A. Bottazzi

Experimental Small Bowel Transplantation From Non–Heart-Beating Donors: A Large-Animal Study

INTRODUCTION The shortage of organs in the last 20 years is stimulating the development of new strategies to expand the pool of donors. The harvesting of a graft from non-heart-beating donors (NHBDs) has been successfully proposed for kidney and liver transplantation. To our knowledge, no studies are available for small bowel transplantation using NHBDs. In an experimental setting of small bowel transplantation, we studied the feasibility of using intestinal grafts retrieved from NHBDs. MATERIALS AND METHODS Twenty five Large White piglets underwent total orthotopic small bowel transplantation and were randomly divided as follow: NHBD group (n = 15) received grafts from NHBDs; heart-beating donor (HBD) group (n = 10) received grafts from HBDs. The NHBD pigs were sacrificed inducing the cardiac arrest by a lethal potassium injection. After 20 minutes (no touch period = warm ischemia), they underwent cardiac massage, laparotomy, and aorta cannulation for flushing and cooling the abdominal organs. In HBDs, the cardiac arrest was induced at the time of organ cold perfusion. In both groups, immunosuppression was based on tacrolimus oral monotherapy. The animals were observed for 30 days. The graft absorptive function was studied at day 30 using the D-xylose absorption test. Histological investigation included HE (Hematoxilin and Eosin) microscopical analysis and immunohistological staining. RESULTS Animals in the NHBD group died due to infection (n = 3), acute cellular rejection (n = 2), technical complications (n = 2), and intestinal failure (n = 8). In the HBD group, all animals but two were alive at the end of the study. The D-xylose absorption was significantly lower among the NHBD compared with the HBD group (P < .05). CONCLUSIONS This study confirmed that intestinal mucosa is sensitive to ischemic injury. When the intestinal graft is harvested from NHBDs, the infectious-related mortality was higher and the absorptive function lower. Histological examination confirmed a higher grade of ischemic injury in the NHBD grafts that correlated with the clinical data. Therefore, this experimental study suggested that non-heart-beating donation may not be indicated for small bowel transplantation.

Transvaginal laparoscopic cholecystectomy: endoscopically assisted

We read with interest the article by Bessler et al. [1], entitled ‘‘Transvaginal laparoscopic cholecystectomy, laparoscopically assisted.’’ In their technique, the authors used a 5-mm trocar for the laparoscopic grasper to retract the fundus of the gallbladder. The entire cholecystectomy was then performed using a 12-mm dual-channel therapeutic gastroscope. Aside from the title of the paper (which may convey a mistake), the authors define their operation as ‘‘transvaginal endoscopic cholecystectomy’’ which is laparoscopically assisted. Interestingly, using the same access in the pig model, we have performed a ‘‘transvaginal laparoscopic cholecystectomy, endoscopically assisted.’’ After approval from the University of Pavia Research Ethical Board and from the Italian Ministry of Health, four 30-kg Large White pigs underwent transvaginal cholecystectomy. After pneumoperitoneum induction with a Veress needle, a 5-mm laparoscopic trocar was placed in the left lower quadrant of the abdomen. Using a 5-mm optic for direct vision control, the intra-abdominal insertion of a 12-mm dual-channel gastroscope through the vagina was safely performed. Using the same vaginal access, a 43-cmlong laparoscopic grasper was inserted to retract the fundus of the gallbladder. The gastroscope was used only for video assistance and further retraction of the gallbladder. The cholecystectomy was performed using 5-mm laparoscopic instruments through the trocar. The cystic structures were dissected using a conventional laparoscopic hook cautery device and a blunt laparoscopic right-angle. The cystic duct and the cystic artery were then closed with clips using a 5mm laparoscopic clip applier and subsequently divided with laparoscopic forceps. The gallbladder was then dissected from its bed using the hook cautery as in conventional laparoscopic cholecystectomy. The laparoscopic grasper inserted through the vagina was used to remove the gallbladder from the abdomen. The trocar access was also used for additional haemostasis and for intra-abdominal washing and aspiration. The only intraoperative complication was bile leakage from the gallbladder, in two of the four cases. Operative time ranged between 65 and 95 min and was significantly less than that reported by Bessler et al. The advent of NOTES on the scene has attracted attention and enthusiasm, but also caution and recommendations for animal studies that better define the surgical technique, test new dedicated instruments, overcome potential problems, and explore applicability to clinical settings [2]. Following this recommendation, a large number of animal studies have been performed during the last 3 years [3]. The experimental techniques described by Bessler et al. and by us are good examples of this strategy for the safe development of NOTES technology. However, the two techniques are two sides of the same coin: one is endoscopically based with laparoscopic assistance; the other is laparoscopically based, with endoscopic assistance. Both of the procedures are performed with conventional endoscopic and laparoscopic devices, which are not specifically designed for this type of surgery, making necessary a hybrid approach to ensure safe M. Alessiani (&) L. Cobianchi S. Zonta P. Dionigi Hepatopancreatic Unit, Department of Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia, P.le Golgi 19, 27100 Pavia, Italy e-mail: m.alessiani@unipv.it