Minh B. Luu

Report from a consensus conference on primary graft dysfunction after cardiac transplantation

Although primary graft dysfunction (PGD) is fairly common early after cardiac transplant, standardized schemes for diagnosis and treatment remain contentious. Most major cardiac transplant centers use different definitions and parameters of cardiac function. Thus, there is difficulty comparing published reports and no agreed protocol for management. A consensus conference was organized to better define, diagnose, and manage PGD. There were 71 participants (transplant cardiologists, surgeons, immunologists and pathologists), with vast clinical and published experience in PGD, representing 42 heart transplant centers worldwide. State-of-the-art PGD presentations occurred with subsequent breakout sessions planned in an attempt to reach consensus on various issues. Graft dysfunction will be classified into primary graft dysfunction (PGD) or secondary graft dysfunction where there is a discernible cause such as hyperacute rejection, pulmonary hypertension, or surgical complications. PGD must be diagnosed within 24 hours of completion of surgery. PGD is divided into PGD-left ventricle and PGD-right ventricle. PGD-left ventricle is categorized into mild, moderate, or severe grades depending on the level of cardiac function and the extent of inotrope and mechanical support required. Agreed risk factors for PGD include donor, recipient, and surgical procedural factors. Recommended management involves minimization of risk factors, gradual increase of inotropes, and use of mechanical circulatory support as needed. Retransplantation may be indicated if risk factors are minimal. With a standardized definition of PGD, there will be more consistent recognition of this phenomenon and treatment modalities will be more comparable. This should lead to better understanding of PGD and prevention/minimization of its adverse outcomes.

The impact of operative timing on outcomes of appendicitis: a National Surgical Quality Improvement Project analysis

BACKGROUND Surgery is indicated for acute uncomplicated appendicitis but the optimal timing is controversial. Recent literature is conflicting on the effect of time to intervention. METHODS We queried the American College of Surgeons National Surgical Quality Improvement Project dataset for patients undergoing laparoscopic and open appendectomy between 2007 and 2012. Logistic regression was used to evaluate 30-day morbidity and mortality of intervention at different time periods, adjusting for preoperative risk factors. RESULTS A total of 69,926 patients undergoing appendectomy were identified. Groups were divided by time to intervention: group 1, less than 24 hours (n = 55,839; 79.9%); group 2, 24 to 48 hours (n = 13,409; 18.6%); and group 3, greater than 48 hours (n = 1,038; 1.5%). After adjustment, the risk of complication remained increased for group 3 versus group 1 or 2 (odds ratio 1.66, 95% confidence interval 1.34 to 2.07). CONCLUSIONS These data demonstrate equivalent outcomes between time to appendectomy of less than 24 and 24 to 48 hours. There was a 2-fold increase in complication rate for patients delayed longer than 48 hours.

Randomized Pilot Trial of Gene Expression Profiling Versus Heart Biopsy in the First Year After Heart Transplant Early Invasive Monitoring Attenuation Through Gene Expression Trial

Background—The endomyocardial biopsy (EMB) is considered the gold standard in rejection surveillance post cardiac transplant, but is invasive, with risk of complications. A previous trial suggested that the gene expression profiling (GEP) blood test was noninferior to EMB between 6 and 60 months post transplant. As most rejections occur in the first 6 months, we conducted a single-center randomized trial of GEP versus EMB starting at 55 days post transplant (when GEP is valid). Methods and Results—Sixty heart transplant patients meeting inclusion criteria were randomized beginning at 55 days post transplant to either GEP or EMB arms. A positive GEP ≥30 between 2 and 6 months, or ≥34 after 6 months, prompted a follow-up biopsy. The primary end point included a composite of death/retransplant, rejection with hemodynamic compromise or graft dysfunction at 18 months post transplant. A coprimary end point included change in first-year maximal intimal thickness by intravascular ultrasound, a recognized surrogate for long-term outcome. Corticosteroid weaning was assessed in both the groups. The composite end point was similar between the GEP and EMB groups (10% versus 17%; log-rank P=0.44). The coprimary end point of first-year intravascular ultrasound change demonstrated no difference in mean maximal intimal thickness (0.35±0.36 versus 0.36±0.26 mm; P=0.944). Steroid weaning was successful in both the groups (91% versus 95%). Conclusions—In this pilot study, GEP starting at 55 days post transplant seems comparable with EMB for rejection surveillance in selected heart transplant patients and does not result in increased adverse outcomes. GEP also seems useful to guide corticosteroid weaning. Larger randomized trials are required to confirm these findings. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00962377.

