable lesions is reviewed.
Collapse
|