Aparna Rege

Autologous Gastrointestinal Reconstruction Review of the Optimal Nontransplant Surgical Options for Adults and Children With Short Bowel Syndrome

Short bowel syndrome (SBS) results in loss of absorptive capacity of the development of gut, leading to malabsorption due to protein, energy, fluid, and electrolyte loss and imbalance while on enteral diet alone. Various nonsurgical and surgical therapeutic options that have emerged improve the survival outcome following SBS in both children and adults. An individualized, complex multidisciplinary approach to medical and surgical intestinal rehabilitation is needed to provide an opportunity for enteral autonomy to be possible in a patient with SBS. The remnant bowel plays a very pivotal role in autologous gastrointestinal reconstruction (AGIR) surgery. Intestinal transplantation, although promising and potentially life-saving for SBS, should be reserved for patients with failed AGIR or those who have no prospect for autologous enteral autonomy. This article reviews the evolution of nontransplant surgical management of patients with SBS.

Benign Metastasizing Leiomyoma: A Rare Cause of Multiple Pulmonary Nodules

Benign metastasizing leiomyoma (BML) is a rare cause of pulmonary nodules that occurs when uterine leiomyomas metastasize to the lung. The management of these lesions varies from resection and hysterectomy to nonsurgical treatments such as hormonal therapy. We report a case of a 45-year-old woman with multiple nodules of the right lung identified during preoperative imaging before her hysterectomy for uterine fibroids.

Posterior Reversible Encephalopathy Syndrome Independently Associated With Tacrolimus and Sirolimus After Multivisceral Transplantation

Posterior reversible encephalopathy syndrome (PRES) is a small vessel microangiopathy of the cerebral vasculature that occurs in 0.5–5% of solid organ transplant recipients, most commonly associated with tacrolimus (Tac). Clinical manifestations include hypertension and neurologic symptoms. We report an adult multivisceral transplant recipient who experienced recurrent PRES initially associated with Tac and subsequently with sirolimus. A 49‐year‐old woman with short bowel syndrome underwent multivisceral transplantation due to total parenteral nutrition–related liver disease. She was initially maintained on Tac, mycophenalate mofetil (MMF) and prednisone. Three months after transplantation, she developed renal dysfunction, leading to a reduction in Tac and the addition of sirolimus. Eight months after transplantation, she developed PRES. Tac was discontinued and PRES resolved. Sirolimus was increased to maintain trough levels of 12–15 ng/mL. Fourteen months after transplant, she experienced recurrent PRES which resolved after discontinuing sirolimus. Currently 3 years posttransplant, she is maintained on cyclosporine, MMF and prednisone with no PRES recurrence. In addition to calcineurin inhibitors, sirolimus may also be associated with PRES after solid organ transplantation. Ours is the first report of sirolimus‐associated PRES in the setting of multivisceral transplantation. Identifying a safe alternative immunosuppression regimen was challenging but ultimately successful.

Use of Vascularized Posterior Rectus Sheath Allograft in Pediatric Multivisceral Transplantation - Report of Two Cases

Restoring abdominal wall cover and contour in children undergoing bowel and multivisceral transplantation is often challenging due to discrepancy in size between donor and recipient, poor musculature related to birth defects and loss of abdominal wall integrity from multiple surgeries. A recent innovation is the use of vascularized posterior rectus sheath to enable closure of abdomen. We describe the application of this technique in two pediatric multivisceral transplant recipients—one to buttress a lax abdominal wall in a 22‐month‐old child with megacystis microcolon intestinal hypoperistalsis syndrome and another to accommodate transplanted viscera in a 10‐month child with short bowel secondary to gastoschisis and loss of domain. This is the first successful report of this procedure with long‐term survival. The procedure has potential application to facilitate difficult abdominal closure in both adults and pediatric liver and multivisceral transplantation.

