Tun Jie

Prolonged diabetes reversal after intraportal xenotransplantation of wild-type porcine islets in immunosuppressed nonhuman primates

Cell-based diabetes therapy requires an abundant cell source. Here, we report reversal of diabetes for more than 100 d in cynomolgus macaques after intraportal transplantation of cultured islets from genetically unmodified pigs without Gal-specific antibody manipulation. Immunotherapy with CD25-specific and CD154-specific monoclonal antibodies, FTY720 (or tacrolimus), everolimus and leflunomide suppressed indirect activation of T cells, elicitation of non-Gal pig-specific IgG antibody, intragraft expression of proinflammatory cytokines and invasion of infiltrating mononuclear cells into islets.

Graft weight/recipient weight ratio: how well does it predict outcome after partial liver transplants?

Partial graft liver recipients with graft weight/recipient weight (GW/RW) ratios < 0.8% are thought to have a higher incidence of postoperative complications, including small‐for‐size syndrome (SFSS). We analyzed a cohort of such recipients and compared those with GW/RW < 0.8% to those with GW/RW ≥ 0.8%. Between 1999 and 2008, 107 adult patients underwent partial graft liver transplants: 76 from live donors [living donor liver transplantation (LDLT)] and 31 from deceased donors [split liver transplantation (SLT)]. Of these, 22 had GW/RW < 0.8% (12 with LDLT and 10 with SLT), and 85 had GW/RW ≥ 0.8% (64 with LDLT and 21 with SLT). The baseline demographics and median length of follow‐up were similar. SFSS developed in 3 recipients with GW/RW < 0.8% (13.6%) and in 8 recipients with GW/RW ≥ 0.8% (9.4%; P = not significant). Other early complications were similar between the 2 groups. Inflow modification with splenic artery occlusion was performed in 13 recipients: 7 with GW/RW < 0.8% and 6 with GW/RW ≥ 0.8%. Graft survival at 1 year post‐transplant did not differ (91% versus 92%; P = not significant). In conclusion, GW/RW did not appear to be the only determinant of outcome after partial liver transplantation. Using techniques such as inflow modification may help to prevent some of the problems seen with smaller grafts. Liver Transpl 15:1056–1062, 2009.

Effect of epidural analgesia on postoperative complications following pancreaticoduodenectomy

BACKGROUND The purpose of this study was to evaluate the effect of epidural analgesia use on postoperative complications in patients undergoing pancreaticoduodenectomy. METHODS This retrospective cohort study used the 2009 Nationwide Inpatient Sample from the Agency for Healthcare Research and Quality. Patients who underwent pancreaticoduodenectomy were grouped on the basis of whether they received epidural analgesia. The effect of epidural use on the composite end point of major complications including death was investigated using a generalized linear model. RESULTS Overall, 8,610 cases of pancreaticoduodenectomy occurred within the United States in 2009, and 11.0% of these patients received epidural analgesia. After controlling for various potential confounders, results of the multivariate regression indicated that epidural analgesia use was associated with lower odds of composite complications including death (odds ratio, .61; 95% confidence interval, .37-.99; P = .044). CONCLUSIONS In patients who underwent pancreaticoduodenectomy, epidural analgesia was associated with significantly lower postoperative composite complications.

Intensive laparoscopic training course for surgical residents: program description, initial results, and requirements

IntroductionThe Department of Surgery at the University of Arizona has created an intensive laparoscopic training course for surgical residents featuring a combined simulation laboratory and live swine model. We herein report the essential components to design and implement a rigorous training course for developing laparoscopic skills in surgical residents.Materials and methodsAt our institution, we developed a week-long pilot intensive laparoscopic training course. Six surgical residents (ranging from interns to chief residents) participate in the structured, multimodality course, without any clinical responsibilities. It consists of didactic instruction, laboratory training, practice in the simulation laboratory, and performance (under the direction of attending laparoscopic surgeons) of surgical procedures on pigs. The pigs are anesthetized and attended by veterinarians and technicians, and then euthanized at the end of each day. Three teams of two different training-level residents are paired. Daily briefing, debriefing, and analysis are performed at the close of each session. A written paper survey is completed at the end of the course.ResultsThis report describes the results of first 36 surgical residents trained in six courses. Preliminary data reveal that all 36 now feel more comfortable handling laparoscopic instruments and positioning trocars; they now perform laparoscopic surgery with greater confidence and favor having the course as part of their educational curriculum.ConclusionA multimodality intensive laparoscopic training course should become a standard requirement for surgical residents, enabling them to acquire basic and advanced laparoscopic skills on a routine basis.

