D. Ramisch

What Is the Normal Small Bowel Length in Humans? First Donor-Based Cohort Analysis

Normal small bowel length (SBL) has been reported within a wide range, but never studied in a cohort of either pediatric or adult deceased donors. Between 5/2006 and 2/2011, SBL was measured in all grafts procured for intestinal transplantation at a single center and used for either isolated intestinal transplant (15) or multiorgan transplants (5) employing a standardized method. SBL was the only not significantly different variable among pediatric and adult donors divided by age 16. Furthermore, donors were classified in 3 groups: group 1: Height < 70 cm, group 2: 71–150 cm and group 3: ≥ 151 cm. Mean age was: 0.58, 5.6, 22.01 years, respectively. Mean height and weight were 65.8, 123.2, 166.1 cm (p = 0.001) and 6.9, 23.8, 65.2 kg (p = 0.001), for each group. The SBL by group was: 283.0, 324.7, 356.0 cm, remaining as the only nonsignificant variable (p = 0.06), in contrast to BMI, BSA (p = 0.001). The SBL/height ratio: 4.24, 2.7, 2.12 (p = 0.001; rho: –0.623) or SBL/BSA ratio was 8.36, 3.7, and 2.03, respectively (p : 0.0001; rho: –0.9). SBL does not increase with growth like other anthropometric variables. The SBL/height ratio significantly decreases with growth; however, bowel diameter increases, which needs further evaluation.

Neo-Suprahepatic Cava: A Case Report of a Modified Technique for Domino Liver Transplantation

Domino liver transplantation, introduced in 1997, originally consisted of a graft from a patient with familial amyloidotic polyneuropathy used as a donor for a compatible recipient, thus increasing the pool of hepatic grafts for liver transplantation. The aim of this report was to present a modification on the technique for outflow reconstruction in domino liver transplantation first proposed by Liu et al and Cescon et al. In this description we proposed a new technique that differs from the one mentioned above by performing a neo-suprahepatic cava, constructed using only an iliac vein graft, facilitating the anastomosis as if it was a regular cadaveric liver transplant.

Analysis of immune cells draining from the abdominal cavity as a novel tool to study intestinal transplant immunobiology

During intestinal transplant (ITx) operation, intestinal lymphatics are not reconstituted. Consequently, trafficking immune cells drain freely into the abdominal cavity. Our aim was to evaluate whether leucocytes migrating from a transplanted intestine could be recovered from the abdominal draining fluid collected by a peritoneal drainage system in the early post‐ITx period, and to determine potential applications of the assessment of draining cellular populations. The cell composition of the abdominal draining fluid was analysed during the first 11 post‐ITx days. Using flow cytometry, immune cells from blood and draining fluid samples obtained the same day showed an almost complete lymphopenia in peripheral blood, whereas CD3+CD4+CD8‐, CD3+CD4‐CD8+ and human leucocyte antigen D‐related (HLA‐DR)+CD19+ lymphocytes were the main populations in the draining fluid. Non‐complicated recipients evolved from a mixed leucocyte pattern including granulocytes, monocytes and lymphocytes to an exclusively lymphocytic pattern along the first post‐ITx week. At days 1–2 post‐Itx, analysis by short tandem repeats fingerprinting of CD3+CD8+ sorted T cells from draining fluid indicated that 50% of cells were from graft origin, whereas by day 11 post‐ITx this proportion decreased to fewer than 1%. Our results show for the first time that the abdominal drainage fluid contains mainly immune cells trafficking from the implanted intestine, providing the opportunity to sample lymphocytes draining from the grafted organ along the post‐ITx period. Therefore, this analysis may provide information useful for understanding ITx immunobiology and eventually could also be of interest for clinical management.

Intrapancreatic Common Hepatic Artery Arising From the Superior Mesenteric Artery, a Challenging Anatomic Variation in a Multiorgan Harvesting

INTRODUCTION Understanding abdominal vascular anatomy is crucial for multiorgan recovery. In this case report, we have described a common hepatic artery that arises from the superior mesenteric artery but follows an intrapancreatic course. METHODS The donor was ideal for multiorgan recovery and the recipient was a 29-year-old woman awaiting a second transplant owing to primary nonfunction of her first engrafted organ. The indication for transplantation was secondary biliary cirrhosis. A type I diabetic recipient on dialysis therapy was awaiting the kidney and pancreas. RESULTS The urgent condition of our liver recipient combined with the anatomical finding prioritized liver procurement, therefore the pancreas was discarded. CONCLUSIONS The recognition of all anatomic variations will allow us to improve the use of the scarce resource of deceased donor organs.

