A. Amaduzzi

Twenty-five consecutive isolated intestinal transplants in adult patients: a five-yr clinical experience

Abstract: Patients and Methods:  Between December 2000 and December 2005, 25 isolated intestinal transplants from cadaveric donors have been performed for short gut syndrome (short bowel syndrome, 52%), chronic intestinal pseudo‐obstruction (24%), Gardner syndrome (16%), radiation enteritis (4%) and massive intestinal angiomatosis (4%). Indications for transplantation were: loss of venous access, recurrent sepsis due to central line infection, major electrolyte and fluid imbalance. Liver dysfunction was present in 13 cases. All patients were adult; median age was 36.3 yr and mean weight at transplantation 61.6 kg. All recipients were on life‐threatening parenteral nutrition for a mean time of 23.7 months. Mean donor/recipient body weight ratio was 1.08. Rejection monitoring was accomplished by graft ileoendoscopies and intestinal biopsies through the temporary ileostomy. Our immunosuppressive regimen was based on induction therapy with three different protocols: daclizumab for induction, tacrolimus and steroids as maintenance therapy; alemtuzumab for induction and low‐dose tacrolimus as maintenance; thymoglobulinTM for induction and maintenance based on low‐dose tacrolimus. Closure of the abdomen at the end of transplantation represented a technical problem with several options performed: graft reduction, only skin closure, prothesic meshes, abdominal closure in two steps, cutaneous flaps and abdominal wall transplant in one case.

Kidney preservation: review of present and future perspective.

One of the main problems in transplant surgery is the preservation of the organ during the cold ischemic time. The interrupted blood supply triggers a cascade of biological modifications resulting in cell death, which predisposes to discharge of a large quantity of toxic metabolites at the moment of organ reperfusion. Many approaches have been studied to prevent the toxic processes. Immediately after procurement, kidneys are flushed with these solutions. Two main: techniques of organ preservation are cold static storage and hypothermic machine perfusion (HMP). Based on age and comorbidities, individuals can be generally divided into 2 groups: ideal and marginal donors. Characteristics of organs from marginal donors are associated with an increased rate of delayed graft function and primary graft nonfunction (PNF), which reduce transplant survival and increase the acute rejection risk. In the last 20 years, the United Network of Organ Sharing has reported a 170% increase in deceased donors older than 50 years of age. Techniques of perfusion have been demonstrated to play a pivotal role in graft function after transplantation. Some studies suggest that HMP may improve outcomes after transplantation.

T.E.A. Study: three-day ertapenem versus three-day Ampicillin-Sulbactam

BackgroundIntra-abdominal infections are one of the most common infections encountered by a general surgeon. However, despite this prevalence, standardized guidelines outlining the proper use of antibiotic therapy are poorly defined due to a lack of clinical trials investigating the ideal duration of antibiotic treatment. The aim of this study is to compare the efficacy and safety of a three-day treatment regimen of Ampicillin-Sulbactam to that of a three-day regimen of Ertapenem in patients with localized peritonitis ranging from mild to moderate severity.MethodsThis study is a prospective, multi-center, randomized investigation performed in the Department of General, Emergency, and Transplant Surgery of St. Orsola-Malpighi University Hospital in Bologna, Italy. Discrete data were analyzed using the Chi-squared and Fisher exact tests. Differences between the two study groups were considered statistically significant for p-values less than 0.05.Results71 patients were treated with Ertapenem and 71 patients were treated with Ampicillin-Sulbactam. The two groups were comparable in terms of age and gender as well as the site of abdominal infection. Post-operative infection was identified in 12 patients: 10 with wound infections and 2 with intra-abdominal infections. In the Ertapenem group, 69 of the 71 patients (97%) were treated successfully, while the therapy failed in 2 cases (3%). Therapy failures were more frequent in the Unasyn group, amounting to 10 of 71 cases (p = 0.03).ConclusionAccording to these preliminary findings, the authors conclude that a three-day Ertapenem treatment regimen is the most effective antibiotic therapy for patients with localized intra-abdominal infections ranging from mild to moderate severity.Trial registrationTrial registration: ClinicalTrials.gov: NCT00630513

Induction Therapy With Alemtuzumab (Campath) in Combined Liver-Kidney Transplantation: University of Bologna Experience

BACKGROUND Combined liver-kidney transplantation (LKT) is considered to be a safe procedure, but the appropriate immunosuppressive regimen is unclear. PATIENTS AND METHODS Between January 1997 and October 2011, 55 patients were listed for LKT: 45 (82%) were effectively transplanted, 5 (9.2%) died whereon here the waiting list, 3 (5.5%) temporarily out of waiting list, 1 (1.8%) was on waiting list and 1 (1.8%) refused LKT. Five LKTs treated with cyclosporine (CyA) were excluded from the analysis. Mean recipient age was 50.32 ± 10.32 years (14-65), MELD score at time of LKT was 19.22 ± 4.69 (8-29), mean waiting list time was 8.14 ± 9.50 months (0.1-35.76), and follow-up, 4.09 ± 3.02 years (0.01-10.41). Main indications for LKT were policystic disease (n = 15; 37%), hepatitis virus C (HCV)-related cirrhosis (n = 9; 22%) metabolic disease (n = 5; 13%), hepatitis virus B (HBV) cirrhosis (n = 4; 10%), alcoholic cirrhosis (n = 4; 10%), and cholestatic disease (n = 3; 8%). Immunosuppressive regimen was based on tacrolimus and steroids in 40 cases with induction therapy with alemtuzumab (Campath; 0.3 mg/kg) in 13 of 40 instances cases administered on day 0 and day 7. RESULTS Postoperative mortality was 2.5%. Acute cellular rejection episodes were biopsy-proven in 2 (5%) cases, post-LKT infections developed in 17 cases (42.5%), and de novo cancer developed in 3 (7.5%) cases. Similar 5-year overall survivals were obtained irrespective of the LKT indication: 100% in cholestatic and alcoholic cirrhosis patients, 86% in policystic disease, 75% in metabolic disease and HBV patients, and 66% in HCV cirrhosis. Overall survivals for the alemtuzumab vs without-induction therapy groups at 1, 3, and 5-years were 100%, 85.7%, and 85.7% vs 76%, 76%, and 70%, respectively (P = .04). CONCLUSION An immunosuppressive regimen based on tacrolimus and steroids with induction therapy with alemtuzumab was safe, with excellent long-term results for combined LKT.

