Acute appendicitis in a kidney-pancreas transplant recipient: report of a case.

The prompt diagnosis and management of acute surgical conditions in immunocompromised solid organ transplant recipients are of critical importance. These conditions may or may not be related or to the transplanted allograft(s). This is a case report of a 41-year-old woman who received a simultaneous pancreas-kidney transplant. Nine years after the transplant, she developed acute appendicitis with a periappendiceal abscess and a fecalith, and she was treated with percutaneous drainage of the abscess and eventual semielective appendectomy. This is the first known report of acute appendicitis in a pancreas allograft recipient in the English literature.

In situ split liver transplantation for adult and pediatric recipients: an answer to organ shortage.

BACKGROUND: We report our initial experience with in situ split liver transplantation (SLT) for adult and pediatric patients. PATIENTS AND METHODS: From June 2003 to August 2005, 177 liver transplantations in 165 patients, 133 adults (81%) and 32 children (19%), were performed at our institution. Over this period, 45 liver transplantations (25%) were performed with an in situ split liver technique in 44 patients: 17 (39%) were adults and 27 (61%) children. All of the adult split liver recipients were transplanted with an extended right graft (ERG; segments I + IV-VIII), while pediatric recipients received in 23 cases a left lateral segment (LLS; segments II-III) and in 4 cases an ERG from a pediatric donor. The 45 split liver grafts (21 ERGs and 24 LLSs) were generated from 35 donors. In 10 cases we used both grafts generated with an in situ split procedure to transplant our patients, while in 25 cases the procurement procedure was performed in collaboration with other transplant centers. RESULTS: After a median follow-up of 9 months (range, 1-27 months), the overall patient survival rate was 88% for adult patients and 82% for pediatric patients. Graft survivals were 88% and 79%, respectively. Two adult patients (12%) died from sepsis in the early postoperative period. Five children (18%) died after their transplantations. Only one pediatric recipient (2%) of primary SLT underwent retransplantation. Vascular complications were absent in adult recipients, whereas 4 arterial (14%) and 4 venous (14%) complications developed in the pediatric population. The incidence of biliary complications was 23% in adult and 18% in pediatric recipients. CONCLUSIONS: The use of in situ SLT for adult and pediatric populations allowed us to expand the cadaveric donor pool, significantly eliminating pediatric waiting list mortality without penalizing the adult population.

Corticosteroid-free immunosuppression in pediatric liver transplantation: safety and efficacy after a short-term follow-up.

BACKGROUND: We report our results with the use of corticosteroid-free immunosuppression after pediatric liver transplantation, evaluating the efficiency and safety of this protocol in the early posttransplantation period. PATIENTS AND METHODS: From July 2003 to October 2005, 34 liver transplantations were performed in 32 pediatric patients (19 boys, 13 girls) at our institution. Recipient median age was 5 years (range, 0.2-14 years), and median body weight was 10 kg (range, 4-49 kg). Twenty-seven patients received a graft from in situ split liver transplantation, 5 a whole graft. Twenty-nine children (90%) received an immunosuppressive therapy based on methylprednisolone IV bolus at reperfusion (10 mg/kg) plus tacrolimus given at an initial dose of 0.08 mg/kg/d and then adjusted to obtain whole blood trough levels of 10 to 15 ng/mL during the first 3 months and 5 to 10 ng/mL after the 3rd month; basiliximab was given on postoperative days 0 and 4. Biopsy-proven acute rejection episodes were treated by methylprednisone IV boluses. RESULTS: After a median follow-up of 9 months (range, 1-27 months), the overall patient survival rate was 84% and graft survival rate was 79%. Three children (9%) died after their transplantations. Three (9%) experienced episodes of biopsy-proven acute rejection, always treated with IV steroid boluses. Mean RAI score was 4. One patient experienced PTLD that resolved with temporary reduction of immunosuppression. Cytomegalovirus infection rate was 14%. Sepsis occurred in 2 cases (6%). CONCLUSIONS: Initial results with a steroid-free immunosuppressive protocol are encouraging, with low rates of acute rejection and infectious complications as in steroid-based protocols.

