Raquel Garcia-Roca

Sleeve gastrectomy surgery in obese patients post-organ transplantation.

BACKGROUND Among organ transplant recipients, a common side effect of immunosuppressive therapy is the development of obesity, which affects a third of the patients within 3 years after transplantation. Bariatric surgery represents a possible surgical option for weight loss among posttransplant patients. OBJECTIVES The aim of this study was to examine percent excess weight loss (%EWL), and percent weight loss (%WL) and perioperative and postoperative complications in posttransplant obese patients after sleeve gastrectomy (SG) compared with nontransplant patients. We hypothesize that transplant patients who undergo SG will not significantly differ in their perioperative or postoperative complications or in their %EWL and %WL compared with nontransplant patients who undergo SG. The second aim was to evaluate the impact of SG on graft function and immunosuppressive therapy in transplant patients. SETTING University hospital. METHODS Among 500 consecutive patients who underwent SG from January 2008 to June 2014, 10 patients were organ transplant recipients. The following variables were compared between groups: patient demographic characteristics and co-morbidities, type of transplant surgery, date of transplant surgery, pretransplant body mass index (BMI), date of bariatric surgery, prebariatric surgery BMI, operative time, length of hospitalization, postoperative complications, and change in BMI, %EWL, and %WL. Data were also collected on renal, liver, and pancreas graft function parameters and changes in immunosuppressive medications. RESULTS Six patients had a kidney transplant, 2 patients had a liver transplant, and 2 had a pancreas transplant. No significant differences were observed in %EWL or %WL at 6 and 12 months follow-up between transplant and nontransplant patients. No transplant patients were lost to follow-up at 6 and 12 months. Among nontransplant patients, 36.7% and 35.7% were lost to follow-up at 6 and 12 months, respectively. No postoperative complications were registered in the transplant group. SG did not negatively affect the graft function. CONCLUSION Initials results found that there were no significant differences in %EWL or %WL at 6 and 12 months follow-up between transplant and nontransplant patients. There were also no perioperative and postoperative complications among transplant patients after SG.

Robotic-Assisted Kidney Transplantation

Robotic-assisted surgery has enabled organ transplantation in a minimally invasive fashion. Kidney transplantation is the best treatment of patients with chronic renal failure. Robotic surgery has reduced the difficulties associated with kidney transplantation for obese patients. Benefits such as reduced recovery period and reduced number of wound complications and surgical site infections have been attained with the robotic surgical approach. We believe that robotic-assisted surgery has expanded the ability to complete complex surgical procedures in a minimally invasive fashion. However, advanced training and experience are required in all surgeons who are interested in pursuing this technique.

Preservation of pancreas graft function after complete venous thrombosis: report of four cases treated conservatively.

Background. Pancreas graft thrombosis is the most common cause of technical graft failure, with an incidence of up to 20% is some series. In most instances, vascular thrombosis of the graft will require immediate removal to avoid further abdominal complications. We present a total of four cases of complete venous thrombosis with preservation of function that were managed conservatively, resulting in long-term graft function. Methods. Retrospective analysis of our case series over 10 years was carried out, obtaining patients with complete graft thrombosis by Doppler ultrasound. We included in the study only those patients who remained asymptomatic with preserved graft function. The clinical status of the patients, radiological findings, and therapeutic approach are evaluated. Patient and graft outcomes are analyzed. Results. Retrospective evaluation of 227 transplants, a total of four patients were found to have complete thrombosis of the graft, remaining asymptomatic and preserving function without complications. Graft thrombosis was found on routine Doppler ultrasound evaluation of the transplanted organs at a median time of 19 days (range, 11–28 days), angiographic confirmation was obtained in all cases. The clinical condition and the presence of collateral flow allowed for conservative treatment. Median hospital stay was 29 days (range, 16–38 days), with a median follow-up of 106 months (range, 24–110 months), all patients are alive with a functioning graft. Conclusions. In rare instances with complete thrombosis of the pancreas transplant in absence of clinical manifestations, the grafts can be closely monitored and treated with systemic anticoagulation, allowing long-term patient and graft survival.

