Martín Fauda

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.

Technical refinements in small bowel transplantation

Purpose of reviewThis review focuses on the recently described or revised refinements or innovations in small bowel transplantation. Recent findingsChanges in donor selection criteria; cadaveric procurement techniques; organ preservation solutions; management of the recipient abdominal wall; technical modifications, pitfalls and recommendations to be applied during the engraftment as well as intestinal living donation will be covered. SummaryIntestinal transplantation has evolved over time to become a clinically accepted therapy for patients with intestinal failure. Short- and long-term results have improved. The surgical procedures have been standardized and the applications broaden, but there have been recently published refinements that might affect the future results of clinical intestinal transplantation and guide research.

Split liver transplantation: Report of right and left graft outcomes from a multicenter Argentinean group

Grafts from split livers (SLs) constitute an accepted approach to expand the donor pool. Over the last 5 years, most Argentinean centers have shown significant interest in increasing the use of this technique. The purpose of this article is to describe and analyze the outcomes of right‐side grafts (RSGs) and left‐side grafts (LSGs) from a multicenter study. The multicenter retrospective study included data from 111 recipients of SL grafts from between January 1, 2009 and December 31, 2013. Incidence of surgical complications, patient and graft survival, and factors that affected RSG and LSG survival were analyzed. Grafts types were 57 LSG and 54 RSG. Median follow‐up times for LSG and RSG were 46 and 42 months, respectively. The 36‐month patient and graft survivals for LSG were 83% and 79%, respectively, and for RSG were 78% and 69%, respectively. Retransplantation rates for LSG and RSG were 3.5% and 11%, respectively. Arterial complications were the most common cause of early retransplantation (less than 12 months). Cold ischemia time (CIT) longer than 10 hours and the use of high‐risk donors (age ≥ 40 years or body mass index ≥ 30 kg/m2 or ≥ 5 days intensive care unit stay) were independent factors for diminished graft survival in RSG. None of the analyzed variables were associated with worse graft survival in LSG. Biliary complications were the most frequent complications in both groups (57% in LSG and 33% in RSG). Partial grafts obtained from liver splitting are an excellent option for patients in need of liver transplantation and have the potential to alleviate the organ shortage. Adequate donor selection and reducing CIT are crucial for optimizing results. Liver Transpl 22:63‐70, 2016.

Visceral Kaposi's Sarcoma Remission After Intestinal Transplant. First Case Report and Systematic Literature Review

Background. Kaposis sarcoma (KS) is an infrequent vascular neoplasm commonly diagnosed as an isolated cutaneous lesion that can involve other organs. So far, there are no data in the literature about the development of KS after intestinal transplant. Methods. In this study, the authors describe a case of “visceral KS” with pulmonary and intestinal involvement and perform a systematic literature review of case reports and single-center series identified in MEDLINE. Results. This case was a 42-year-old man, diagnosed with visceral KS 9 months after receiving an isolated intestinal transplant. He was successfully treated with a combination of sirolimus and liposomal doxorubicin and achieved an 18-month disease-free survival. A total of 54 cases from 27 manuscripts and the present case were analyzed in this study. The mean time from transplant to diagnosis was 17.2 months. Lungs and gastrointestinal tract were the main organs involved. Immunosuppressants were discontinued in two of the three (66.7%) cases, and sirolimus was added in eight cases. Doxorubicin was used in 12 cases. In a univariate analysis, the use of Tacrolimus, type of transplant, and presence of cutaneous KS seem to be the significant predictors of response to therapy and survival; the addition of doxorubicin showed a reduction in graft loss. Conclusions. Treatment of KS in posttransplant patients should be designed aiming to obtain a complete response, irrespective of the organ affected. Only recipients who are able to achieve a sustained response would be able to obtain long-term disease-free survival.

Neurological events after liver transplantation: a single-center experience

The aim of this study was to identify potential risk factors linked to neurologic events (NE) occurring after liver transplantation (LT) and use them to construct a model to predict such events. From odds ratios (OR) of risk factors, a scoring system was assessed using multivariate regression analysis. Forty‐one of 307 LT patients presented NE (13.3%), with prolonged hospital stay and decreased post‐LT survival. On multivariate analysis, factors associated with NE included: severe pre‐LT ascites OR 3.9 (1.80–8.41; P = 0.001), delta sodium ≥12 mEq/l OR 3.5 (1.36–8.67; P = 0.01), and post‐LT hypomagnesemia OR 2.9 (1.37–5.98; P = 0.005). Points were assigned depending on ORs as follows: ascites 4 points, and hypomagnesemia and delta sodium ≥12 mEq/l, 3 points each (score range = 0–10 points). ROC curve analysis suggested good discriminative power for the model, with a c‐statistic of 0.72 (CI 0.62–0.81; P < 0.0001), best performance for a cutoff value >3 points (71% sensitivity, 60% specificity). NE risk increased progressively from 6.4%, to 10.3%, 12.8%, 31.5% and 71.0% as scores rose from 0 to 3, 4, 6–7 and 10 cumulative points, respectively. The score described helps to identify patients potentially at risk for neurologic events, and its prevention would decrease morbidity and mortality after LT.