A safe immunosuppressive protocol in adult-to-adult living related liver transplantation.

BACKGROUND: In this series of 32 adult-to-adult living related liver transplantations, we assessed the efficacy and safety of basiliximab in combination with a tacrolimus-based regimen. Basiliximab, a chimeric monoclonal antibody directed against the alpha chain of the interleukin-2 (IL-2) receptor (CD25), has been extensively evaluated as induction therapy for cadaveric liver transplant recipients. PATIENTS AND METHODS: Thirty-two adult-to-adult living related liver transplantations were performed in the last 3 years. All patients received two 20 mg doses of basiliximab (days 0 and 4 posttransplantation) followed by tacrolimus (0.15 mg/kg/d; 10-15 ng/mL target trough levels) and steroids (starting with 20 mg IV switched to PO as soon as the patient was able to eat and weaned within 1-2 months). The average follow-up was 395 days after transplantation. RESULTS: Of the patients, 93.75% remained rejection-free during follow-up with an actuarial rejection-free probability of 92.59% within 3 months. Two patients (6%) had one episode of biopsy-proven acute cellular rejection (ACR). Actuarial patient and graft survival rates at 3 years were 86.85% and 81.25%. One patient (3%) experienced one episode of sepsis. There was no evidence of cytomegalovirus infections or side effects related to the basiliximab. We found zero de novo malignancy but we observed two patients with metastatic spread of their primary malignancy during the follow-up. CONCLUSION: Basiliximab in association with tacrolimus and steroids is effective as prophylaxis of ACR among adult living related liver transplant recipients.

Basiliximab in a triple-drug regimen with tacrolimus and steroids in liver transplantation.

BACKGROUND: Basiliximab, a chimeric monoclonal antibody (mAb) directed against the alpha chain of the interleukin-2 (IL-2) receptor (CD25), has been extensively evaluated as induction therapy for kidney transplant recipients, more frequently in combination with a cyclosporine-based regimen. In this study, we assessed the efficacy and safety of basiliximab in combination with tacrolimus and steroids following liver transplantation. METHODS: One hundred fifty-two liver transplant recipients (141 cadaveric donors and 11 living donors [LRLT]) in the last 4 years were treated with 2 20-mg doses of basiliximab (days 0 and 4 posttransplantation) followed by tacrolimus (0.15 mg/kg/d; 10-15 ng/mL target trough levels) and steroids (500 mg intravenous [IV] bolus at the reperfusion followed by 20 mg orally daily and weaning off in 1 or 2 months). Follow-up ranged from 104 to 1630 days after transplantation (mean, 665 days; SD +/- 442.65; median, 509 days). RESULTS: Eighty-five percent of patients remained rejection-free during follow-up with an actuarial rejection-free probability of 78% within 3 months. Nineteen patients had 22 episodes of biopsy-proven acute cellular rejection (ACR). Actuarial patient and graft survival rates at 3 years were 86.7% and 75.8%, respectively. Twenty-seven patients (20.6%) experienced 1 episode of sepsis, requiring temporary reduction of immunosuppressive therapy. There was no evidence of CMV infections or side effects related to basiliximab. We observed 2 de novo malignancies, 1 recurrence from an ileal carcinoid tumor and 1 pulmonary recurrence of hepatocellular carcinoma (HCC) in 1 recipient of LRLT. CONCLUSIONS: Basiliximab in association with tacrolimus and steroids is effective prophylaxis of ACR in liver transplant recipients and does not increase the incidence of infections or adverse effects.

Acceptance of marginal liver donors increases the volume of liver transplant: early results of a single-center experience.

To expand the donor pool, clinicians are continually modifying criteria to accept organs, particularly those in the so-called expanded or marginal donor pool. The concept and definition of a marginal donors continues to evolve. The impact of their use is the result of a combination of donor and recipient factors. Most clinicians accept steatosis above 30%, donor age over 60 years, prolonged ischemia time, prolonged intensive care unit stay, hypernatremia, previous cardiac arrest, prolonged episodes of hypotension, large use of inotrope drugs, and elevated liver function tests as criteria for designation of a marginal organ. In June 2003, we started to use marginal donors each year tripling the number of transplants per year at our center.

