Danhua Yao

Is it feasible to implement enteral nutrition in patients with enteroatmospheric fistulae? A single-center experience.

BACKGROUND Published experience in feeding patients with enteroatmospheric fistulae is scarce. This study aimed to determine if enteral nutrition (EN) could be safely delivered in the presence of enteroatmospheric fistula. MATERIALS AND METHODS This is a retrospective descriptive study from a major fistula treatment center in China. Medical records of patients who developed enteroatmospheric fistulae in the open abdomen after abdominal trauma were reviewed. The timing of initiation and achievement of full strength (25 kcal/kg/d) EN after enteroatmospheric fistula were noted, as well as the incidence of feeding-associated complications and weaning of parenteral nutrition (PN). The outcomes of open abdomen and enteroatmospheric fistula were also noted. RESULTS Nine patients were included in this study. EN was successfully implemented in all patients. The median timing of initiation and achievement of full strength of EN after enteroatmospheric fistula was 9 (interquartile range [IQR], 3–22) and 27 (IQR, 22–43) days, respectively. Feeding-associated complications developed in 1 (11.1%) patient. All patients were liberated from PN at hospital discharge. Split-thickness skin grafting was performed in all patients, of whom 5 underwent successful delayed abdominal closure, and 4 were awaiting definitive closure. Repair or resection of enteroatmospheric fistula occurred in 8 (88.9%) patients. CONCLUSION This study showed that EN could be safely implemented in patients with enteroatmospheric fistulae without complicating the treatment of open abdomen and enteroatmospheric fistula.

Effects of recombinant activated factor VIIa on abdominal trauma patients.

Recombinant activated factor VIIa (rFVIIa) has been highlighted by correcting uncontrollable traumatic haemorrhage. Compared with routine coagulation tests, thromboelastography (TEG) can evaluate the coagulation function of trauma patients more rapidly, accurately and comprehensively, and can also diagnose trauma-associated coagulopathy (TAC) in an early stage. Thirty-eight cases conforming to rFVIIa indications were screened according to TEG results and divided into an rFVIIa group (n = 20) and a nonrFVIIa group (n = 18). Their coagulopathy was goal-directedly corrected under the guidance of TEG. The parameters examined by routine coagulation tests and TEG were compared. The blood components transfused in the two groups were also calculated. When rFVIIa was administered by an average dose of 52.3 &mgr;g/kg (24.0–95.6 &mgr;g/kg), blood coagulation function was significantly improved in 48 h. Compared with the nonrFVIIa group, the treatment group experienced decreased R time. Moreover, significant fewer red blood cells, platelet and fresh frozen plasma were transfused in the rFVIIa group. All patients underwent daily bedside vascular ultrasound screening within a week after haemostatic treatment, of which no thromboembolic events occurred. TEG can sensitively detect TAC. rFVIIa administered goal-directedly guided by TEG is more effectively in correcting TAC and decreasing the amount of blood product transfusion.

Perioperative Alanyl-Glutamine–Supplemented Parenteral Nutrition in Chronic Radiation Enteritis Patients With Surgical Intestinal Obstruction A Prospective, Randomized, Controlled Study

