John R. Lilly

Long-term survival after renal transplantation in humans: With special reference to histocompatibility matching, thymectomy, homograft glomerulonephritis, heterologous ALG, and recipient malignancy

AT the University of Colorado Medical Center, 189 patients have been given kidney homografts at a remote enough time to permit relatively long follow-up in the event of continued survival. On the basis of this experience, a reassessment will be attempted of the practical value of renal transplantation. In addition, the effect of various factors upon short and long-term survival will be examined including the organ source, the quality of HL-A antigen matching, thymectomy before or after transplantation, the addition of heterologous antilymphocyte globulin (ALG) to the immunosuppressive regimen, the development of glomerulonephritis in the transplants, and the occurrence of a significantly increased incidence of de novo malignancies in the recipients.

Ongoing cirrhosis after successful porticoenterostomy in infants with biliary atresia.

Thirty-one patients were treated by portoenterostomy procedures for extrahepatic biliary atresia. In 20, there was unequivocal evidence of bile drainage. Eleven of these 20 were restudied from 3 to 23 mo postoperatively by liver biopsy. The clinical condition of most of these infants was satisfactory. Despite absence of clinical jaundice, normal rose bengal scan, and normal liver function studies, eight showed progressive degrees of hepatic fibrosis when compared to the results of the biopsy taken at the time of portoenterostomy. Two patients showed stable histology and one, after progressing on a second biopsy, had normal liver histology on a third study. The implications of progressive hepatic histopathology despite bile drainage are discussed.

Live transplantation in children with biliary atresia and vascular anomalies

Eight of 29 infants and children undergoing orthotopic liver transplantation for extrahepatic biliary atresia had associated major vascular anomalies. A distinctive and highly unusual vascular malformation consisting of absent inferior vena cava, anomalous origin of the hepatic artery, and preduodenal portal vein was encountered in three of these children. Although at times technically difficult, single anomalies of hepatic vasculature were satisfactorily handled. In contrast, transplantation attempts were lethal in all three infants having the complex vascular malformation. The suggestion is made that this specific subgroup of patients with biliary atresia be identified in advance and that, at the moment, children with this composite anomaly are highly questionable candidates for liver transplantation.

Peptic ulcer in children with gastric tube interposition.

An infrequent, but potentially serious, complication of gastric tube interposition is ulceration within the conduit. It is important, therefore, to recognize ulcer formation in its early stages by serial radiographs throughout the childhood years. While redundancy and partial obstruction with impaired drainage of the tube appear to be etiologic factors, distension of the transposed antrum may lead to hyperacidity and may play a role in ulcerogenesis. A course of dietary and antacid therapy may heal the ulcer, but surgical revision of the tube may prove necessary.

Split portal flow in heterotopic hepatic transplantation

Heterotopic hepatic transplantation was carried out in 31 pigs using three different methods of homograft revascularization. In one experimental group the host portal inflow was split between the homograft and native liver so that the graft was provided with intestinal-pancreatic effluent; the host liver with gastric-splenic venous blood. The liver grafts flourished in this environment. A small and variable degree of atrophy took place in the host liver. In the other two experimental groups in which the grafts were supplied with different kinds of systemic inflow only, atrophy invariably followed. Long-term homograft analysis was prevented by the intensity of immunologic rejection regardless of the location of the ectopic liver. The implications for clinical auxiliary liver transplantation are (1) heterotopic liver homografts must be supplied with a portal inflow from the host splanchnic bed, but (2) the total host splanchnic effluent is unnecessary. (3) The portal inflow must contain the pancreatic venous blood. (4) There is a criticial recipient--donor size relationship for successful portal revascularization in this type of auxiliary hepatic graft.