Single Center Experience With Robotic Kidney Transplantation for Recipients With BMI of 40 kg/m2 Or Greater: A Comparison With the UNOS Registry

Background Obesity represents a barrier to kidney transplantation, but the increasing prevalence among renal failure patients has forced some centers to carefully consider such candidates. Morbidly obese patients may be at increased risk of delayed graft function, higher postoperative complications, and inferior graft outcomes. Nevertheless, mortality on the waiting list remains significantly higher than after transplant. We have applied minimally invasive surgery to perform kidney transplant in individuals with body mass index (BMI) of 40 kg/m2 or greater. We compared our results to the national United Network of Organ Sharing database. Methods The United Network of Organ Sharing registry was reviewed for adult living donor kidney transplant recipients with BMI of 40 kg/m2 or greater performed from September 2009 to December 2014. We compared transplants performed with robotic technique (RKT) versus patients performed with open surgery at all US centers including our own (open kidney transplant). Subgroup analysis in patients with BMI of 45 kg/m2 or greater was conducted. We compared outcomes including patient and graft survival, renal function, and technical complications. Results Robotic kidney transplantation group had a significantly higher mean BMI overall. The 1-year patient and graft survival rates were similar between groups. Renal function was also similar at 6, 12, and 36 months. Thrombosis caused 1.3% of the graft losses in open kidney transplant and 0% in the RKT group. Interestingly, 52.8% of the overall experience in patients with BMI of 45 kg/m2 or greater was performed with the robotic technique. Conclusions Robotic surgery offers similar patient and graft survivals with comparable renal function to open technique. Robotic kidney transplantation permits transplantation in extreme BMI categories without additional technical complications. Further studies are required to establish the role of RKT for obese candidates but preliminary data are encouraging.

Simultaneous Living Donor Kidney and Parathyroid Allotransplantation: First Case Report and Review of Literature.

Background Congenital hypoparathyroidism can be severely debilitating for patients, leading to renal failure at young age. Parathyroid transplantation may represent a permanent parathyroid replacement therapy. In patients already on immunosuppression for other organ transplant, there is little additional risk involved with parathyroid allotransplantation. Methods Robotic assisted transaxillary single parathyroidectomy is performed on a living donor also donating a kidney to her sibling. Results Recipient total serum PTH levels became detectable after 3 days from the procedure and maintained for 9 months after transplant with minimal calcium supplementation after the procedure. Literature review and previous results are summarized. Conclusions Obtaining a parathyroid gland and a kidney from the same donor reduces the exposure to different HLA antigens. The combined procedure using minimally invasive surgery is safe, with the additional cosmetic advantage and convenience for the willing donor. In the setting of need for immunosuppression, additional transplantation to treat the cause is safe and justified in the recipients.

Successful living donor intestinal transplantation in cross-match positive recipients: Initial experience

Sensitized patients tend to have longer waiting times on the deceased donor list and are at increased risk of graft loss from acute or chronic rejection compared to non-sensitized candidates. Desensitization protocols are utilized to decrease the levels of alloantibodies and to convert an initial positive cross-match to prospective donors into a negative crossmatch. These procedures are mostly available in the setting of living donation. Due to the elective nature of the procedure, desensitization protocols can be extended until the desire result is obtained prior to transplantation. We present two cases of successful desensitization protocol applied to living donor intestinal transplant candidates that converted to negative cross-match to their donors. We present two cases of intestinal transplant candidates with a potential living donor to whom they are sensitized. Both cases underwent successful transplantation after desensitization protocol. No evidence of humoral rejection has occurred in either recipient. Living donor intestinal transplantation in sensitized recipients against the prospective donors provides the ability to implement a desensitization protocol to convert to negative cross-match.

Hand-assisted robotic right donor nephrectomy in patient with total situs inversus: A case report.

Highlights • “Total situs inversus” is an infrequent congenital condition.• The robot has been already proved as a safe and attractive approach for living donor neprectomies.• “Total situs inversus” presents the surgeon with a challenging situation.• In these cases, preoperative planning is essential.• This is the first robotic right donor nephrectomy in a patient with total sinus inversus.

Percutaneous Pancreatic Islet Cell Transplantation

Percutaneous pancreatic islet cell transplantation is a promising cellular-based therapy for type 1 diabetes mellitus (DM). This procedure involves portal venous injection of islet cells and affords 1-year insulin independence in up to 70 % of recipients. While transplant surgeons represent the historical drivers of islet therapy, requirement for image-guidance and transcatheter techniques has fostered collaboration with interventional radiologists (IRs), who play a significant role in clinical performance of islet transplantation. The following case reviews the procedural elements of islet cell transplantation with stepwise illustration of the interventional radiologic technique. The logistics involved in establishing and developing an islet cell transplantation program and the technical aspects of pancreatic organ harvest and islet cell isolation and preparation are beyond the scope of this chapter and will not be presented.