A. Tzakis

The Incidence, Timing, and Management of Biliary Tract Complications After Orthotopic Liver Transplantation

ObjectiveThis study analyzed the incidence and timing of biliary tract complications after orthotopic liver transplantation (OLTx) in 1792 consecutive patients. These results were then compared with those of previously reported series. Finally, recommendations were made on appropriate management strategies. Summary Background DataTechnical complications after OLTx have a significant impact on patient and graft survival. One of the principle technical advances has been the standardization of techniques for biliary reconstruction. Nonetheless, biliary complications still occur. A 1983 report from the University of Pittsburgh reported biliary complications in 19% of all transplants, and an update in 1987 reported biliary complications in 13.2% of transplants. MethodsThe medical records of all patients who underwent liver transplantation and were hospitalized between January 1, 1988 and July 31, 1991 were reviewed. The case material consisted of the medical records of 217 patients treated for 245 biliary complications. ResultsPrimary biliary continuity was established by either choledochocholedochostomy over a T-tube (C-C, n = 129) or a Roux-en-Y choledochojejunostomy with an internal stent (C-RY, n = 85). The overall incidence for biliary complication in this large series was 11.5%. Strictures (n = 93) and bile leak (n = 58) were the most common complications (69.6%). Most billary complications (n = 143, 66%) occurred within the first 3 months after surgery. In general, leaks occurred early, and strictures developed later. Bile leaks were equally frequent in both C-C and C-RY (27.1% and 25.9%, respectively); strictures were more common after a C-RY type of reconstruction (36.4% and 52.9%, respectively). Twenty-one patients died, an incidence of 9.6%. Fifteen of the 21 biliary-related deaths were among patients treated for rejection before the recognition of biliary tract pathologic findings. ConclusionsProgress has been made on improving the result of biliary reconstruction after OLTx. Nonetheless, patients continue to experience biliary complications after OLTx, and these complications cause considerable loss of grafts and life. If significant additional improvement in patient and graft survival are to be obtained, the technical performance of OLTx must continue to improve.

Composition of human islet cell preparations for transplantation

To study the cellular composition of human islet cell isolates for transplantation, formalin-fixed and paraffin-embedded cell pellets were stained by the immunoperoxidase method with a panel of antibodies characterising endocrine, epithelial, soft tissue and haematolymphoid components. Immediately after separation, the isolates contained 30–80% islet cells, differing mainly in the content of islet and acinar cells, whereas the soft tissue, ductal/ductular and haematolymphoid elements comprised a relatively constant 10–20%. After 1 week in culture the islet cell content of less highly purified isolates (30–40% islets) dropped dramatically to 5%. The highly purified isolates (70–80% islets) showed only a minimal change in cellular composition; however, approximately two-thirds of islet cells were degranulated and did not stain for insulin. Haematolymphoid components were still present in all cultured isolates. We conclude that primarily mechanical purification methods and short-term culture are not sufficient to eliminate highly immunogenic cells. In addition, short-term culture is deleterious to the isolate if a significant number of acinar cells is still present after enrichment.

Liver transplantation today

In summary, liver transplantation has truly come of age. To put things in perspective, the recipient waiting list at the University of Pittsburgh never includes fewer than 200 suitable candidates, and it continues to grow in spite of the fact that we are now doing essentially one transplant per day. There are many excellent transplant centers throughout the United States and Europe, the only limiting factor being the supply of donors. Orthotopic liver transplantation is now covered by most major health insurance carriers, and some form of government coverage is anticipated for the indigent. As the supply of donors increases with aggressive education programs, the need for transplantation centers will also increase. However, this should not be uncontrolled growth. Mandatory training in transplantation surgery will surely be required as a prerequisite to the establishment of transplant centers in the future. The field of organ transplantation is the newest and most dynamic in medicine today. The results are encouraging and acceptable and offer the only hope to many persons dying of end-stage organ failure. With improvements in immune modulation at hand, organ transplantation will soon become a commonplace procedure offering a completely normal life expectancy.