Three liver transplants after a single cadaveric procurement: Split liver transplantation plus domino liver transplantation, an infrequent but valid alternative for maximizing transplant sharing and applicability—report of the first Latin American case

The development of liver surgery and the need to overcome the shortage of cadaveric grafts have stimulated the creativity of surgeons in describing different options for using segmental liver grafts. Reduced size liver transplantation, ex vivo and in situ split liver transplantation, and living related donor liver transplantation are options that have spread since their original descriptions. In the setting of these accepted strategies, the option of performing sequential or domino liver transplantation with livers from patients with familial amyloidotic polyneuropathy (FAP) has become possible, and these patients have started to be used worldwide as whole living donors for patients who otherwise would not benefit from the current allocation system and cannot apply for a segmental adult living donor graft. The success of some of the aforementioned techniques can be currently followed via Web-based registries such as the Familial Amyloidotic Polyneuropathy World Transplant Registry, which includes 62 centers in 21 countries performing orthotopic liver transplantation with FAP donors. The need to foster maximal sharing has led to surgical innovations for further splitting FAP livers or performing split liver transplants for a pediatric recipient and an adult recipient with FAP followed by sequential or domino liver transplantation; however, only a small number of cases of this kind have been described. Therefore, we report here our experience with the first case of split transplantation plus domino transplantation in Latin America at 2 Argentinean institutions.

Long Term Outcomes after Intestinal Transplantation from a Single South-American Center, Lessons Learned

Introduction In many countries, intestinal failure patients (IF pts) had the only option of parenteral nutrition (PN) as available treatment until intestinal transplantation (ITx) evolves as part of a multidisciplinary team. We would like to report the long-term outcomes of a series of ITx performed in children and adults at a single center, 9 years after its creation. Material and Methods retrospective analysis of all consecutive ITx performed between May 2006 and Oct 2017. Diagnoses, pre ITx mean time on PN, indication for ITx, time on the waiting list (WL), type of ITx, mean total ischemia time (TIT), and warm ischemia time (WIT), time for PN discontinuation, 5-year actuarial patient survival are reported. Results 44 patients received 47 ITx. The mean time on PN for the Tx group was 1604 days*. The main indication for ITx was: lack of central venous accesses followed by PN associated liver disease, and catheter related infectious complications. The mean time on the WL was 222 days (SD: 195 days). ITx were performed in 28 children and 16 adults. Thirty-seven procedures were isolated ITx; 10 multiorgan (MTO) (4 combined, 7 multivisceral - 2 with kidney); 4 (8,5%) were re-transplants: 3 isolated, 1 multivisceral; 8 included right colon. Sixteen pts (36%) received the abdominal rectus fascia. All procedures were performed by the same team; TIT was 7:36±2:10 hs, WIT was 39.1±10.5 min. Mean length of implanted intestine: 325 ± 59.5 cm, BC ileostomy were performed in 59.5% of the cases. 18/47 Tx required early re-operations. The overall mean follow up time is 49±45.2 months; the mean time to be off PN was 68 days (* p: 0,001); the overall 5 year pt survival is 55.1%; 60.5% for Isolated ITx vs 35% for MTO (p=0,01); 60.3% for ped recipient’s vs 44.9% for adults (p=NS). Conclusions After 11 years of establishing a dedicated adult and ped IF program, we proved that ITX is a valid therapeutic alternative for pediatric and adult candidates. Long term results are comparable to a large series reported from centers of develop countries or the ITR.

Paneth and Intestinal Stem Cells are Differentially Affected during Worsening of Acute Cellular Rejection in Small Bowel Transplantation compared to Intestinal Ischemia Reperfusion Injury and Graft versus Host Disease