Transjugular intrahepatic portosystemic shunt in adult liver recipient with delayed graft function.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) has become an effective treatment for the complications of portal hypertension. We assessed the feasibility and outcome of TIPS in liver transplant recipients who developed delayed graft function (DGF) with portal hypertension. METHODS: From June 2003 to June 2004, 80 cadaveric orthotopic liver transplantation (OLTx) have been performed at our institution. Five patients (6.25%) developed DGF with hyperbilirubinemia and ascites with severe portal hypertension and were treated with TIPS placement (in the 6-month time period from the transplantation). RESULTS: There were no complications related to the procedure. No episodes of encephalopathy were seen. Four patients had better control of the ascites. In one case, we observed complete recovery of the transplanted liver with normalization of the liver function test. Three patients underwent retransplantation (within 7 days from the TIPS), whereas 1 is still on the list 6 months after TIPS placement with recurrent episodes of ascites. CONCLUSIONS: In our preliminary series, TIPS reduced dramatically the portosystemic gradient and improved clinical conditions. The results were negatively affected by the fact that the transplanted liver did not recover its function.

Pediatric liver transplantation: preliminary results at Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione.

Between July 2003 and November 2004 14 pediatric liver transplantations (LTx) have been performed in 12 children using cadaveric donors. The primary diseases were as follows biliary atresia in 9 cases, whereas the other 3 children were affected by cystic fibrosis, Langherans cells histiocytosis, and hepatoblastoma, respectively. Median patient waiting time was 103 days (range, 2-158); no patient died while on the waiting list. Patients who underwent transplantation included 7 boys and 5 girls, ranging in age from 6 months to 14 years (median age, 5 years). Recipient median weight was 16 kg (range, 6-38). Donor median age was 19 years (range, 3-47), whereas donor median weight was 74 kg (range, 15-90). All children who underwent primary LTx were United Network for Organ Sharing (UNOS) status 2B. Of the 12 transplanted patients, 9 received a left lateral segment (LLS) from an in situ split liver, whereas 3 received a whole graft. Two children developed an episode of acute cellular rejection on the seventh postoperative day, which was treated successfully with a course of intravenous steroids for 3 days. After a median follow-up of 245 days, 10 children are alive but 2 children died due to primary nonfunction (PNF) on the second postoperative day and septic shock on the fifth postoperative day after retransplantation for acute hepatic artery thrombosis, respectively. One child who underwent retransplantation for hepatic artery thrombosis on the 31st postoperative day after primary LTx is currently alive. Evaluation of our initial data suggests that the split liver technique has the potential to meet the needs of pediatric LTx allowing grafting early in the course of the original disease and reducing waiting time.

Multivisceral transplantation for megacystis microcolon intestinal hypoperistalsis syndrome.

BACKGROUND: Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) is a rare autosomal recessive disorder causing a functional neonatal bowel obstruction. Its etiopathogenesis is not fully understood. The prognosis is poor in the majority of cases; most patients die before the age of 6 months. In this report, we describe our experience with three patients with MMIHS in whom multivisceral transplantation was performed. METHODS: Three patients with MMIHS underwent multivisceral transplantation. All patients were females with a history of long-term total parenteral nutrition (TPN) with TPN-related cholestatic liver disease. RESULTS: Patient 1 died 17 months after transplantation because of aspiration after revision of her feeding gastrostomy. At the time of death, the graft was functioning and the patient was completely off TPN. Patient 2 is alive 17 months after transplant. She is a fully functional, active 2-year-old and has also recently begun oral feeding after intensive rehabilitation. Patient 3 died on day 44 of multisystem failure. CONCLUSIONS: This is the first report in the literature of multivisceral transplantation for MMIHS. Although one of the three patients died 44 days after surgery from multiorgan system failure, the other two patients had long-term survival after transplant and both grew well on enteral feeding alone. One patient died 17 months from a non-transplant-related complication, while the other is living at home off of TPN, with almost complete dietary rehabilitation 17 months after transplant. Our case reports suggest that multivisceral transplantation is a valuable therapeutic option for patients affected by MMIHS with TPN-induced liver failure.

