Chandra Bhati

The Role of Splenectomy in the Setting of Refractory Humoral Rejection After Kidney Transplantation

Living donor kidney transplantation remains the best option for presensitized recipients to avoid excessive time on the waiting list. However, the possibility for a positive crossmatch with a potential living donor is high. A desensitization protocol may be required to avoid antibody-mediated rejection (AMR). Current protocols are not always effective to prevent AMR and in some cases fail to convert subjects to a negative crossmatch before transplantation. From March 2006 to January 2011, the 11 presensitized patients who displayed AMR after living donor kidney transplantation underwent splenectomy as a rescue procedure due to failure of standard rejection treatments. Splenectomy was considered to be effective in six recipients who normalized their renal function without the need for other immunomodulating therapy. Our analysis suggested that splenectomy can be successfully performed alone or in association with other treatments like bortezomib or rituximab to overcome severe AMR.

Rescue splenectomy in a case of humoral rejection in ABO-incompatible simultaneous liver-kidney transplantation.

Simultaneous liver-kidney transplantation has become the standard of care for patients with combined end-stage liver and concurrent renal disease (1). ABO-incompatible liver transplantation has historically resulted in lower patient and graft survival, along with a significantly higher incidence of acute cellular rejection. This has limited the practice only to life-threatening situations. To the best of our knowledge, we report the first case of an ABOincompatible simultaneous liver-kidney transplantation, which presented early postoperative acute humoral rejection of the kidney.

Long‐term follow‐up in adult living donors for combined liver/bowel transplant in pediatric recipients: A single center experience

Ghafari JL, Bhati C, John E, Tzvetanov IG, Testa G, Jeon H, Oberholzer J, Benedetti E. Long‐term follow‐up in adult living donors for combined liver/bowel transplant in pediatric recipients: A single center experience.
Pediatr Transplantation 2011: 15: 425–429.

Small bowel obstruction from breast cancer metastasis: A case report and review of the literature

Small bowel obstruction from luminal gastrointestinal metastasis is a rare, but recognized, presentation of metastatic breast cancer. Herein, we report a case of a small bowel obstruction from lobular breast cancer metastasis to the terminal ileum, occurring over a decade after diagnosis and treatment of the initial primary cancer. Our review highlights the presentation and management of this unusual disease manifestation, including diagnosis of the gastrointestinal process, identification of the primary cancer, surgical treatment of the abdominal pathology, systemic therapy for metastatic disease, and survival data for patients with this disease process.

Calibrated extra-anatomic hepatic arterial reconstruction in living donor liver transplantation.

Dear Editors, In LDLT, there exists a limitation in the length of the vascular pedicles and the bile duct stump that can be obtained in the partial hepatic allograft. As a result of this limitation, anatomic arterial reconstruction between the right or left hepatic artery of the partial hepatic allograft and the inflow artery of the recipient may be difficult. This problem is further exacerbated when recipients have compromised arterial walls as a result of previous chemoembolization [1] or neoadjuvant chemoradiation [2]. A few alternative techniques of hepatic arterial reconstruction in LDLT have been described in the literature. Attempts have been made to use the transposed splenic artery [3] or the right gastroepiploic artery [4]. However, transposition of the splenic artery may create splenic infarction, and the gastroepiploic artery may not be able to deliver enough blood flow. In addition, interposition techniques using various interposition grafts have been reported [5,6], and extra-anatomic bypass using a deceased donor iliac arterial graft may become technically difficult to adequately adjust caliber of stumps for anastomosis. The authors herein describe a novel calibrated anastomotic technique through an aortic conduit using an iliac arterial graft from a deceased donor to reliably reconstruct the hepatic arterial supply to the partial hepatic allograft. We had a 50-year-old male patient with a history of PSC and ulcerative colitis. On surveillance ERCP with brush cytology, the patient was diagnosed with cholangiocarcinoma. There was no identifiable mass lesion on triphasic intravenous hepatic CT scan, despite diffuse thickening of the biliary tree on intraductal ultrasonography. Considering the patient’s background of PSC through the entire biliary tree with possible multifocality of the tumor, liver transplantation after neoadjuvant chemoradiation was decided as the best therapeutic option. The patient underwent chemoradiation and transcatheter irradiation with Iridium in preparation for liver transplantation, according to the Mayo protocol [7]. The patient’s 22-year-old daughter volunteered to donate the right lobe of her liver. Donor evaluations were performed in sequence of blood test, cardiovascular evaluation, abdominal triphasic intravenous contrast CT scan for volume measurement of the prospective right lobe allograft, and MR cholangiography. The donor’s anatomy of vasculature and biliary tree was normal. The donor’s height and weight were 166 cm and 81 kg, respectively. Abdominal CT scan with IV contrast images of 5-mm thick slice were obtained by a multi-detector Lightspeed CT scanner (General Electric, Milwaukee, WI, USA) and the measured whole liver volume was 1679 ml and right lobe volume, including the middle hepatic vein, was 883 ml. With the recipient’s body weight of 86 kg, the graft versus body weight ratio (GWR) was 1.026. Graft weight after flush with 2 l of HTK solution was 855 g. In consideration of the perceived higher risk of vascular complication because of pretransplant radiotherapy, extra-anatomic hepatic arterial reconstruction from infrarenal aorta using a deceased donor iliac artery conduit was planned for the recipient operation. To calibrate the diameter of the tip of the extra-anatomic arterial conduit, an iliac artery graft, including the distal branches of the internal iliac artery (superior gluteal, inferior gluteal, and obturator arteries), was recovered from an ABO-identical deceased donor a week before the LDLT. In the recipient, hilar dissection was initiated from the upper margin of duodenum to isolate the most distal portion of the common bile duct. After dividing the common duct, resection margin was examined through frozen histologic examination. The entire segments of common and proper hepatic arteries were included in the specimen with ligation of proximal common hepatic artery and gastroduodenal artery. Lymphatic and areolar tissue in the hepatic hilum that turned fibrotic was removed en bloc with hepatic artery and common bile duct while skeletonizing the portal vein. The anterior wall of infrarenal aorta was exposed for implantation of the iliac arterial conduit. The rest of native hepatectomy was performed with preservation of the entire length of the vena cava. On the back table, the internal iliac artery was divided at its origin from the common iliac artery and the opening of the common iliac artery was closed with 6-0 prolene running stitch (Fig. 1a). The inferior gluteal artery in