BACKGROUND A prospective, randomized, controlled study was performed to evaluate the effects of perioperative alanyl-glutamine-supplemented parenteral nutrition (PN) support on the immunologic function, intestinal permeability, and nutrition status of surgical patients with chronic radiation enteritis (CRE)-induced intestinal obstruction. METHODS Patients who received 0.4 g/kg/d alanyl-glutamine and isonitrogenous PN were assigned to an alanyl-glutamine-supplemented PN (Gln-PN) group and a control group, respectively. Serum levels of alanine aminotransferase and glutamine, body fat mass (FM), immunologic function, and intestinal permeability were measured before and after surgery. RESULTS Serum glutamine levels of the Gln-PN group significantly exceeded that of the control group (P < .001; Gln-PN, baseline 460.7 ± 42.5 vs 523.3 ± 48.6 µmol/L on postoperative day 14 [POD14], P < .001; control, baseline 451.9 ± 44.0 vs 453.8 ± 42.3 µmol/L on POD14, P = .708). Lactulose/mannitol ratios of both groups decreased over time (Gln-PN, baseline 0.129 ± 0.0403 vs 0.024 ± 0.0107 on POD1 4; control, baseline 0.125 ± 0.0378 vs 0.044 ± 0.0126 on POD14, P < .001 in both groups). CD4/CD8-positive T-lymphocyte ratios significantly rose in both groups, with significant intergroup difference (P < .001; Gln-PN, baseline 1.36 ± 0.32 vs 1.82 ± 0.30 on POD14, P < .001; control, baseline 1.37 ± 0.25 vs 1.63 ± 0.31 on POD14, P < .001). In the Gln-PN group, FM increased from 3.68 ± 1.68 kg at baseline to 5.22 ± 1.42 kg on POD14 (P < .001). FM of control group increased from 3.84 ± 1.57 kg at baseline to 5.40 ± 1.54 kg on POD14 (P < .001). However, there were no significant intergroup differences (P = .614). CONCLUSION Gln-PN significantly boosted the immune state and decreased the intestinal permeability of CRE patients. However, Gln-PN was not superior to standard PN in improving the nutrition state and intestinal motility of surgical patients with CRE-induced intestinal obstruction.

Early- Versus Late-Onset Prosthetic Mesh Infection: More than Time Alone

Prosthetic mesh used for ventral incisional hernia makes hernia repair surgery simple, effective, and safe. The mesh infection is a formidable complication and bimodal distribution. The differences between early- and late-onset are unknown. This is a cohort study of patients undergoing ventral incisional hernia (VIH) repair from January 2003 to September 2013. Data of specific risk variables were collected from electronic medical record systems in Jinling Hospital. And, the quality of lives was evaluated by WHO Quality of Life-BREF. A total of 102 VIH repair patients were analyzed and followed including the noninfection group and early- and late-onset group. There were significant differences between the early- and late-onset group in clinical manifestation, descriptive analysis of the study population, and postoperative quality of lives. These differences might imply the different pathophysiologic process of early- and late-onset mesh infection. Permanent prosthetic mesh should be used with caution, and the study of intraperitoneal onlay mesh is still needed in long-term follow-up.

Normothermic Extracorporeal Membrane Oxygenation Support: Improves Donor Intestinal Graft Function After Cardiac Death.: Abstract# 2227