The Surgical Approach to Short Bowel Syndrome - Autologous Reconstruction versus Transplantation

Background: Short bowel syndrome (SBS) is a state of malabsorption resulting from massive small bowel resection leading to parenteral nutrition (PN) dependency. Considerable advances have been achieved in the medical and surgical management of SBS over the last few decades. Methods: This review discusses in detail the surgical approach to SBS. Results: Widespread use of PN enables long-term survival in patients with intestinal failure but at the cost of PN-associated life-threatening complications including catheter-associated blood stream infection, venous thrombosis, and liver disease. The goal of management of intestinal failure due to SBS is to enable enteral autonomy and wean PN by means of a multi-disciplinary approach. Availability of modified enteral feeding formulas have simplified nutrition supplementation in SBS patients. Similarly, advances in the medical field have made medications like growth hormone and glucagon-like peptide (GLP2) available to improve water and nutrient absorption as well as to enable achieving enteral autonomy. Autologous gastrointestinal reconstruction (AGIR) includes various techniques which manipulate the bowel surgically to facilitate the bowel adaptation process and restoration of enteral nutrition. Ultimately, intestinal transplantation can serve as the last option for the cure of intestinal failure when selectively applied. Conclusion: SBS continues to be a challenging medical problem. Best patient outcomes can be achieved through an individualized plan, using various AGIR techniques to complement each other, and intestinal transplantation as a last resort for cure. Maximum benefit and improved outcomes can be achieved by caring for SBS patients at highly specialized intestinal rehabilitation centers.

Update on surgical therapies for intestinal failure.

Purpose of reviewParenteral nutrition enables long-term survival in patients with intestinal failure; however, it is associated with life-threatening complications necessitating alternative techniques of management to enable weaning parenteral nutrition and minimizing parenteral nutrition-associated comorbidities. This review aims at discussing the indications and techniques most commonly utilized for surgical management in a short gut. Recent findingsSurgical therapy for short gut has evolved and undergone refinement in the past 30–40 years with the older procedures being largely abandoned and replaced by newer and refined techniques. Lengthening surgeries (longitudinal intestinal lengthening and tapering and serial transverse enteroplasty) are the most commonly applied procedures in a dilated bowel with intestinal transplantation option reserved as a last resort for recurrent life-threatening central venous line infections, progressive loss of central venous access, and development of progressive liver disease. SummaryManagement of intestinal failure requires a multidisciplinary approach to optimize intestinal rehabilitation and overall patient outcome. Although intestinal transplantation remains an excellent option for patients with severe life-threatening complications, autologous intestinal reconstruction appears to remain the better overall option.

Trends in Usage and Outcomes for Expanded Criteria Donor Kidney Transplantation in the United States Characterized by Kidney Donor Profile Index.

There has been increasing concern in the kidney transplant community about the declining use of expanded criteria donors (ECD) despite improvement in survival and quality of life. The recent introduction of the Kidney Donor Profile Index (KDPI), which provides a more granular characterization of donor quality, was expected to increase utilization of marginal kidneys and decrease the discard rates. However, trends and practice patterns of ECD kidney utilization on a national level based on donor organ quality as per KDPI are not well known. We, therefore, performed a trend analysis of all ECD recipients in the United Network for Organ Sharing (UNOS) registry between 2002 and 2012, after calculating the corresponding KDPI, to enable understanding the trends of usage and outcomes based on the KDPI characterization. High-risk recipient characteristics (diabetes, body mass index ≥30 kg/m2, hypertension, and age ≥60 years) increased over the period of the study (trend test p<0.001 for all). The proportion of ECD transplants increased from 18% in 2003 to a peak of 20.4% in 2008 and then declined thereafter to 17.3% in 2012. Using the KDPI >85% definition, the proportion increased from 9.4% in 2003 to a peak of 12.1% in 2008 and declined to 9.7% in 2012. Overall, although this represents a significant utilization of kidneys with KDPI >85% over time (p<0.001), recent years have seen a decline in usage, probably related to regulations imposed by Centers for Medicare & Medicaid Services (CMS). When comparing the hazards of graft failure by KDPI, ECD kidneys with KDPI >85% have a slightly lower risk of graft failure compared to standard criteria donor (SCD) kidneys with KDPI >85%, with a hazard ratio (HR) of 0.95, a confidence interval (CI) of 0.94-0.96, and statistical significance of p<0.001. This indicates that some SCD kidneys may actually have a lower estimated quality, with a higher Kidney Donor Risk Index (KDRI), than some ECDs. The incidence of delayed graft function (DGF) in ECD recipients has significantly decreased over time from 35.2% in 2003 to 29.6% in 2011 (p=0.007), probably related to better understanding of the donor risk profile along with increased use of hypothermic machine perfusion and pretransplant biopsy to aid in optimal allograft selection. The recent decline in transplantation of KDPI >85% kidneys probably reflects risk-averse transplant center behavior. Whether discard of discordant SCD kidneys with KDPI >85% has contributed to this decline remains to be studied.

