Gonzalo Rodriguez-Laiz

Use of the Abdominal Rectus Fascia as a Nonvascularized Allograft for Abdominal Wall Closure After Liver, Intestinal, and Multivisceral Transplantation

Introduction. Abdominal wall closure management has become an important challenge during recipient candidate selection, at the time of donor to recipient matching and during the planning of the surgical procedure for intestinal or multiorgan transplantation. Different strategies have been proposed to overcome the lack of abdominal domain: to reduce the graft size or to increase the abdominal domain. Based on the recent concept of using an acellular dermis matrix (Alloderm) and the availability of abdominal wall tissues from the same organ donor, we conceived the idea of using the fascia of the rectus muscle (FoRM) as a nonvascularized tissue allograft. Materials and Methods. This is a retrospective report of a series of 16 recipients of FoRM as part of a liver, intestinal, or multiorgan transplant procedure performed between October 2004 and May 2008 at three different transplant centers. Results. Of the 16 recipients of FoRM, all but one case was performed during their transplantation (four multivisceral, two modified multivisceral, three isolated intestine, and two livers). Five patients underwent a retransplant surgery (two livers, two multivisceral, and one isolated intestine). Abdominal wall infection was present in 7 of 16 cases. Nine patients are still alive. No deaths were related to wound infection. Long-term survival showed complete wound healing and only one ventral hernia. Discussion. The use of a nonvascularized FoRM is a novel and simple surgical option to resolve complex abdominal wall defects in liver/intestinal/multivisceral transplant recipients when it can be covered with the recipient skin.

Recurrent hepatic sarcoidosis post‐liver transplantation manifesting with severe hypercalcemia: A case report and review of the literature

Sarcoidosis is a systemic granulomatous disease primarily involving the lungs, lymph nodes, skin, eyes and nervous system; liver involvement is asymptomatic in most cases. However, once the patient develops clinical symptoms liver disease is usually progressive and may necessitate orthotopic liver transplantation. There are a few reports of asymptomatic recurrent sarcoidosis developing within the liver allograft. We report a case of early recurrence of sarcoidosis in the liver allograft diagnosed on biopsy in a patient who presented with severe hypercalcemia, kidney dysfunction, and increase in size of abdominal lymph nodes. The liver chemistry tests were within normal limits. The patient responded well to steroid treatment by normalizing serum calcium and creatinine levels and reducing lymph node size. To date, there has been no report in the literature of symptomatic recurrence of hepatic sarcoidosis following orthotopic liver transplantation. (Liver Transpl 2005;11:1611–1614.)

Risk factors for intra-abdominal infection after pancreas transplantation

Abstract Background: This study was designed to determine risk factors for intra-abdominal abscess after pancreas transplantation. Methods: We performed a single-center retrospective review of all pancreas transplants from 1994 to 1999. Risk factors studied were donor age, body weight, body mass index, peak serum glucose, peak serum amylase, need for pressor agents, cause of death, cold ischemic preservation time, recipient age, type of dialysis, surgical technique, and peak recipient amylase. Results: The 1-year graft survival rate was 90%. Of the 34 patients studied, there were 4 cases of peripancreatic abscess formation (12%). Elevated donor body weight ( P P P Conclusions: These data suggest that pancreas grafts from obese donors may be more susceptible to ischemia-reperfusion injury resulting in abscess formation.

Improved outcomes in pediatric liver transplantation for acute liver failure

Miloh T, Kerkar N, Parkar S, Emre S, Annunziato R, Mendez C, Arnon R, Suchy F, Rodriguez‐Laiz G, Del Rio Martin J, Sturdevant M, Iyer K. Improved outcomes in pediatric liver transplantation for acute liver failure.
Pediatr Transplantation 2010: 14:863–869.

Pretransplant immunomodulation of highly sensitized small bowel transplant candidates with intravenous immune globulin.

Presence of preformed lymphocytotoxic antibodies may represent a barrier to isolated intestinal transplantation (IITx). We developed an intravenous immunoglobulins (IVIg) based desensitization protocol for candidates with high panel-reactive antibodies (PRA). Six patients with a mean PRA of 72±22% were included in a four-level (L) protocol with escalating doses of IVIg (L1, L2), addition of mycophenolate mofetil (MMF) or plasmapheresis (L3); and anti-CD20 (Rituximab) (L4). Four of six candidates improved their PRAs (from a mean of 66.2% to 25.5%; P=0.01) and were successfully transplanted. At a mean follow-up of 8 months, number and severity of rejection episodes of protocol patients did not differ from patients with low PRA transplanted during the same period. These data support the use of IVIg to desensitize patients waiting for IITx. It increases the applicability of IITx, and reduces the waiting time and mortality on the waiting list with outcomes comparable to nonsensitized recipients.