Instituto de Estudios Inmunológicos y Fisiopatológicos, UNLP-CONICET, La Plata, Argentina. Introduction Acute cellular rejection (ACR) is one of the leading causes of graft loss after small bowel transplantation (SBTx). Although crypt epithelial cell apoptosis is used as histopathological criteria for ACR diagnosis, it is not clear which of epithelial lineages are the target of ACR. It was shown that the number of enteroendocrine progenitor cells in intestinal crypts was reduced during mild ACR, however, no results on other cell types of the crypt have been depicted so far. The aim of our work was to elucidate integrity and functionality of Paneth and stem cells during different degrees of ACR, in comparison with other clinical conditions such as graft vs. host disease (GVHD) and ischemia reperfusion injury (IRI). Material and Methods 44 patients of SBTx and controls treated in our center between 2006 and 2016 were included in the study. Rejection diagnosis was established by an experienced pathologist according to the recommendations of the pathology workshop of the VIII Small Bowel Transplantation Symposium. We compared small biopsies from SBTx patients with no, mild, moderate or severe ACR by immunohistochemistry and quantitative PCR (n=10 per group as average) for different cell markers (Lgr5, lysozyme, defensin5, IL22R, Ki67). Other conditions such as different degree of intestinal GVHD and IRI were included as separate groups. Comparisons among groups of data were performed with the Kruskal-Wallis test and the Dunn`s post-test when more than two groups were analyzed, whereas the Mann-Whitney U test was chosen to compare data from two groups. Results and Discussion Using differential immunofluorescence counting of different markers we observed that numbers of Paneth and stem cells remain constant in all ACR groups, whereas the transit-amplifying zone is the region that concentrates most of the apoptotic bodies during ACR (p<0.05). We detected unchanged level of antimicrobial peptides in Paneth cells and similar numbers of Ki-67+IL-22R+ stem cells revealing cell functionality in moderate ACR samples. Oppositely, in GVHD of moderate to severe, as well as IRI, Paneth cell number and markers were diminished (p<0.05), indicating differential mechanism that operate to trigger epithelial cell apoptosis in different situations. Conclusion Paneth and stem cells are not primary target cells during ACR. IL-22R + Ki-67+ stem cells might be an interesting target cell population for protection and regeneration of the epithelial monolayer during/after a severe ACR in ITx patients.

Unusual spontaneous porto-systemic shunt: The importance of diagnosing non-anatomical porto-systemic shunts to improve portal flow in pediatric living-related liver transplantation. Case report

Collateral circulation secondary to liver cirrhosis may cause the development of large PSSs that may steal flow from the main portal circulation. It is important to identify these shunts prior to, or during the transplant surgery because they might cause an insufficient portal flow to the implanted graft. There are few reports of “steal flow syndrome” cases in pediatrics, even in biliary atresia patients that may have portal hypoplasia as an associated malformation. We present a 12‐month‐old female who received an uneventful LDLT from her mother, and the GRWR was 4.8. During the early post‐operative period, she became hemodynamically unstable, developed ascites, and altered LFT. The post‐operative ultrasound identified reversed portal flow, finding a non‐anatomical PSS. A 3D CT scan confirmed the presence of a mesocaval shunt through the territory of the right gonadal vein, draining into the right iliac vein, with no portal inflow into the liver. The patient was re‐operated, and the shunt was ligated. An intraoperative Doppler ultrasound showed adequate portal inflow after the procedure; the patient evolved satisfactorily and was discharged home on day number 49. The aim was to report a case of post‐operative steal syndrome in a pediatric recipient due to a mesocaval shunt not diagnosed during the pretransplant evaluation.

Case Report: Spleen-preserving Multivisceral Transplant for Peutz–Jeghers Syndrome

CASE REPORT A 24-year-old man diagnosed with Peutz-Jeghers syndrome as a child underwent multiple surgeries owing to intussusception. Pretransplant workup showed >150 polyps along the gastrointestinal (GI) tract, some of them with high-grade dysplasia. Despite having intestinal sufficiency, a modified multivisceral transplantation was offered. PROCEDURE An 18-year-old donor was procured using University of Wisconsin solution. The recipients surgery started with a midline incision. Mobilization of the right colon and the root of the mesentery was done to isolate the superior mesenteric artery. The same maneuver was done with the left and sigmoid colon. The common bile duct was then isolated and transected at the cystic duct level. The abdominal portion of the esophagus and the proximal stomach were isolated and divided at the gastroesophageal junction. After that, the pancreas was mobilized, preserving the spleen with the splenic vessels. The distal GI tract was transacted at the level of the proximal rectum. For engraftment, an arterial conduit was placed in the infrarenal aorta and anastomosed to the grafts aortic patch. End-to-side portal reconstruction was made at the level of the portal vein, allowing performing a duct-to-duct biliary reconstruction over a 5-Fr T-tube. A hand-sewn gastrogastric anastomosis and piloroplasty were performed; the distal anastomosis was done with circular staplers. A gastrojejunostomy and a loop ileostomy were the final steps of the procedure. RESULTS The patient stayed in intensive care for 2 days and enteral feeds were started on day 7. Currently, 23 months after transplant he is alive with an excellent quality of life.