Liver transplantation in an adolescent with acute liver failure from acute lymphoblastic leukemia

The most common identifiable causes of acute liver failure in pediatric patients are infection, drug toxicity, metabolic disease, and autoimmune processes. In many cases, the etiology of acute liver failure cannot be determined. Acute leukemia is an extremely rare cause of acute liver failure, and liver transplantation has traditionally been contraindicated in this setting. We report a case of acute liver failure in a previously healthy 15‐yr‐old male from pre‐B‐cell acute lymphoblastic leukemia. He underwent liver transplantation before the diagnosis was established, and has subsequently received chemotherapy for pre‐B‐cell acute lymphoblastic leukemia. He is currently alive 31 months post‐transplantation. The published literature describing acute lymphoblastic leukemia as a cause of acute liver failure is reviewed.

Could the Use of an Enhanced Recovery Protocol in Laparoscopic Donor Nephrectomy be an Incentive for Live Kidney Donation

Introduction and Background: Gastrointestinal (GI) recovery after major abdominal surgery can be delayed from an ongoing need for narcotic analgesia thereby prolonging hospitalization. Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway designed to facilitate early recovery after major surgery by maintaining preoperative body composition and physiological organ function and modifying the stress response induced by surgical exposure. Enhanced recovery programs (ERPs) in colorectal surgery have decreased the duration of postoperative ileus and the hospital stay while showing equivalent morbidity, mortality, and readmission rates in comparison to the traditional standard of care. This study is a pilot trial to evaluate the benefits of ERAS protocols in living kidney donors undergoing laparoscopic nephrectomy. Methods: This is a single-center, non-randomized, retrospective analysis comparing the outcomes of the first 40 live kidney donors subjected to laparoscopic nephrectomy under the ERAS protocol to 40 donors operated prior to ERAS with traditional standard of care. Our ERAS protocol includes reduced duration of fasting with preoperative carbohydrate loading, intraoperative fluid restriction to 3 ml/kg/hr, target urine output of 0.5 ml/kg/hr, use of subfascial Exparel injection (bupivacaine liposome suspension), and postoperative narcotic-free pain regimen with acetaminophen, ketorolac, or tramadol. Short-term patient outcomes were compared using Pearsons’s Chi-Squared test for categorical variables and the Kruskal-Wallis test for continuous variables. Additionally, a multivariate analysis was conducted to evaluate factors influencing patient length of stay and likelihood of readmission. Results: ERAS protocol reduced the postoperative median length of stay decreased from 2.0 to 1.0 days (p=0.001). Overall pain scores were significantly lower in the ERAS group (peak pain score 6.0 vs. 8.00, p< 0.001; morning after surgery pain score 3.0 vs. 7.0, p=0.001; lowest pain score 0.0 vs. 2.0, p=0.016) despite the absence of postoperative narcotics. The average duration of surgery was shorter in the ERAS group (248 vs. 304 minutes, p<0.001). The average amount of intraoperative fluid used was significantly lower in the ERAS group (2500 ml vs. 3525 ml, p<0.001) without affecting the donor renal function. The incidence of delayed graft function was similar in the two groups (p=0.541). A trend toward lower readmission was noted with the ERAS protocol (12.8% vs. 27.5%, p=0.105). GI dysfunction was the most common reason for readmission. Conclusion: Application of an ERAS protocol in a laparoscopic living donor nephrectomy was associated with reduced length of hospitalization and improved pain scores related likely to intraoperative use of subfascial Exparel and a shorter duration of ileus. Restricted use of intraoperative fluids prevents excessive third spacing and bowel edema, enhancing gut recovery without adversely impacting recipient graft function. This study suggests that ERAS has the potential to enhance the advantages of laparoscopic surgery for live kidney donation through optimizing donor outcomes and perioperative patient satisfaction.