Importance of Renal Mass on Graft Function Outcome After 12 Months of Cadaveric Donor Kidney Transplantation

BACKGROUND Few studies have measured cadaveric kidney weight to investigate its relation to recipient kidney function related to it. The aim of this study was to evaluate kidney weight (cadaveric donor) and its relationship to creatinine clearance (CrCl) after 12 months posttransplantation. METHODS We evaluated 81 renal transplantation recipients from cadaveric donors. We collected donor and recipient demographic, clinical and anthropometric data. Data about kidney weight were obtained through kidney measurement using an electronic machine at the moment of transplantation. RESULTS The mean kidney weight was 201.4 +/- 10.2 g (200.5 +/- 11.6 g in women and 210.3 +/- 14.1 g in men). Kidney weight correlated with CrCl at 12 months (0.001). The CrCl at 12 months showed a significant correlation of graft weight/recipient weight ratio (P < .01). CONCLUSION The cadaveric donor kidney weight significantly influenced the CrCl at 12 months after transplantation.

Pulsatile perfusion of kidney allografts with Celsior solution.

BACKGROUND Use of pulsatile perfusion (PP) to optimize outcomes in deceased donor renal transplantation remains controversial. This prospective analysis describes all cadaveric renal allografts transplanted at our center that were preserved with PP using Celsior solution. METHODS We used the LifePort Kidney Transporter (Organ Recovery Systems) perfusion machine. Study outcomes included 1-year graft and patient survivals as well as rates of delayed graft function and need for posttransplant dialysis. RESULTS Graft survival for PP was 90% and patient survival 100%. The incidences of delayed graft function was 10% and of posttransplant dialysis, 10%. CONCLUSION These data support the use of PP with Celsior solution.

Renal Transplantation: Surgical Technique

The principles of the vascular anastomosis technique proposed by Carrel in 1902 and the accomplishment of the implantation in the iliac vessels by Kuss in 1951 are still in use. During renal transplantation the standard vein anastomosis technique is an end-to-side anastomosis performed between the graft renal vein and the recipient’s external iliac vein with an extraperitoneal approach. For arterial anastomosis end-to-side anastomosis to the external iliac artery is the preferred technique in deceased donors. The extravesical ureteroneocystostomy was first described by Witzel in 1896 and was popularized by Lich. Herein called the Lich-Gregoir, it is characterized by extravesicular access, the formation of an antireflux tunnel, and a urothelial anastomosis. Double kidney transplantation (DKT) is another approach for expansion of the existing deceased donor pool. Transplantation of two marginal kidneys rather than one suboptimal kidney to one recipient would result in more functioning nephrons that ultimately may improve the patient and graft outcome.

Renal Transplantation: Postoperative Technical Complications

Lymphocele after renal transplantation has been reported from 0.6 to 18 %. The treatment consists of simple aspiration, external drainage, and marsupialization of the cyst into the peritoneal cavity by standard surgical technique or laparoscopy. Stricture of the ureterovesical junction (UVJ) anastomosis, with reported incidence rates of 2–10 %, is the most frequent urologic complication in kidney allograft recipients. Open surgery has traditionally been used for correction of the obstruction. Development of percutaneous modalities of treatment such as percutaneous nephrostomy (PCN) with low complication rates has altered the approach to ureteral stricture. Urine leakage is usually the result of ureteral necrosis as a consequence of rejection or vascular insufficiency and can be treated by insertion of an indwelling ureteral catheter for 21–60 days without the need for surgery. A urine leak can increase rapidly, and drainage often needs to be performed with ultrasound guidance to relieve compression and urinary ascites. Anterograde pyelography is necessary to depict the site of leak and to plan the appropriate intervention. Small urine leaks may be treated with PCN. Transplant artery stenosis is the most common vascular complication (up to 10 %). When treatment is necessary, percutaneous transluminal angioplasty with or without stent placement is nowadays accepted as the initial treatment of choice. Renal vein thrombosis is an unusual posttransplant complication; it happens in <5 % of patients within the first postoperative week; early recognition is crucial because the allograft may sometimes be salvaged by prompt thrombectomy. Thrombosis of the main renal artery occurs very rarely (<1 % of cases) in the early postoperative period and usually leads to graft loss; early diagnosis and treatment are vital for allograft salvage.

Living Donor Nephrectomy

Kidney transplantation (KT) is the principal treatment of end-stage renal disease (ESRD) because it improves patient survival and quality of life compared to dialysis.

Renal Transplantation: Kidney Procurement from Cadaveric Donors

Kidney retrieval is often just part of a more complex procedure such as multiorgan procurement in which different surgical teams are involved. A good knowledge of the individual phases of the procedure and of the possible anatomical variations is crucial. In this chapter, we will describe the surgical technique used for kidney retrieval, discussing both en bloc and single kidney harvest.