Anoplasty for stenosis and other anorectal defects.

Anorectal strictures have been a serious problem for many years. The aim of this study was to determine the experience with anoplasty in our institution. A group of 17 patients, (six males and 11 females) were evaluated between May 1989 and February 1994, with an age range of 20 to 78 (mean 61 years). The main symptoms were difficulty to pass stool or constipation in 10 patients (58.8 per cent), rectal bleeding in eight patients (47 per cent), and anorectal pain in seven patients (41.1 per cent). The patients underwent clinical examination and the findings were anal stenosis in 13 patients (76.4 per cent), perianal fistula in two patients (11.8 per cent), key hole deformity in one patient (5.9 per cent), and unhealed chronic fissure in one patient (5.9 per cent). The technical procedure was S plasty in six patients (35.2 per cent) and advancement flaps in 11 (64.8 per cent). The follow-up period was between 3 and 59 (mean 18) months. In 16 patients, surgery had good results with improvement of their preoperative symptoms and preservation of continence. There was one septic complication; mean hospital stay was 3 days. In conclusion, anoplasty appears to be a safe and successful alternative for the treatment of anal stenosis.

The role and timing of surgery in the treatment of pseudomembranous colitis. A case complicated by toxic megacolon.

The authors describe a particularly serious case of pseudomembranous colitis due to Clostridium difficile that was complicated by toxic megacolon. It was resolved by surgical intervention, and the reasons why subtotal colectomy is preferable to simple ileostomy are discussed.

[Pylorus-preserving pancreatoduodenectomy allows a better maintenance of glucose homeostasis]. / La duodenocefalopancreatectomia con conservazione del piloro assicura il mantenimento di una fisiologica omeostasi glicidica.

BACKGROUND: Pancreatic diseases and pancreatic surgery usually cause a derangement of glucose metabolism ranging from a change in glucose tolerance test to insulin-dependent diabetes. The authors assess the changes in glycemia both in basal condition and after a challenge test in a group of patients who underwent Pylorus Preserving Pancreatoduodenectomy (PPPD) according to an original technique of reconstruction with two separate bowel loops. MATERIALS AND METHODS: Ten patients who underwent PPPD either for chronic pancreatitis or ampullar carcinoma were enrolled in this study. Pre- and postoperative assessment of pancreatic endocrine function was carried out in all the patients. The evaluation included: 1) oral glucose tolerance test (OGTT), 2) intravenous glucose tolerance test (IVGTT) and 3) glucagon challenge test. RESULTS: Plasma glucose level in basal condition, after oral glucose tolerance test, intravenous glucose tolerance test and glucagone challenge test, shows that insulin secretion and/or its effectiveness is not impaired after PPPD. Two patients with preoperative insulin-dependent diabetes needed a lower dose of insulin in the postoperative period. One patient responded abnormally to OGTT both in the preoperative and postoperative periods. Seven patients maintained normal glucose homeostasis in the postoperative period. DISCUSSION: PPPD allows a normal control of glucose metabolism. Better digestive and endocrine function noted in our patients in the postoperative period is due to the integrity of the stomach and the reconstruction technique with two bowel loops used to drain biliary and pancreatic secretion separately.

[Juvenile polyposis coli associated with hereditary spherocytosis]. / Associazione morbosa tra poliposi giovanile del colon e sferocitosi ereditaria.

The first case of colorectal juvenile polyposis associated with hereditary spherocytosis is reported. Symptoms, diagnosis and therapy of juvenile polyposis are described along with the associated syndromes reported in the literature. The scientific and clinical consequences of this association are discussed.