Novel Technique of Total Pancreatectomy Before Autologous Islet Transplants in Chronic Pancreatitis Patients

i d c v c a l s U t t Chronic pancreatitis is a disease characterized by progressive destruction of the pancreatic exocrine tissue, leading to fibrosis and calcification of the pancreas. Patients develop severe and debilitating chronic abdominal pain and have an extremely poor quality of life. Pain is a major cause of morbidity, but exocrine and endocrine insufficiency is severe as well. Chronic pancreatitis may be a sequela of acute recurrent pancreatitis; causes include anatomic defects resulting in obstruction of the pancreatic duct, use of drugs (especially, chronic alcohol abuse), and underlying genetic or autoimmune disorders of the pancreas. Often, no speific cause can be identified in a proportion of patients, specially in the Asia-Pacific region. Treatment methods have included pancreatic enzyme replacements, pain management, ERCP with stenting, and decompressive surgical procedures of the pancreatic duct, partial resection, and total pancreatectomy. A comprehensive review of the subject was recently published. In paients with chronic pancreatitis (instead of a primary maignancy), the decision to perform a total pancreatectomy is ot an easy one because of the extensive nature of the urgery and the resulting endocrine deficiency, which alost always results in brittle insulin-dependent diabetes ellitus. But the development of autologous islet (autoiset) transplants has provided an opportunity to prevent evelopment of insulin-dependent diabetes mellitus in uch patients. Their quality of life is improved by undergong both procedures: the total pancreatectomy addresses heir pain, and the autoislet transplant maintains their enocrine function. Total pancreatectomy is not a new procedure. Billroth performed the first reported pancreatectomy for pancreatic cancer in 1884; more than 80 years later, Warren performed the first pancreatectomy for intractable pain and

The survival outcomes following liver transplantation (SOFT) score: validation with contemporaneous data and stratification of high‐risk cohorts

Models to project survival after liver transplantation are important to optimize outcomes. We introduced the survival outcomes following liver transplantation (SOFT) score in 2008 (1) and designed to predict survival in liver recipients at three months post‐transplant with a C statistic of 0.70. Our objective was to validate the SOFT score, with more contemporaneous data from the OPTN database. We also applied the SOFT score to cohorts of the sickest transplant candidates and the poorest‐quality allografts. Analysis included 21 949 patients transplanted from August 1, 2006, to October 1, 2010. Kaplan–Meier survival functions were used for time‐to‐event analysis. Model discrimination was assessed using the area under the receiver operating characteristic (ROC) curve. We validated the SOFT score in this cohort of 21 949 liver recipients. The C statistic was 0.70 (CI 0.68–0.71), identical to the original analysis. When applied to cohorts of high‐risk recipients and poor‐quality donor allografts, the SOFT score projected survival with a C statistic between 0.65 and 0.74. In this study, a validated SOFT score was informative among cohorts of the sickest transplant candidates and the poorest‐quality allografts.

Isolated intestinal transplants vs. liver‐intestinal transplants in adult patients in the United States: 22 yr of OPTN data

Desai CS, Gruessner AC, Khan KM, Fishbein TM, Jie T, Rodriguez Rilo HL, Gruessner RWG. Isolated intestinal transplants vs. liver‐intestinal transplants in adult patients in the United States: 22 yr of OPTN data.

Histopathology and immunophenotype of the spleen during acute antibody-mediated rejection.

Splenectomy has been reported to have a beneficial effect in treating Acute antibody‐mediated rejection (ABMR). This reason for this often rapid and profound beneficial effect is not readily apparent from what is known about normal splenic immunoarchitecture. While the spleen is rich in mature B cells, it has not been noted to be a repository for direct antibody‐secreting cells. We present a case of a Native American female who received a renal transplant and developed a severe episode of ABMR. The patient was initially refractory to both plasmapheresis and IVIG. The patient underwent an emergent splenectomy with almost immediate improvement in her renal function and a rapid drop in her DR51 antibodies. Immunohistochemical stains of the spleen demonstrated abundant clusters of CD138+ plasma cells (>10% CD138 cells as opposed to 1% CD138 cells as seen in traumatic controls). Though this is a single case, these findings offer a rationale for the rapid ameliorative effect of splenectomy in cases of antibody rejection. It is possible that the spleen during times of excessive antigenic stress may rapidly turn over B cells to active antibody‐secreting cells or serve as a reservoir for these cells produced at other sites.

Early liver retransplantation in adults

Up to 23% of liver allografts fail post‐transplant. Retransplantation is only the recourse but remains controversial due to inferior outcomes. The objective of our study was to identify high‐risk periods for retransplantation and then compare survival outcomes and risk factors. We performed an analysis of United Network for Organ Sharing (UNOS) data for all adult liver recipients from 2002 through 2011. We analyzed the records of 49 288 recipients; of those, 2714 (5.5%) recipients were retransplanted. Our analysis included multivariate regression with the outcome of retransplantation. The highest retransplantation rates were within the first week (19% of all retransplantation, day 0–7), month (20%, day 8–30), and year (33%, day 31–365). Only retransplantation within the first year (day 0–365) had below standard outcomes. The most significant risk factors were as follows: within the first week, cold ischemia time >16 h [odds ratio (OR) 3.6]; within the first month, use of split allografts (OR 2.9); and within the first year, use of a liver donated after cardiac death (OR 4.9). Each of the three high‐risk periods within the first year had distinct causes of graft failure, risk factors for retransplantation, and survival rates after retransplantation.

Single-incision robotic-assisted living donor nephrectomy: case report and description of surgical technique

The introduction of laparoscopic surgery, and more recently of robotics, has increased the number of living donor kidney transplants. This approach has already improved living donor acceptance rates. Even newer developments in the field have now been introduced with the purpose of further reducing postoperative pain and length of hospital stay, while offering better cosmetic results. In particular, single‐incision surgery has gained popularity by improving the well‐known benefits of minimally invasive surgery. In this case report, we present the first single‐incision robotic‐assisted living donor nephrectomy.