Predicting early discharge from hospital after liver transplantation (ERDALT) at a single center: a new model.

BACKGROUND & RATIONALE Limited information related to Liver Transplantation (LT) costs in South America exists. Additionally, costs analysis from developed countries may not provide comparable models for those in emerging economies. We sought to evaluate a predictive model of Early Discharge from Hospital after LT (ERDALT = length of hospital stay ≤ 8 days). A predictive model was assessed based on the odds ratios (OR) from a multivariate regression analysis in a cohort of consecutively transplanted adult patients in a single center from Argentina and internally validated with bootstrapping technique. RESULTS ERDALT was applicable in 34 of 289 patients (11.8%). Variables independently associated with ERDALT were MELD exception points OR 1.9 (P = 0.04), surgery time < 4 h OR 3.8 (P = 0.013), < 5 units of blood products consumption (BPC) OR 3.5 (P = 0.001) and early weaning from mechanical intubation OR 6.3 (P = 0.006). Points in the predictive scoring model were allocated as follows: MELD exception points (absence = 0 points, presence = 1 point), surgery time < 4 h (0-2 points), < 5 units of BPC (0-2 points), and early weaning (0-3 points). Final scores ranged from 0 to 8 points with a c-statistic of 0.83 (95% CI 0.77-0.90; P < 0.0001). Transplant costs were significantly lower in patients with ERDALT (median

Domino liver graft with hepatocellular carcinoma used as bridge therapy for a patient with acute liver failure: A case report

23,078 vs.

Análisis de la morbi-mortalidad en 225 resecciones hepáticas

28,986; P < 0.0001). Neither lower patient and graft survival, nor higher rates of short-term re-hospitalization and acute rejection events after discharge were observed in patients with ERDALT. In conclusion, the ERDALT score identifies patients suitable for early discharge with excellent outcomes after transplantation. This score may provide applicable models particularly for emerging economies.

Liver Transplantation and Concomitant Prostate Cancer: Is it Feasible?

We report a unique case of orthotopic domino livertransplantation for a patient with ALF: a noncirrhoticliver graft with HCC was used as bridge therapy untila permanent deceased donor graft became available.A 42-year-old Hispanic woman presenting with ALFwas admitted to the emergency department and waspromptly listed for emergency liver transplantation.However, her clinical deterioration progressed rapidly,the patient required mechanical ventilatory support,and an epidural intracranial pressure monitor wasplaced. The patient developed intracranial hyperten-sion (25-30 mm Hg), which was successfully con-trolled with medical therapy. Synchronously,scheduled living donor liver transplantation (LDLT)was being performed for a 60-year-old female patientwith a history of recurrent HCC in a noncirrhotic liver.This patient had previously undergone a series of sur-gical and ablative treatments. The actual tumor bur-den was 2 HCC lesions (each 20 mm in diameter), theserum alpha-fetoprotein level was 2.4 ng/mL, and novascular or extrahepatic metastasis was found at thetime of LDLT.Progressive worsening of an already critical clinicalcondition in the first patient, the absence of either adeceased donor or a living donor after 5 days on thewaiting list, and no access to liver support systems orbioartificial devices at that time led the transplantteam to consider a domino liver transplant using theexplanted noncirrhotic liver with HCC from the secondpatient undergoing synchronous LDLT as bridge ther-apy. Consent was obtained from both the recipientand donor families, the institutional ethics committee,and the Instituto Nacional Central Unico Coordinadorde Ablacion e Implante. A sequential triple-procedureschedule was followed: left lobe LDLT; back-tableresection of the two 2-cm HCC lesions in segments VIand IV; and, finally, domino implantation of the HCCliver graft with the piggyback technique. The coldischemia time lasted 4 hours, and the warm ischemiatime was 40 minutes. Shortly after transplantation,vasopressor infusion was discontinued, and the intra-cranial pressure parameters improved to 15 to 17 mmHg (Fig. 1). Twelve hours after the domino procedure,a deceased donor graft from a 49-year-old female,located 600 km from the hospital, was made availablefor this patient. The deceased donor liver transplanta-tion procedure began 11 hours after the completion ofthe bridge domino liver transplant with the resectedHCC graft, and it lasted a total of 165 minutes with acold ischemia time of 6 hours.A pathological examination of the explanted dominoHCC liver graft confirmed 2 small HCC nodules: one