2270 A GMP Treg Expansion Protocol Restores Treg Suppressor Function in End-Stage Liver Disease; Implications For Adoptive Transfer Therapy. N. Safi nia, T. Vaikunthanathan, H. Fraser, C. Scotta, R. Lechler, G. Lombardi. MRC Centre for Transplantation, King’s College, London, United Kingdom. Background Long-term survival in liver transplant recipients remains suboptimal because of the morbidity and mortality associated with long-term use of immunosuppression (IS). However, IS weaning early post liver transplantation (LT) has been largely unsuccessful, supporting the need for active tolerance induction strategies. CD4+CD25+FOXP3+(Tregs) play an important role in immunoregulation and have been shown in animal models to promote transplantation tolerance. Phase I trials in bone marrow transplantation have shown that ex vivo expanded Tregs have an excellent safety profi le, encouraging for the broader application of these cells. The clinical trial, ThRIL, soon to be initiated at King’s College London, aims to investigate the therapeutic potential of Tregs in the setting of LT. We have devised a GMP compatible protocol that ensures the successful isolation and expansion of a functional and stable human Treg population in preparation for this trial. Methods and Results Tregs were isolated from 150ml of blood from patients with end-stage liver disease by a CliniMACS-based GMP isolation technique and expanded using anti-CD3/CD28 beads, IL-2 and rapamycin. A 580-fold expansion of pure Tregs was achieved (97% CD4+CD25+ and 0.008% CD8+ cells) and the cells maintained FoxP3 expression (99% FoxP3+). The populations of Tregs obtained were also stable and did not convert to Th17 cells when cultured in the presence of pro-infl ammatory stimuli. This protocol further proved to be ideal for the expansion of Tregs from patients with liver disease in view of restoring the Treg suppressive function (1:1 ratioexpanded Tregs 91% vs. freshly isolated Tregs 29% suppression, 1:10 ratio81% vs. 21% respectively). Based on these fi ndings, we subsequently conducted an in-depth phenotypic characterisation of freshly isolated Tregs in order to delineate a population responsible for the apparent lack of suppressive function. An investigation into the possible mechanisms is currently ongoing. Conclusions The feasibility of Treg based therapy is now widely accepted, provided that tailor-made clinical grade procedures for isolation and ex-vivo cell handling are available. Our rapamycin-based protocol is ideal in this setting as it not only satisfi es the rigors of GMP manufacturing standards, but also derives a population of Tregs that is stable and functionally superior compared to freshly isolated Tregs. Abstract# 2271 Combination of ATG and Rapamycin Prolongs the Persistence of Adoptively-Transferred, Ex Vivo-Expanded Third Party Treg in Cynomolgus Monkeys. H. Zhang, M. Ezzelarab, L. Lu, A. Zahorchak, H. Guo, D. Coper, A. Thomson. Surgery, University of Pittsburgh, Pittsburgh, PA. Background: It has been shown that ex vivo-expanded regulatory T cells (Treg) can promote transplant tolerance in small animal models as well as in phase I clinical trials of hematopoietic stem cell transplantation. The issue has been raised of establishing Treg banks for adoptive cell therapy of organ transplant rejection and autoimmune disease. However, little is known about the persistence, stability and fate of infused Treg, especially third-party allogeneic Treg, and the infl uence of T cell-depleting and other immunosuppressive agents on their survival and therapeutic effi cacy. Methods and Results: In this study, we fl ow-sorted CD4+CD25+CD127Treg from normal juvenile cynomolgus monkey PBMC and expanded these cells using a protocol with artifi cial antigen-presenting cells. Three rounds of stimulation expanded the cells over 1000-fold and consistently generated over 108 Treg from 30 ml peripheral blood, while maintaining expression of Foxp3, CD25, CTLA-4, Helios; potent capacity to suppress T cell proliferation in vitro; demethylation status at the Treg-Specifi c Demethylation Region (TSDR), and down-regulated expression of CD45RA, CCR7, CD62L and upregulation of CXCR3 suggesting that these cells are likely to migrate to infl amed sites immediately after infusion in vivo. More importantly, when CFSE-labeled autologous (auto) and VPD450-labeled allogeneic (allo) ex vivo expanded Tregs were transferred simultaneously into monkeys, the number of auto-Treg was up to 100 per ml peripheral blood for at least 6 days (ie. for the duration of the experiment) in both control and ATG/rapamycin-treated (IS) monkeys. In contrast, by day 3 after their infusion, allo-Treg could not be detected in control monkeys, while they were maintained up to 100 cells per ml peripheral blood for at least 15 days in IS monkeys. These Tregs maintain high expression of Foxp3, CD25, and CXCR3 expression, and low expression of CD127, CCR7, and CD62L. Conclusion: The fi nding that allo-Treg can survive in IS-treated monkeys and maintain Treg phenotype supports the concept and potential utility of Treg banks for clinical application in transplantation and autoimmune disease and provides valuable information required to take allo-Treg therapy towards phase II/III clinical trials for effi cacy assessment. 