The role of magnetic resonance cholangiography in the management of children and young adults after liver transplantation

Abstract: We reviewed the results of 50 magnetic resonance (MR) cholangiograms to evaluate their usefulness in directing clinical management in young patients after liver transplantation (LTx). Thirty‐two patients underwent 50 MR cholangiograms on a 1.5‐T unit. Studies were performed from 1 week to 16 yr after LTx. Indications included biochemical abnormalities with (n = 19) or without (n = 16) biopsy evidence for chronic rejection, sepsis (n = 14), and intractable ascites (n = 1). Original interpretations were compared to laboratory and ultrasound findings, and clinical outcome. Of 19 studies performed on 14 patients with biopsy evidence of chronic rejection, 16 were abnormal on MR (but only one was abnormal on ultrasound), resulting in corrective surgery (n = 1), re‐Tx (n = 1), and endoscopic dilatation (n = 1). Of 16 studies on 16 patients with biochemical abnormalities without evidence of chronic rejection on biopsy, 14 were abnormal on MR (but only five of 13 on ultrasound), leading to corrective surgery (n = 3) and re‐listing for Tx (n = 3). Thirteen of 14 studies on six patients with sepsis were abnormal on MR (five of nine were abnormal on ultrasound), identifying surgically correctable strictures (n = 2), and leading to re‐Tx (n = 1) and percutaneous biliary drainage procedures (n = 2). The one patient with ascites had a normal study. We advocate usage of MR cholangiography for the detection of biliary complications after LTx, particularly in those patients who present with biochemical abnormalities that are not easily explained by acute cellular rejection or viral infection and in those with biliary sepsis.

The beneficial impact of temporary porto-caval shunt in orthotopic liver transplantation: a single center analysis

The use of temporary porto‐caval shunt (TPCS) has been shown to improve hemodynamic stability and renal function in patients undergoing orthotopic liver transplantation (OLT). We evaluated the impact of TPCS in OLT and analyzed the differences according to model for end‐stage liver disease (MELD), donor risk index (DRI) and D‐MELD. This is a retrospective single‐center analysis of 148 consecutive OLT. Fifty‐eight OLT were performed using TPCS and 90 without TPCS. Donor and recipient data with pre‐OLT, intraoperative and postoperative variables were reviewed. Overall graft survival was 89.9% at 3 months and 81.7% at 1 year. Graft survival at 3 months and 1 year was 93.1% and 79.2%, respectively, in TPCS group versus 85.6% and 82.2%, respectively, in non‐TPCS group (P = NS). Intraoperative packed red blood cells requirement was lower in TPCS group (7.5 ± 5.8 vs. 12.2 ± 14.2, P = 0.006) and non‐TPCS group required higher intraoperative total dose of phenylephrine (16% vs. 28%, P = 0.04). TPCS group had lower 30‐day postoperative mortality (1.7% vs. 10%, P = 0.04), no difference was observed at 90 days. Graft survival was lower in patients with high DRI; in this group graft loss was higher at 1 month (25% vs. 4.3%, P = 0.005) and 3 months (25% vs. 4.3%, P = 0.005) when TPCS was not used. TPCS improves perioperative outcome, this being more evident when high‐risk grafts are placed into high‐risk patients.

Surgical portosystemic shunts and the Rex bypass in children: a single-centre experience

OBJECTIVES This study aimed to illustrate the indications for, and types and outcomes of surgical portosystemic shunt (PSS) and/or Rex bypass in a single centre. METHODS Data were collected from children with a PSS and/or Rex bypass between 1992 and 2006 at Mount Sinai Medical Center, New York. RESULTS Median age at surgery was 10.7 years (range 0.3-22.0 years). Indications included: (i) refractory gastrointestinal bleeding in portal hypertension associated with (a) compensated cirrhosis (n= 12), (b) portal vein thrombosis (n= 10), (c) hepatoportal sclerosis (n= 3); (ii) refractory ascites secondary to Budd-Chiari syndrome (n= 3), and (iii) familial hypercholesterolaemia (n= 4). There were 20 distal splenorenal, four portacaval, three Rex bypass, two mesocaval, two mesoatrial and one proximal splenorenal shunts. At the last follow-up (median 2.9 years, range 0.1-14.1 years), one shunt (Rex bypass) was thrombosed. Two patients had died and two had required a liver transplant. These had a patent shunt at last imaging prior to death or transplant. CONCLUSIONS Portosystemic shunts and Rex bypass have been used to manage portal hypertension with excellent outcomes. In selected children with compensated liver disease, PSS may act as a bridge to liver transplantation or represent an attractive alternative.

Partial HLA matching and RH incompatibility resulting in graft versus host reaction and Evans syndrome after liver transplantation

We report a case of a 67‐year‐old male who underwent OLT from a deceased, sex‐matched donor. Two months later he developed Evans syndrome and GVHD of the skin. Donor and recipient were matched for HLA‐A and ‐B loci in the direction of rejection but mismatched in the direction of GVHD and fully mismatched for DRB1. These mismatches were permissible for engraftment of donor T‐cells but led to GVHD. Chimerism appeared restricted to the T‐cell compartment. In this case, partially matched passenger lymphocytes triggered a graft versus host reaction. In addition, alloantibodies caused cytopenias that improved after immunosuppression. HLA typing was critical in confirming this rare diagnosis and elucidating its cause. Recipients of solid organs from donors that are partially matched in the direction of rejection may need to be closely monitored for GVHD. Am. J. Hematol., 2008.

Common hepatic artery arising from the left gastric artery: a rare anatomic variation identified on a cadaveric liver donor

Anatomical variations of the arterial supply of the liver are not uncommon. The typical normal “textbook” anatomy of the hepatic artery is found only in approximately half of the cases. Some of the variations such as the presence of a right or left hepatic branch are more common, but other ones are extremely rare. We describe here a rare case in which the common hepatic artery arose from the left gastric artery, found during a cadaveric liver donor harvesting and confirmed with imaging studies. Cases like this one highlight the importance of knowing the hepatic arterial anatomy and the possibility of its numerous variations by the transplant and hepatobiliary surgeon.