PERIPHERAL BLOOD GENE EXPRESSION ANALYSIS IN SMALL BOWEL TRANSPLANTATION: 2798

P. tryphonopoulos1, V. Andreev2, P. Ruiz3, A. Volsky4, E. Island5, G. Selvaggi5, A. Tekin5, S. Nishida5, D. Levi5, J. Moon5, D. Weppler2, T. Defranc6, M. Torres4, S. Shin4, A. Tzakis5 1Surgery-transplant, University of Miami, Miami/fl/UNITED STATES OF AMERICA, 2, University of Miami, Miami/FL/UNITED STATES OF AMERICA, 3Miller School Of Medicine, University of Miami, Miami/ UNITED STATES OF AMERICA, 4, University of Miami, Miami/ UNITED STATES OF AMERICA, 5Surgery, UNIVERSITY OF MIAMI, MIAMI/UNITED STATES OF AMERICA, 6Surgery Transplant, University of Miami, Miami/UNITED STATES OF AMERICA

ANTI-DONOR SPECIFIC ANTIBODIES ASSOCIATED WITH ACUTE REJECTION IN THE EARLY POST-TRANSPLANT PERIOD OF SMALL BOWEL AND MULTIVISCERAL ALLOGRAFT RECIPIENTS: 1838

H. TSAI1, A. Tzakis2, I. Gonzalez-Pinto3, J. CHANG1, P. Tryphonopoulos2, S. Nishida2, E. Island2, G. Selvaggi2, A. Tekin2, J. Moon2, D. Levi2, E.S. Woodle4, P. Ruiz5 1Division Of Pediatric Surgery, TAIPEI VETERANS GENERAL HOSPITAL, TAIPEI/TAIWAN, 2Surgery, UNIVERSITY OF MIAMI, MIAMI/UNITED STATES OF AMERICA, 3, Universidad de Oviedo, Oviedo/SPAIN, 4Transplant Surgery, University of Cincinnati, cincinnati/UNITED STATES OF AMERICA, 5Miller School Of Medicine, University of Miami, Miami/UNITED STATES OF AMERICA

ABROGATION OF THE ALLOREACTIVE RESPONSES OF CADAVER DONOR INTESTINAL LYMPHOCYTES BY INTRA-OPERATIVE CAMPATH-1H EXPOSURE

A number of recent reports in clinical and experimental intestinal transplantation have suggested that the donor lymphocytes present in and around the gastrointestinal system are potent mediators of graft-versus-host (GvH) reactivity and that GvH responses may contribute to posttransplant morbidity. Therefore, we have tested the proliferative and cytotoxic capabilities of gut-associated lymphocytes from cadaveric donors obtained prerevascularization (pre-r) and about 6 hours postrevascularization (post-r) in recipients pretreated with Campath-1H antibody (alemtuzumab). Mixed lymphocyte reactions (MLR) were performed with lymphoid cells isolated from intestinal epithelial mucosa, lamina propria, and lymph nodes. The pre-r lymphocytes responded strongly to both the recipient and third-party alloantigenic stimulating cells. However, similar preparations from the post-r samples responded in MLR at significantly lower levels (P < .01). This post-r decrease in responsiveness was not observed in similar lymphocyte samples obtained from donors of recipients not treated with Campath-1H. Both the pre-r and post-r samples had similar flow cytometric profiles, suggesting that there was no receptor loss in these lymphoid tissues by the short-term 6-hour exposure to Campath-1H given to the recipient. Conversely, in preliminary experiments where the donor were treated with Campath-1H, it was observed that very few lymphocytes could be obtained from intestinal tissues (n = 3). These results suggested that Campath-1H treatment of the recipient could bring about a drastic reduction in an otherwise strong GvH reactivity by the donor intestinal immune cells.