2271 Combination of ATG and Rapamycin Prolongs the Persistence of Adoptively-Transferred, Ex Vivo-Expanded Third Party Treg in Cynomolgus Monkeys. H. Zhang, M. Ezzelarab, L. Lu, A. Zahorchak, H. Guo, D. Coper, A. Thomson. Surgery, University of Pittsburgh, Pittsburgh, PA. Background: It has been shown that ex vivo-expanded regulatory T cells (Treg) can promote transplant tolerance in small animal models as well as in phase I clinical trials of hematopoietic stem cell transplantation. The issue has been raised of establishing Treg banks for adoptive cell therapy of organ transplant rejection and autoimmune disease. However, little is known about the persistence, stability and fate of infused Treg, especially third-party allogeneic Treg, and the infl uence of T cell-depleting and other immunosuppressive agents on their survival and therapeutic effi cacy. Methods and Results: In this study, we fl ow-sorted CD4+CD25+CD127Treg from normal juvenile cynomolgus monkey PBMC and expanded these cells using a protocol with artifi cial antigen-presenting cells. Three rounds of stimulation expanded the cells over 1000-fold and consistently generated over 108 Treg from 30 ml peripheral blood, while maintaining expression of Foxp3, CD25, CTLA-4, Helios; potent capacity to suppress T cell proliferation in vitro; demethylation status at the Treg-Specifi c Demethylation Region (TSDR), and down-regulated expression of CD45RA, CCR7, CD62L and upregulation of CXCR3 suggesting that these cells are likely to migrate to infl amed sites immediately after infusion in vivo. More importantly, when CFSE-labeled autologous (auto) and VPD450-labeled allogeneic (allo) ex vivo expanded Tregs were transferred simultaneously into monkeys, the number of auto-Treg was up to 100 per ml peripheral blood for at least 6 days (ie. for the duration of the experiment) in both control and ATG/rapamycin-treated (IS) monkeys. In contrast, by day 3 after their infusion, allo-Treg could not be detected in control monkeys, while they were maintained up to 100 cells per ml peripheral blood for at least 15 days in IS monkeys. These Tregs maintain high expression of Foxp3, CD25, and CXCR3 expression, and low expression of CD127, CCR7, and CD62L. Conclusion: The fi nding that allo-Treg can survive in IS-treated monkeys and maintain Treg phenotype supports the concept and potential utility of Treg banks for clinical application in transplantation and autoimmune disease and provides valuable information required to take allo-Treg therapy towards phase II/III clinical trials for effi cacy assessment. Abstract# 2272 B7-H1 Expression Is Critical to Cardiac Allograft Tolerance Induced By the Combination Therapy of Mesenchymal Stem Cells and Rapamycin. H. Wang,1,2 F. Qi,1 W. Tian,1 X. Dai,1 T. Liu,1,2 H. Han,1 B. Zhang,1 H. Li,2 Z. Zhang,1,2 C. Du.3 1Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China; 2Tianjin General Surgery Institute, Tianjin, China; 3Department of Urologic Sciences, University of British Columbia Vancouve, Vancouver, BC, Canada. Background: Mesenchymal stem cells (MSCs) become an attractive tool to suppress immune response. We have previously reported that MSC-based therapy in combination with rapamycin induced cardiac allograft tolerance in a mouse model. The present study investigated the role of MSC-expressing B7-H1 in MSC-mediated cardiac allograft protection. Methods & Results:MSCs (1x106, i.v.) from C57BL/6 donor mice were injected into BALB/c recipients 24 hours after receiving a heterotopic C57BL/6 heart graft. Grafts in untreated recipients were rapidly rejected in 7.5±0.7 days. Either MSCs or rapamycin monotherapy doubled allograft survival time to 15.8±1.5 days and 16.3±1.1 days, respectively. MSCs in combination with rapamycin induced heart allograft tolerance with normal graft histology and achieved graft mean survival time (MST) for more than 100 days. In contrast, treatment with B7-H1-blocking MSCs was not able to prolong allograft survival (MST: 8.7±1.1 days), and in combination with rapamycin prevented tolerance induction. Graft MST in the recipients treated with B7-H1-blocking MSC-based combination therapy was signifi cantly reduced to 18.5±0.8 days. In addition, Flow cytomytry analysis showed that B7-H1 is required for MSC-mediated downregulation of antibody production and enhancement of the frequency of tolerogeneic dendritic cells (Tol-DCs) and CD4+CD25+Foxp3+ cells in tolerant recipients. In vivo treatment with MSCs expressing B7-H1 is also involved in the modulation of CD83 and cytokine (IL-4 and IL-10) expression of B cells. Furthermore, MSC-mediated suppression of B cell