Anthony Gyamfi

100 Multivisceral Transplants at a Single Center

Objective:The objective of this study was to summarize the evolution of multivisceral transplantation over a decade of experience and evaluate its current status. Summary Background Data:Multivisceral transplantation can be valuable for the treatment of patients with massive abdominal catastrophes. Its major limitations have been technical and rejection of the intestinal graft. Methods:This study consisted of an outcome analysis of 98 consecutive patients who received multivisceral transplantation at our institution. This represents the largest single center experience to date. Results:The most common diseases in our population before transplant were intestinal gastroschisis and intestinal dysmotility syndromes in children, and mesenteric thrombosis and trauma in adults. Kaplan Meier estimated patient and graft survivals for all cases were 65% and 63% at 1 year, 49% and 47% at 3 years, and 49% and 47% at 5 years. Factors that adversely influenced patient survival included transplant before 1998 (P = 0.01), being hospitalized at the time of transplant (P = 0.05), and being a child who received Campath-1H induction (P = 0.03). Among 37 patients who had none of these 3 factors (15 adults and 22 children), estimated 1- and 3-year survivals were 89% and 71%, respectively. Patients transplanted since 2001 had significantly less moderate and severe rejections (31.6% vs 67.6%, P = 0.0005) with almost half of these patients never developing rejection. Conclusions:Multivisceral transplantation is now an effective treatment of patients with complex abdominal pathology. The incidences of serious acute rejection and patient survival have improved in the most recent experience. Our results show that the multivisceral graft seems to facilitate engraftment of transplanted organs and raises the possibility that there is a degree of immunologic protection afforded by this procedure.

Preliminary experience with campath 1H (C1H) in intestinal and liver transplantation

Background. The aim of this research was to study the efficacy of campath 1H in combination with low-dose tacrolimus immunosuppression for intestinal, multivisceral, and liver transplantation. Methods. Campath 1H (0.3 mg/kg) was administered in four doses: Preoperatively, at the completion of the transplant, and on postoperative days 3 and 7. Tacrolimus levels were maintained between 5 to 10 ng/dL. Suspected or mild rejections were treated with steroids. Moderate or severe rejections were treated with OKT3. Patients. We studied three groups of patients: adult recipients of intestinal or multivisceral transplants, high-risk pediatric recipients of small-bowel or multivisceral grafts, and adult liver-transplant recipients. Results. Twenty-one adult intestinal recipients received 24 grafts. With follow-up of 2.4 to 16 months, 14 patients are alive and 14 grafts are functioning. Eleven high-risk pediatric intestinal recipients received 12 grafts. There were four mortalities in this group, and after a follow up of 1 to 8.5 months, four patients have not experienced a rejection episode. Five adult liver recipients received five grafts. With a follow-up of 3 to 6.2 months, all five patients are alive. There were no rejection episodes in this group, and none of them required steroid therapy. Conclusions. This immunosuppressive regimen allows for the avoidance of maintenance adjuvant-steroid treatment in the majority of our patients. Our preliminary data show a trend toward a reduction of the incidence and the severity of rejection episodes, although we need to follow-up larger numbers of patients to confirm these results.

Piggyback technique in adult orthotopic liver transplantation: an analysis of 1067 liver transplants at a single center

BACKGROUND Orthotopic liver transplantation (OLT) in adult patients has traditionally been performed using conventional caval reconstruction technique (CV) with veno-venous bypass. Recently, the piggyback technique (PB) without veno-venous bypass has begun to be widely used. The aim of this study was to assess the effect of routine use of PB on OLTs in adult patients. PATIENTS AND METHODS A retrospective analysis was undertaken of 1067 orthotopic cadaveric whole liver transplantations in adult patients treated between June 1994 and July 2001. PB was used as the routine procedure. Patient demographics, factors including cold ischemia time (CIT), warm ischemia time (WIT), operative time, transfusions, blood loss, and postoperative results were assessed. The effects of clinical factors on graft survival were assessed by univariate and multivariate analyses.In all, 918 transplantations (86%) were performed with PB. Blood transfusion, WIT, and usage of veno-venous bypass were less with PB. Seventy-five (8.3%) cases with PB had refractory ascites following OLT (p=NS). Five venous outflow stenosis cases (0.54%) with PB were noted (p=NS). The liver and renal function during the postoperative periods was similar. Overall 1-, 3-, and 5-year patient survival rates were 85%, 78%, and 72% with PB. Univariate analysis showed that cava reconstruction method, CIT, WIT, amount of transfusion, length of hospital stay, donor age, and tumor presence were significant factors influencing graft survival. Multivariate analysis further reinforced the fact that CIT, donor age, amount of transfusion, and hospital stay were prognostic factors for graft survival. CONCLUSIONS PB can be performed safely in the majority of adult OLTs. Results of OLT with PB are as same as for CV. Liver function, renal function, morbidity, mortality, and patient and graft survival are similar to CV. However, amount of transfusion, WIT, and use of veno-venous bypass are less with PB.

Successful living related liver transplantation in an adult with fulminant hepatic failure

We report a case of an adult female who developed fulminant hepatic failure (FHF) during the second trimester of pregnancy and underwent a successful living related liver transplantation because no cadaveric donor was available during the development of life-threatening symptoms. A left lateral segment hepatic graft was procured from her brother, whose body weight was similar to hers. Her postoperative course was complicated by bleeding at the biliary anastomosis and subsequently by a biliary leak. Nevertheless, the complications were corrected surgically and the patient recovered well with a good quality of life 5 months after the transplant. This case suggests that living related liver transplantation should be considered more frequently for adult FHF patients. As the window of therapeutic opportunity is narrow for the dramatic condition of FHF, wide acceptance of this procedure will be of great benefit for the patients suffering from FHF.

Analysis of vascular access in intestinal transplant recipients using the Miami classification from the VIIIth International Small Bowel Transplant Symposium.

Background. Loss of vascular access in patients with intestinal failure is considered an indication for intestinal transplantation. Such patients often have one or more occluded vein sites. Venous access could be classified according to the number of occluded vessels, to facilitate pre- and postoperative management. Methods. At the VIIIth International Small Bowel Transplant Symposium in September 2003, a new classification of vascular access in patients who were candidates for bowel transplant was proposed. The classification was then applied to stratify all patients that underwent intestinal transplantation at the University of Miami between 1998 and 2003. Data were collected on Doppler ultrasonography, angiography, and vein angioplasty in such patients. Results. A total of 106 cases in 91 patients were included in the study. Based on Doppler ultrasound results, 51.9% of patients fell into class I (no thrombosed vessels), 21.7% were in class II (one occluded vessel, or positive risk factors for thrombosis), 24.5% were in class III (multiple thrombosed vessels), and 1.9% were in class IV (all vessels thrombosed). Fifteen percent of the patients required preoperative angiography to better evaluate venous access. Most of the patients that required angiography were in class III or IV, and 53.3% of patients requiring angiography needed additional venous angioplasty to achieve access. Conclusions. All patients that are referred for intestinal transplantation should undergo preliminary mapping of their venous access by Doppler ultrasound and then be assigned to a vascular access class. Those patients with multiple thrombosed vessels (class III and above) should be strongly considered for additional angiographic evaluation.