RESUMO
Intestinal malrotation usually presents in the pediatric population with midgut volvulus requiring emergency Ladd's procedure. Rarely, it remains asymptomatic and is discovered incidentally only during adulthood when it seldom causes intestinal complications. The scenario of a cirrhotic adult being diagnosed with asymptomatic intestinal malrotation with subsequent intestinal complications is thus extremely rare and to our knowledge has not been previously reported. We describe a 56-year-old man with decompensated alcoholic cirrhosis (Child-Pugh class C, MELD score 22) who was initially observed after an incidental diagnosis of intestinal malrotation on computed tomography. Observation continued as his liver disease improved with alcohol cessation (Child-Pugh class A, MELD score 8). He later presented with a closed loop bowel obstruction secondary to midgut volvulus at the time of alcohol relapse and liver redecompensation (Child-Pugh class C, MELD score 22-29). He underwent emergency Ladd's procedure during which his midjejunum was volvulized into an internal hernia space created by a thick Ladd's band containing large varices. The postoperative course was complicated by ileus and loculated bacterial peritonitis. Based on our experience, we discuss special considerations with regard to the surgical technique and timing of Ladd's procedure when encountering intestinal malrotation in a cirrhotic adult with portal hypertension.
RESUMO
Most transplant centers decline morbidly obese people for living kidney donation. Their inclusion in the living donor pool after weight loss and reversal of comorbidities by bariatric surgery could reverse the downward living donation trend. We investigated whether bariatric surgery in the morbidly obese altered their candidacy for donation, complicated their subsequent donor nephrectomy, and impacted their early postoperative outcomes in a series of 22 donors who had bariatric surgery 0.7-22 years prior to laparoscopic living donor nephrectomy. Eighteen would have been excluded from donation prior to bariatric surgery based on a body mass index (BMI) > 40. Seventeen reached a BMI < 35 after bariatric surgery. One had hypertension that resolved after bariatric surgery. Prior bariatric surgery did not influence port placement and laterality of donor nephrectomy. None required open conversion or blood transfusion. In an exploratory comparison with 37 donors with a BMI 35-40, length of stay and warm ischemic time were shorter, blood loss and postoperative complications were similar, and operative time was longer. We therefore advocate the consideration of bariatric surgery in preparation for donation in morbidly obese people since it positively alters their candidacy without major impact on the subsequent living donor nephrectomy and early outcomes.
Assuntos
Cirurgia Bariátrica , Seleção do Doador , Transplante de Rim/métodos , Doadores Vivos , Nefrectomia , Obesidade Mórbida/complicações , Obesidade Mórbida/cirurgia , Adulto , Índice de Massa Corporal , Feminino , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Período Pós-Operatório , Período Pré-Operatório , Estudos Retrospectivos , Coleta de Tecidos e Órgãos , Resultado do TratamentoRESUMO
BACKGROUND: Delayed graft function (DGF) and slow graft function (SGF) are ischemia-reperfusion-associated acute kidney injuries (AKI) that decrease long-term graft survival after kidney transplantation. Regulatory T (Treg) cells are protective in murine AKI, and their suppressive function predictive of AKI in kidney transplantation. The conventional Treg cell function coculture assay is however time-consuming and labor intensive. We sought a simpler alternative to measure Treg cell function and predict AKI. METHODS: In this prospective observational cohort study, pretransplant recipient circulating CD4+CD25+CD127lo/- and CD4+CD127lo/- tumor necrosis factor receptor 2 (TNFR2)+ Treg cells were measured by flow cytometry in 76 deceased donor kidney transplant recipients (DGF, n = 18; SGF, n = 34; immediate graft function [IGF], n = 24). In a subset of 37 recipients, pretransplant circulating Treg cell-suppressive function was also quantified by measuring the suppression of autologous effector T-cell proliferation by Treg cell in coculture. RESULTS: The TNFR2+ expression on CD4+CD127lo/- T cells correlated with Treg cell-suppressive function (r = 0.63, P < 0.01). In receiver operating characteristic curves, percentage and absolute number of CD4+CD127lo/-TNFR2+ Treg cell predicted DGF from non-DGF (IGF + SGF) with area under the curves of 0.75 and 0.77, respectively, and also AKI (DGF + SGF) from IGF with area under the curves of 0.76 and 0.72, respectively (P < 0.01). Prediction of AKI (DGF + SGF) from IGF remained significant in multivariate logistic regression accounting for cold ischemic time, donor age, previous transplant, and pretransplant dialysis modality. CONCLUSIONS: Pretransplant recipient circulating CD4+CD127lo/-TNFR2+ Treg cell is potentially a simpler alternative to Treg cell function as a pretransplant recipient immune marker for AKI (DGF + SGF), independent from donor and organ procurement characteristics.