Laparoscopic Revision of Failed Fundoplication and Hiatal Herniorraphy

OBJECTIVE The aim of this study was to evaluate the mechanisms of failure after laparoscopic fundoplication and the results of revision laparoscopic fundoplication. BACKGROUND Laparoscopic Nissen fundoplication has become the most commonly performed antireflux procedure for the treatment of gastroesophageal reflux disease, with success rates from 90 to 95%. Persistent or new symptoms often warrant endoscopic and radiographic studies to find the cause of surgical failure. In experienced hands, reoperative antireflux surgery can be done laparoscopically. We performed a retrospective analysis of all laparoscopic revision of failed fundoplications done by the principle author and the respective fellow within the laparoscopic fellowship from 1992 to 2006. METHODS A review was performed on patients who underwent laparoscopic revision of a failed primary laparoscopic fundoplication. RESULTS Laparoscopic revision of failed fundoplication was performed on 68 patients between 1992 and 2006. The success rate of the laparoscopic redo Nissen fundoplication was 86%. Symptoms prior to the revision procedure included heartburn (69%), dysphagia (8.8%), or both (11.7%). Preoperative evaluation revealed esophagitis in 41%, hiatal hernia with esophagitis in 36%, hiatal hernia without esophagitis in 7.3%, stenosis in 11.74%, and dysmotility in 2.4%. The main laparoscopic revisions included fundoplication alone (41%) or fundoplication with hiatal hernia repair (50%). Four gastric perforations occurred; these were repaired primarily without further incident. An open conversion was performed in 1 patient. Length of stay was 2.5 +/- 1.0 days. Mean follow-up was 22 months (range, 6-42), during which failure of the redo procedure was noted in 9 patients (13.23%). CONCLUSION Laparoscopic redo antireflux surgery, performed in a laparoscopic fellowship program, produces excellent results that approach the success rates of primary operations.

Abdominal wall reconstruction: a case series of ventral hernia repair using the component separation technique with biologic mesh

BACKGROUND Sixty-eight consecutive patients from October 2008 until February 2012 were selected for this retrospective review. METHODS A midline fascial closure with component separation was completed using biologic mesh onlay in all cases. Recurrence rates of the hernias, complication rates, patient satisfaction, and time to return to work/normal activities were investigated. RESULTS The recurrence rate was 1.5% (n = 65) with ongoing follow-ups (mean = 20 months). The average age was 57 years, and the average body mass index was 36 kg/m(2) (range 22 to 60). The average hernia defect was 20 cm (range 12 to 26) transversely. Wound infection and/or breakdown occurred in 32%, and seroma formation occurred in 9% of patients. Patient satisfaction was 3.63 of 4. The average time to return to work/normal activities was 16 weeks (range 1 to 76 weeks). CONCLUSIONS Large complex ventral hernias can be reliably repaired using the component separation technique. The short-term recurrence rate is significantly reduced in this case series using a biologic mesh onlay.

Report from a forum on US heart allocation policy.

Since the latest revision in US heart allocation policy (2006), the landscape and volume of transplant waitlists have changed considerably. Advances in mechanical circulatory support (MCS) prolong survival, but Status 1A mortality remains high. Several patient subgroups may be disadvantaged by current listing criteria and geographical disparity remains in waitlist time. This forum on US heart allocation policy was organized to discuss these issues and highlight concepts for consideration in the policy development process. A 25‐question survey on heart allocation policy was conducted. Among attendees/respondents were 84 participants with clinical/published experience in heart transplant representing 51 US transplant centers, and OPTN/UNOS and SRTR representatives. The survey results and forum discussions demonstrated very strong interest in change to a further‐tiered system, accounting for disadvantaged subgroups and lowering use of exceptions. However, a heart allocation score is not yet viable due to the long‐term viability of variables (used in the score) in an ever‐developing field. There is strong interest in more refined prioritization of patients with MCS complications, highly sensitized patients and those with severe arrhythmias or restrictive physiology. There is also strong interest in distribution by geographic boundaries modified according to population. Differences of opinion exist between small and large centers.