Proceedings of the American Society for Enhanced Recovery/Evidence Based Peri-Operative Medicine 2016 Annual Congress of Enhanced Recovery and Perioperative Medicine

Table of contentsA1 Effects of enhanced recovery pathways on renal functionCharles R. Horres, Mohamed A. Adam, Zhifei Sun, Julie K. Thacker, Timothy J. Miller, Stuart A. GrantA2 Economic outcomes of enhanced recovery after surgery (ERAS)Jeffrey HuangA3 What does eating, drinking and mobilizing after enhanced recovery surgery really mean?Kirstie McPherson, Sanjiv Patel, Su Cheen Ng, Denise Veelo, Bart Geerts, Monty MythenA4 Intra-operative fluid monitoring practicesSu Cheen Ng, Mark Foulger, Tim Collins, Kirstie McPherson, Michael MythenA5 Development of an integrated perioperative medicine care pathwayMark Edwards, Denny Levett, Tristan Chapman, Imogen Fecher – Jones, Julian Smith, John Knight, Michael GrocottA6 Cardiopulmonary exercise testing for collaborative decision making prior to major hepatobiliary surgeryMark Edwards, Thomas Sharp, Sandy Jack, Tom Armstrong, John Primrose, Michael Grocott, Denny LevettA7 Effect of an enhanced recovery program on length of stay for microvascular breast reconstruction patientsAdam B. King, Kye Higdon, Melissa Bellomy, Sandy An, Paul St. Jacques, Jon Wanderer, Matthew McEvoyA8 Addressing readmissions associated with an enhanced recovery pathway for colorectal surgeryAnne C. Fabrizio, Michael C. Grant, Deborah Hobson, Jonathan Efron, Susan Gearhart, Bashar Safar, Sandy Fang, Christopher Wu, Elizabeth WickA9 The Manchester surgical outcomes project: prevalence of pre operative anaemia and peri operative red cell transfusion ratesLeanne Darwin, John MooreA10 Preliminary results from a pilot study utilizing ears protocol in living donor nephrectomyAparna Rege, Jayanth Reddy, William Irish, Ahmad Zaaroura, Elizabeth Flores Vera, Deepak Vikraman, Todd Brennan, Debra Sudan, Kadiyala RavindraA11 Enhanced recovery after surgery: the role of the pathway coordinatorDeborah WatsonA12 Hospitalization costs for patients undergoing orthopedic surgery treated with intravenous acetaminophen (IV-APAP) + IV opioids or IV opioids alone for postoperative painManasee V. Shah, Brett A. Maiese, Michael T. Eaddy, Orsolya Lunacsek, An Pham, George J. WanA13 Development of an app for quality improvement in enhanced recoveryKirstie McPherson, Thomas Keen, Monty MythenA14 A clinical rotation in enhanced recovery pathways and evidence based perioperative medicine for medical studentsAlexander B Stone, Christopher L. Wu, Elizabeth C. WickA15 Enhanced recovery after surgery (ERAS) implementation in abdominal based free flap breast reconstructionRachel A. Anolik, Adam Glener, Thomas J. Hopkins, Scott T. Hollenbeck, Julie K. Marosky ThackerA16 How the implementation of an enhanced recovery after surgery (ERAS) protocol can improve outcomes for patients undergoing cystectomyTracey Hong, Andrea Bisaillon, Peter Black, Alan So, Associate Professor, Kelly MaysonA17 Use of an app to improve patient engagement with enhanced recovery pathwaysKirstie McPherson, Thomas Keen, Monty MythenA18 Effect of an enhanced recovery after surgery pathway for living donor nephrectomy patientsAdam B. King, Rachel Forbes, Brad Koss, Tracy McGrane, Warren S. Sandberg, Jonathan Wanderer, Matthew McEvoyA19 Introduction and implementation of an enhanced recovery program to a general surgery practice in a community hospitalPatrick Shanahan, John Rohan, Desirée Chappell, Carrie ChesherA20 “Get fit” for surgery: benefits of a prehabilitation clinic for an enhanced recovery program for colorectal surgical patientsSusan VanderBeek, Rebekah KellyA21 Evaluation of gastrointestinal complications following radical cystectomy using enhanced recovery protocolSiamak Daneshmand, Soroush T. Bazargani, Hamed Ahmadi, Gus Miranda, Jie Cai, Anne K. Schuckman, Hooman DjaladatA22 Impact of a novel diabetic management protocol for carbohydrate loaded patients within an orthopedic ERAS protocolVolz L, Milby JA23 Institution of a patient blood management program to decrease blood transfusions in elective knee and hip arthroplastyOpeyemi Popoola, Tanisha Reid, Luciana Mullan, Mehrdad Rafizadeh, Richard Pitera