Use of gracilis muscle as a "walking" flap for repair of a rectovaginal fistula.

Rectovaginal fistula is a rare but debilitating complication of a variety of pelvic operations. Management remains challenging with high incidence of failure. The majority of patients eventually require surgical intervention. Several surgical procedures have been described including local repair, muscle transposition, or laparotomy. Among the muscles used for rectovaginal fistula repair, the gracilis muscle interposition flap is an excellent option. However, in a small percentage of cases it fails, and alternative techniques should be entertained. We describe the case of a 50-year-old female who underwent stapled hemorrhoidopexy that was complicated by a 30 mm rectovaginal fistula, and required fecal diversion. Four months later, gracilis muscle interposition flap was performed but failed. The right gracilis flap was then re-used successfully as a "walking" flap. At three months the patient underwent closure of the temporary loop ileostomy, and continues to do well with no evidence of rectovaginal fistula recurrence one year later. To our knowledge, this is the first report of the use of a gracilis muscle as a "walking" flap for repair of a rectovaginal fistula, and should be considered as an alternative appropriate treatment for persistent rectovaginal fistulas after failure of initial gracilis muscle interposition flap.

Heart retransplantation in children without the use of blood product.

This article reports a case of a cardiac retransplantation without the use of blood products, in a 6 year old, with severe dilated cardiomyopathy after chronic graft rejection and refractory to clinical treatment. To avoid a blood transfusion in this surgery a multidisciplinary approach was planned, which involved the use of preoperative erythropoietin, acute normovolemic hemodilution and intraoperative cell savage with autologous blood recovery system, as well as a meticulous hemostasis and reduced postoperative phlebotomy.

Retransplante cardíaco em criança sem o uso de hemoderivados / Heart retransplantation in children without the use of blood product

Este artigo relata um caso de retransplante cardíaco sem o uso de hemoderivados, em uma criança de 6 anos, com miocardiopatia dilatada grave, após rejeição crônica do enxerto e refratária ao tratamento clínico. Para evitar transfusão sanguínea nessa cirurgia, foi realizado planejamento multidisciplinar, que envolveu o uso de eritropoietina no pré-operatório, hemodiluição normovolêmica aguda e recuperação de sangue autólogo no intraoperatório (cell saver), bem como hemostasia meticulosa e redução de flebotomias no pós-operatório.

This article reports a case of a cardiac retransplantation without the use of blood products, in a 6 year old, with severe dilated cardiomyopathy after chronic graft rejection and refractory to clinical treatment. To avoid a blood transfusion in this surgery a multidisciplinary approach was planned, which involved the use of preoperative erythropoietin, acute normovolemic hemodilution and intraoperative cell savage with autologous blood recovery system, as well as a meticulous hemostasis and reduced postoperative phlebotomy.

Chronic rejection in a small bowel transplant with successful revision of the allograft by segmental resection: case report.

An 8-year-old girl was admitted for severe electrolyte imbalance and for hyponatremic seizure. In July 2005, at 3 years of age, she underwent isolated small-bowel transplantation of 100 cm ileum from her father. Her own bowel was only 50 cm of proximal jejunum which had been directly connected to the anus due to extended total aganglionosis. The graft was placed into the middle of her remaining bowel, using the splenic artery and vein as feeding vessels with saving of the spleen. Daclizumab induction and tacrolimus monotherapy were applied for immunosuppression. Two acute cellular rejection episodes, E on day 10 and 4 years after transplantation, were successfully treated with OKT-3 and recombinant antithymocyte globulin, respectively. However, because of intermittent bowel dysfunction, she was hospitalized several times for hydration and metabolic care. On admission, her abdomen was moderately distended, and a simple abdominal film showed a fixed dilated loop. Colonoscopy could not pass the narrowed lumen, with stiffness at the anastomosis between the graft and the distal bowel. Endoscopic biopsy at the entrance to the stricture showed a nonspecific inflammatory reaction with fibrosis. Similar findings on a gastrograffin enema suggested chronic rejection (CR). On laparotomy, an irregularly narrowed fibrotic loop was noticed at the distal part of the graft, proximal to the anastomosis. We performed a 20-cm segmental resection with an end-to-end anastomosis. Histopathologic findings showed CR with fibrosis and hyalinization of the entire bowel wall and vessel walls with mild cellular infiltrations. She recovered in 10 days. The graft may have been saved, but intermittent requirement of hydration over the following months suggested progressive graft dysfunction. A case of segmental involvement of CR with subsequent successful graft salvage by partial resection is rare in the literature.

Regression of vascular calcification in a patient treated with cinacalcet: a case report.

The purpose of this case report is to describe the regression of vascular calcifications (VC) in a patient with secondary hyperparathyroidism (SHPT) after having added cinacalcet to her treatment. We present the clinical case of a 48-year-old woman with chronic renal failure secondary to tubulointerstitial disease. She was being treated with long-term haemodialysis (HD) and underwent two kidney transplants with transplantectomies. The patient presented with severe SHPT caused by parathyroid gland hypertrophy. The radiology test showed signs of VC in the radial and interdigital arteries, and VC in a linear arrangement were observed in both breasts on the mammography. Cinacalcet was added to her treatment with vitamin D derivatives and phosphate-binding agents, which resulted in a good control of mineral metabolism. The radiology test showed that the calcification in the interdigital artery had disappeared and that the bone appeared to be more structured. The mammography also showed regression of the VC. To conclude, cinacalcet may have potential for regression of VC in patients with SHPT.

Deoxyspergualin delays xenograft rejection in the guinea pig-to-C6-deficient rat heart transplantation model.

This study aimed to investigate the effects of 15-deoxyspergualin (DSG), tacrolimus (FK 506) and cyclosporin A (CyA), alone or in combination, on delayed xenograft rejection (DXR). We used the guinea-pig-to-C6-deficient (C6-)-PVG-rat heart transplantation model, since in this strain combination, hyperacute rejection is avoided. In C6- control rats, the guinea pig xenografts survived for 39.2 +/- 6.3 h (mean +/- SD). Splenectomy alone resulted in a xenograft survival of 71.8 +/- 7.8 h, but the addition of CyA or FK 506 did not further improve graft survival (73.6 +/- 3.0 h and 72.0 +/- 17.6 h, respectively). In contrast, DSG treatment increased graft survival to a mean of 99.8 +/- 9.2 h. When CyA or FK 506 was combined with DSG, no additional effects were observed (105 +/- 24.3 h and 95.1 +/- 5.6 h, respectively). DSG alone or in combination with FK 506 or CyA resulted in a significant reduction in the serum IgM levels and reduced the deposits of IgM and IgG in rejected grafts. However, all xenografts were still heavily infiltrated by ED1 + macrophages, regardless of the treatment used. Thus, DSG treatment resulted in moderate prolongation of xenograft survival in C6- rats. The effect seems to be related to suppression of xenoreactive antibody production. To prolong xenograft survival further, strategies that inhibit macrophage infiltration seem required.