[The surgical treatment of hepatic echinococcosis and of its biliary complications]. / Il trattamento chirurgico dell'echinococcosi epatica e delle sue complicanze biliari.

The authors report the experience of 47 patients submitted to surgery for hepatic hydatidosis. Results from different therapeutic procedures are then compared. Finally, possible biliary complications of the hepatic echinococcosis and their surgical treatment are discussed.

[A case of extrarenal angiomyolipoma with intestinal localization]. / Un caso di angiomiolipoma extrarenale a localizzazione intestinale.

The Authors present a case of extrarenal angiomyolipoma. The tumor arose from the pericolonic fat of the sigmoid colon and, increasing in size, caused intestinal obstruction by extrinsic lesion. Extrarenal angiomyolipoma is extremely rare and to our knowledge this is the first reported case arising from the colonic wall.

[Digestive hemorrhage caused by rupture of an aneurysm of the superior pancreaticoduodenal artery]. / Emorragia digestiva causata dalla rottura di un aneurisma dell'arteria pancreatico-duodenale superiore.

Aneurysms of the pancreaticoduodenal artery are rare. Nonoperative management of an iatrogenic superior pancreaticoduodenal artery aneurysm which ruptured into the duodenal stump of a Billroth II partial gastrectomy, is described here. Based on a literature review, both aetiology and site of rupture of this observation are very uncommon. Super-selective angiography was used for diagnosis and embolisation for definitive treatment.

[Long-term results of surgical treatment of early cancers of the stomach]. / Résultats à long terme du traitement chirurgical des cancers précoces de l'estomac.

The postoperative course of 172 patients with early gastric cancer operated between 1974 and 1987 was reviewed with a median follow-up of 7 years. The survival probability at the end of 1989 was 0.916 (excluding operative mortality and other causes of death) or 0.876 when the operative mortality was included. Univariate analysis showed a significant survival difference according to the presence or absence of submucosal invasion (p = 0.02, Log-Rank test) and lymph node invasion (p = 0.04, age greater than or less than 50 years (p = 0.03) and according to the type of resection performed (total gastrectomy with gastric and perigastric lymph node dissection or subtotal gastrectomy with incomplete lymph node dissection (p = 0.05). Eleven patients died from cancer recurrence, one is still alive with a recurrence of the gastric stump. The other deaths were due to cancers of other organs (6), cardiovascular disease (2), pneumonia (3), septicaemia (1) and a car accident. Although the prognosis of early gastric cancer is relatively favourable in European countries, patients must be carefully followed for a long period because of recurrences and the high incidence of cancers in other organs.

[Traumatic diaphragmatic hernia]. / Ernie diaframmatiche traumatiche.

The authors analyse a series of 10 patients urgently treated for traumatic disruption of the diaphragm. Main aetiopathogenetic, pathophysiological, diagnostic and surgical aspects of the condition are discussed.

[Perioperative pain and stress: a comparison between video laparoscopic cholecystectomy and "open" cholecystectomy]. / Dolore e stress perioperatori: confronto tra videolaparocolecistectomia e colecistectomia "open".

Pain and endocrine-metabolic response to surgical stress, during surgery and in the early postoperative period, was compared in two groups of patients affected by gallstones and randomly assigned to Laparoscopic Cholecystectomy or Open Cholecystectomy. Pain was assessed by the VAS method also taking into account the need of analgesic administration in the postoperative period. The so called "stress hormones" (Prolactin (PRL), Cortisol (CORT), Human Growth Hormone (HGH)) and glycaemia were monitored during surgery and in the first postoperative 24 hours. The minimal invasive technique of laparoscopic cholecystectomy accounted for a very limited analgesic administration. In the intraoperative period laparoscopic cholecystectomy plasma hormone levels overlapped the open cholecystectomy ones, while in the postoperative period a constant increase in PRL and CORT levels was registered in the open cholecystectomy group demonstrating a prolonged stressful condition. The end results of this study show that laparoscopic cholecystectomy has major advantages than open cholecystectomy in the treatment of gallstones as far as pain and endocrine-metabolic response are concerned.