Thiago Beduschi

Multivisceral transplantation for diffuse portomesenteric thrombosis

Objective:To evaluate the clinical outcomes of multivisceral transplantation (MVT) in the setting of diffuse thrombosis of the portomesenteric venous system. Background:Liver transplantation (LT) in the face of cirrhosis and diffuse portomesenteric thrombosis (PMT) is controversial and contraindicated in many transplant centers. LT using alternative techniques such as portocaval hemitransposition fails to eliminate complications of portal hypertension. MVT replaces the liver and the thrombosed portomesenteric system. Methods:A database of intestinal transplant patients was maintained with prospective analysis of outcomes. The diagnosis of diffuse PMT was established with dual-phase abdominal computed tomography or magnetic resonance imaging with venous reconstruction. Results:Twenty-five patients with grade IV PMT received 25 MVT. Eleven patients underwent simultaneous cadaveric kidney transplantation. Biopsy-proven acute cellular rejection was noted in 5 recipients, which was treated successfully. With a median follow-up of 2.8 years, patient and graft survival were 80%, 72%, and 72% at 1, 3, and 5 years, respectively. To date, all survivors have good graft function without any signs of residual/recurrent features of portal hypertension. Conclusions:MVT can be considered as an option for the treatment of patients with diffuse PMT. MVT is the only procedure that completely reverses portal hypertension and addresses the primary disease while achieving superior survival results in comparison to the alternative options.

Impact of Positive Flow Cytometry Crossmatch on Outcomes of Intestinal/Multivisceral Transplantation: Role Anti-IL-2 Receptor Antibody

Background Positive crossmatch may be associated with an increased risk of acute rejection (AR) and worse overall outcomes after intestinal/multivisceral (MV) transplantation. However, the evidence from published studies in this setting is sparse and contradictory. This study reports the impact of positive flow cytometry crossmatch on clinical outcomes after intestinal/MV transplantation and the use of anti–interleukin (IL)-2 receptor antibody as a maintenance immunosuppressant. Methods Records of all intestinal/MV transplants from 2003 to 2010 were reviewed. Flow cytometry was used to evaluate T- and B-cell crossmatch status. Standard immunosuppression included rabbit anti-thymocyte globulin–rituximab induction with tacrolimus and steroid maintenance. From 2008 onwards (second era), monthly anti-IL-2 receptor antibody was added to the maintenance immunosuppression in patients receiving liver-excluding transplants. Results Of 131 intestinal/MV transplants, 27 (21%) had a positive crossmatch. Positive crossmatch was not associated with an increased incidence of AR and graft loss (30% and 37% vs. 29% and 47%; P=0.94 and 0.35, respectively). This effect was maintained in liver-excluding transplants. Overall rate of AR decreased from 39% to 22% in the second era. In liver-excluding transplants, there was a significant decrease in AR from 75% to 44% with the use of anti-IL-2 receptor antibody therapy. Conclusions With rabbit anti-thymocyte globulin–rituximab induction, positive crossmatch status is not associated with worse outcomes after intestinal/MV transplantation. Use of anti-IL-2 receptor antibody as a part of maintenance immunosuppression may be beneficial in liver-excluding transplants.

Vascular catastrophes following pancreas transplantation: an evolution in strategy at a single center.

Fridell JA, Johnson MS, Goggins WC, Beduschi T, Mujtaba MA, Goble ML, Powelson JA. Vascular catastrophes following pancreas transplantation: an evolution in strategy at a single center. 
Clin Transplant 2012: 26: 164–172. 
© 2011 John Wiley & Sons A/S.

Multivisceral transplantation for diffuse splanchnic venous thrombosis

Purpose of reviewThe development of diffuse splanchnic venous thrombosis continues to be a challenging undertaking for patients waiting for liver transplantation, requiring the utilization of highly complex surgical techniques. The aim of this article is to review the status of multivisceral transplantation (MVT) in the setting of diffuse portomesenteric thrombosis. Recent findingsEven though many anatomical reconstructions of the venous system have been proposed to revascularize the transplanted liver, there are only few articles describing the use of these techniques. Here we describe a succinct review of these alternatives with emphasis on MVT. SummaryMVT is a complex procedure; however, it is the only one capable of reestablishing the venous anatomy and physiology of the abdominal cavity, resolving completely the effects of portal hypertension and the baseline disease.

Thoracotomy versus transhiatal esophageal dissection: which is the best surgical approach to short esophagus?

PURPOSE To evaluate different approaches performed to obtain a more significant esophageal length. METHODS An experimental model using 28 cadavers was conceived. Randomized groups: Group A (n=10) underwent laparotomic transhiatal approach; Group B (n=9) which differed from the first in the conduction of a wide phrenotomy and Group C (n=9) esophageal dissection was performed through a left anterolateral thoracotomy. RESULTS Final length variations for Group A were 2.12cm and 3.29cm and for Group B 3.24 cm and 3.66cm, without and with esophageal traction, respectively. In Group C length gain observed was 3.81 cm. The mediastinal dissections conducted through the hiatus was considered the procedure that produced the better esophageal mobilization, and the association of wide phrenotomy significantly improved the results. CONCLUSION The mediastinal dissection was the most effective to improving gain in abdominal esophagus. When toracotomy and laparotomy were compared, no significant differences were observed in the outcome.

Comparison in outcome with tailored antibiotic prophylaxis postoperatively in pediatric intestinal transplant population

BIs are ubiquitous among the pediatric intestinal transplant patient population. Personalizing postoperative prophylaxis antibiotic regimens may improve outcomes in this population. A retrospective analysis of all pediatric patients who underwent intestinal transplantation was evaluated to compare standardized and tailored regimens of antibiotics provided as prophylaxis postoperatively. Patients in the standard group have both shorter time to and higher rate of BIs, which was statistically significant (P < 0.001). Of the children who developed a BI, there was no statistical difference in average times to the development of a second BI (293 vs 119 days, P = 0.211). The tailored group had prolonged times until the development of a MDRO (52.6 vs 63.9 days, P = 0.677). Although not statistically significant, the tailored group had a propensity to present with gram‐negative pathogens after transplant as compared to the standard regimen group, which presented with gram‐positive pathogens (P = 0.103). Children with a history of an MDRO held a 7.3 (P < 0.01) times more likelihood of death within a year of transplant. A tailored prophylactic antibiotic regimen in the post‐transplant period appears to prolong the time to the first BI. Although the data do not show differences in mortality, further study may prove the impact of a tailored antibiotic regimen on morbidity and mortality rates.