Michela Assalino

Recurrence of type 1 diabetes after simultaneous pancreas-kidney transplantation in the absence of GAD and IA-2 autoantibodies

We report herein the patterns of type 1 diabetes recurrence in a simultaneous pancreas–kidney transplant (SPK) recipient, in the absence of rejection. A 38‐year‐old female underwent SPK for end‐stage nephropathy secondary to type 1 diabetes. Fasting blood glucose, HbA1c, fructosamine, C‐peptide and autoantibodies (GAD‐65, IA‐2) were monitored throughout follow‐up. At 3.5 years post‐SPK, HbA1c and fructosamine increased sharply, indicating loss of perfect metabolic control, despite C‐peptide levels in the normal‐high range. Exogenous insulin was restarted 4 months later. C‐peptide levels abruptly fell and became undetectable at 5.5 years. Autoantibody levels, which were undetectable at the time of SPK, never converted to positivity. Pancreas retranspantation was performed at 6 years. The failed pancreas graft had a normal macroscopic appearance. On histology, there were no signs of cellular or humoral rejection in the kidney or pancreas. A selective peri‐islet lymphocytic infiltrate was observed, together with near‐total destruction of β cells. At 2.5 years post retransplantation, pancreatic graft function is perfect. This observation indicates unequivocally that pancreas graft can be lost to recurrence of type 1 diabetes in the absence of rejection. GAD‐65 and IA‐2 autoantibodies are not reliable markers of autoimmunity recurrence.

In-situ split liver splitting under extra-corporeal membrane oxygenation in brain-dead donor

Hemodynamic instability is generally considered as a contraindication to liver splitting, in particular when using an in situ technique. We describe the cases of two young donors with brain death in whom refractory cardiac arrest and hemodynamic instability were supported by veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO), allowing uneventful in situ splitting. Two adult and two pediatric liver recipients were successfully transplanted with immediate graft function. Favorable outcomes were also observed for the other transplanted organs, including one heart, two lungs, and four kidneys. Refractory cardiac arrest and hemodynamic instability corrected by VA‐ECMO should not be considered as a contraindication to in situ liver splitting.

Successful pregnancy and delivery after simultaneous islet-kidney transplantation

Allogeneic islet of Langerhans transplantation is a recognized beta‐cell replacement therapy for patients affected by type 1 diabetes mellitus. Type 1 diabetes mellitus is a condition associated with an increased risk of adverse outcomes for pregnant women and fetuses. We report the case of a 29‐year‐old woman with type 1 diabetes mellitus, who underwent successful allogeneic islet transplantation with simultaneous kidney transplantation. She achieved durable insulin independence after 2 islet infusions. Pregnancy was desired and planned 2 years after the last islet infusion. Multidisciplinary monitoring of pregnancy was carried out and the immunosuppressive regimen was adapted. Euglycemia was maintained throughout pregnancy without the need for exogenous insulin. After an uneventful pregnancy, she delivered on term an otherwise healthy male child with imperforate anus that was immediately surgically corrected. In conclusion, allogeneic islet transplantation is a suitable treatment for women of childbearing age with complicated type 1 diabetes mellitus, allowing physiologic glycemic control during pregnancy with a low risk of graft loss. This target can be achieved only by a tight multidisciplinary follow‐up, including immunosuppressive therapy adaptation and adequate diabetes and obstetrical monitoring.

Procurement professionalization: a mandatory step to improve the availability and quality of whole pancreas grafts.

The lack of available organs remains one of the main limitations in the field of solid organ transplantation. Most transplant organizations work on improving donation rate through public information programs, and by exploring new organ sources, such as donors after cardiocirculatory death (DCD). The impact of technical issues during organ procurement remains underexplored. A significant technical problem in a single donor can compromise the organ procurement and potentially jeopardize multiple transplantations. This is especially true for the pancreas, which is associated with the highest rate of technical failure [1]. In their report “Professionalization of surgical abdominal organ recovery leading to an increase in pancreatic allografts accepted for transplantation in The Netherlands: A serial analysis,” Lam et al. describe the impact on pancreas transplantation of the new Dutch policy, aiming at improving the expertise of procurement surgeons. Worldwide, most procurements are performed by training fellows. Senior fellows often supervise the training in organ procurement, and junior fellows are expected to become independent and operational as fast as possible. However, procuring organs is one of the most challenging procedures: One often has to work in remote hospitals, sometimes in a foreign language, with unfamiliar material. The procedure itself is complex and can be stressful, and the surgeon can also face important decisions such as “is the quality of this organ acceptable for transplantation?”. In the particular case of the pancreas, the dissection involves several major vessels, the organ is very sensitive to excessive manipulation—even when considered for islets transplantation [2]—and the scarcity of potential pancreas donors renders this surgery somewhat unusual. As a consequence, many fellows will not have the opportunity of being exposed to pancreas procurements on a regular basis before being sent for a procurement on their own. Some adverse events can be anticipated from these considerations: 1 Technical mistakes because of the lack of experience can be the source of parenchymal or vascular injuries.

Repair of Large Abdominal Wall Defects Using Total Anterior Aponeurotic Flap: Anatomical Feasibility Study and Comparison with Ramirez’s Technique

Summary: In this cadaveric study, we explored the feasibility of a maximal mobilization of the superficial abdominal fascia, in a continuous flap, to achieve a tension-free covering of midline defects. The aponeurosis of the external oblique muscle was incised along the anterior axillary line and then detached up to the anterior rectus sheath. The latter was opened between the external and the internal oblique aponeurosis while keeping the continuity with the external oblique fascia. The obtained flap was solid and uninterrupted. The width gain reached 15 ± 3 cm on each sides, providing tissue advancement 60% longer than Ramirez’s technique (n = 8). The described technique allows large covering with respect to the anatomical planes. Further clinical tests should evaluate the validity of such concept in the repair of giant and asymmetrical hernias.