Unusual Complications of Gallstones

Extrinsic compression of the bile duct from gallstone disease is associated with bilio-biliary fistulization, requiring biliary-enteric reconstruction. Biliary-enteric fistulas are associated with intestinal obstruction at various levels. The primary goal of therapy is relief of intestinal obstruction; definitive repair is performed for selected patients. Hemobilia from gallstone-related pseudoaneurysms is preferentially controlled by selective arterial embolization. Rapidly increasing jaundice with relatively normal liver enzymes is a diagnostic hallmark of bilhemia. Acquired thoraco-biliary fistulas are primarily treated by percutaneous and endoscopic interventions.

Long-term symptom relief and patient satisfaction after Heller myotomy and Toupet fundoplication for achalasia

BACKGROUND The goal of this study was to review the results, symptom relief, and patient satisfaction after laparoscopic Heller myotomy and Toupet fundoplication. METHODS A cohort of patients who underwent laparoscopic esophagomyotomy and a Toupet fundoplication was identified. A retrospective chart review was conducted and patients then were interviewed by telephone using a modified 5-point Likert scale. RESULTS Long-term follow-up data were obtained for 51 patients with a mean of 5.9 years. Thirty-two (63%) patients reported infrequent or no dysphagia. Chest pain, heartburn, or regurgitation were reported in 6 of 51 (12%) patients, 14 of 51 (27%) patients, and 11 of 51 (22%) patients, respectively. Two patients (3.9%) had pneumatic dilation and 1 patient underwent completion esophagectomy (1.9%). Thirty-three (33 of 51; 65%) patients were on acid-suppression therapy. Forty-one (80%) patients reported their overall satisfaction with the procedure was either excellent or good, and 46 of 51 (90%) patients stated they would undergo surgery again. CONCLUSIONS Our data show acceptable long-term results.

Report From the American Society of Transplantation Conference on Donor Heart Selection in Adult Cardiac Transplantation in the United States

Cardiac transplantation remains the only definitive treatment for end‐stage heart failure. Transplantation rates are limited by a shortage of donor hearts. This shortage is magnified because many hearts are discarded because of strict selection criteria and concern for regulatory reprimand for less‐than‐optimal posttransplant outcomes. There is no standardized approach to donor selection despite proposals to liberalize acceptance criteria. A donor heart selection conference was organized to facilitate discussion and generate ideas for future research. The event was attended by 66 participants from 41 centers with considerable experience in cardiac donor selection. There were state‐of‐the‐art presentations on donor selection, with subsequent breakout sessions on standardizing the process and increasing utilization of donor hearts. Participants debated misconceptions and established agreement on donor and recipient risk factors for donor selection and identified the components necessary for a future donor risk score. Ideas for future initiatives include modification of regulatory practices to consider extended criteria donors when evaluating outcomes and prospective studies aimed at identifying the factors leading to nonacceptance of available donor hearts. With agreement on the most important donor and recipient risk factors, it is anticipated that a consistent approach to donor selection will improve rates of heart transplantation.

Toxoplasma gondii Serology and Outcomes After Heart Transplantation: Contention in the Literature.

BACKGROUND Toxoplasma gondii is an endemic pathogen to which approximately half of healthy patients develop antibodies. Toxoplasma serology is routinely assessed prior to heart transplantation. It has been suggested that donor or recipient toxoplasma serologic status may be associated with poor long-term outcomes post-transplantation, but current literature reveals conflicting results. METHODS From 1995 to 2012 at our single center, we retrospectively reviewed 785 heart transplant patients for pre-transplantation T. gondii serology. Patients were divided into T. gondii seronegative and seropositive groups. Subgroups in each group were created based on whether the donor was seropositive or seronegative. We assessed survival, freedom from nonfatal major adverse cardiac events, and freedom from cardiac allograft vasculopathy at 5 years post-transplantation. RESULTS No significant difference was found between 5-year outcomes of pre-transplant T. gondii seronegative and T. gondii seropositive recipients post-heart transplantation. However, in the donor-seropositive/recipient-seronegative subgroup (D+/R-), there was a significantly lower 5-year survival rate compared to the cohort of donor-seronegative/recipient-seronegative (D-/R-) patients (60% vs 87%, P = .04). After adjustment by multivariate analysis, D+/R- status conferred a trend towards increased mortality (HR 3.0, P = .06). CONCLUSIONS Toxoplasma serology prior to heart transplantation does not appear to impact post-transplantation outcome. However, toxoplasma seronegative patients who receive toxoplasma seropositive hearts appear to have poorer 5-year survival compared to toxoplasma seronegative patients who received toxoplasma seronegative hearts. Due to the small sample size, the association between T. gondii serology mismatch and long-term survival warrants further study.