Alternative technique to cannulate the descending aorta for abdominal organ procurement in a hemodynamically unstable patient.

During organ procurement, maintaining adequate organ perfusion is crucial. Hemodynamic instability may compromise organ viability and demand quick intervention, sometimes rapid, early cannulation of vessels, so that organs may be salvaged. In this case report of an unstable donor with large retroperitoneal hematoma, a surgical approach is presented that has previously not been described. The technique facilitated hemodynamic stability while allowing rapid cannulation of the retrocardiac descending aorta.

Choice of surgical technique influences perioperative outcomes in liver transplantation.

OBJECTIVE: To examine how the choice of surgical technique influenced perioperative outcomes in liver transplantation. SUMMARY BACKGROUND DATA: The standard technique of orthotopic liver transplantation with venovenous bypass (VVB) is commonly used to facilitate hemodynamic stability. However, this traditional procedure is associated with unique complications that can be avoided by using the technique of liver resection without caval excision (the piggyback technique). METHODS: A prospective comparison of the two procedures was conducted in 90 patients (34 piggyback and 56 with VVB) during a 2.5-year period. Although both groups had similar donor and recipient demographic characteristics, posttransplant outcomes were significantly better for the patients undergoing the piggyback technique. The effect of surgical technique was examined using a stepwise approach that considered its impact on two levels of perioperative and postoperative events. RESULTS: The analysis of the first level of perioperative events found that the piggyback procedure resulted in a 50% decrease in the duration of the anhepatic phase. The analysis of the second level of perioperative events found a significant relation between the anhepatic phase and the duration of surgery and between the anhepatic phase and the need for blood replacement. The analysis of the first level of postoperative events found that the intensive care unit stay was significantly related to both the duration of surgery and the need for blood replacement. The intensive care unit stay was in turn related to the second level of postoperative events, namely the length of hospital stay. Finally, total charges were directly related to length of hospital stay. The overall 1-year actuarial patient and graft survival rates were 94% in the piggyback and 96% in the VVB groups, respectively. CONCLUSIONS: These data demonstrate that surgical choices in complex procedures such as orthotopic liver transplantation trigger a chain of events that can significantly affect resource utilization. In the current healthcare climate, examination of the sequence of events that follow a specific treatment may provide a more complete framework for choosing between treatment alternatives.

Small intestinal function following syngeneic transplantation in the rat.

Improvements in immunosuppression have led to the use of small intestinal transplantation clinically. Previous studies have suggested that the transplantation process and immunosuppression with cyclosporin independently affect small intestinal function. This study describes the effects of syngeneic small intestinal transplantation and cyclosporine in rats on intestinal permeability and nutrient transport. Orthotopic transplantation of the small intestine was performed between syngeneic (Lewis) rats. Transplanted animals received chronic treatment with cyclosporine (10 mg/kg) or vehicle on alternate days. Sham operated controls received treatment with vehicle. Animals were followed for 60 days monitoring weight gain, feed intake, intestinal permeability, in vivo absorption of dietary fat and carbohydrate, and at sacrifice in vitro transmural flux of 3-O-methyl-D-glucose. Weight gain, feed intake, and absorption of fat and carbohydrate from the diet were not altered by intestinal transplantation alone; transplantation plus cyclosporine treatment caused a slight reduction in dietary fat absorption. Both the transplant and transplant plus cyclosporine groups demonstrated increased permeability to 51Cr-EDTA and mannitol but not lactulose. Jejunal and ileal 3-O-methyl-D-glucose net transmural flux was decreased in both transplant and transplant plus cyclosporin groups. Intestinal transplantation and cyclosporin treatment reduce mucosal glucose transport and increase intestinal permeability. These altered transport characteristics could affect dietary choices and the selection of immunosuppressive drugs during clinical transplantation efforts, however, the overall impact on animal well-being was minimal, and support the continued study of intestinal transplantation for clinical application.

The impact of surgical technique on the development of graft versus host disease in a rat small intestinal transplant model.

The small intestine and its mesentery contain a large amount of lymphoid tissue that can mediate graft-versus-host disease (GVHD) in small intestinal transplant recipients. To assess the impact of surgical technique and the retention of the recipient's small intestine on GVHD intensity, 12 adult Lewis rats received heterotopic small bowel transplants and 12 received orthotopic small bowel transplants from Brown Norway donors. Twelve Lewis to Lewis heterotopic small-bowel-transplanted animals served as the control group. All recipients were given cyclosporine (10 mg/kg/alternate days) subcutaneously. The parameters followed were: weight gain and feed intake; clinical signs of GVHD; relative spleen weight; popliteal lymph node enlargement assay; and histological evaluation of spleen, liver, skin, native intestine, and transplanted intestine. According to the clinical scoring system, heterotopically transplanted animals were found to have a more severe GVHD than the orthotopic group. There were statistically significant differences between the relative spleen weights of the heterotopic transplant group and the control group (P = 0.001, 0.004, and 0.007 on days 7, 14, and 21, respectively) and between the heterotopic and orthotopic groups at 7 days (P = 0.037). Lymph node enlargement assays were statistically different between heterotopic and orthotopic groups (P = 0.019, 0.020, and 0.007 on days 7, 14, and 21, respectively). Histological evaluation of skin biopsy specimens also demonstrated that GVHD was indeed more severe in the heterotopic transplanted group when compared with orthotopically transplanted animals. These findings confirm that retention of the native small intestine in the heterotopic intestinal transplant model significantly increases the severity of GVHD following transplantation.

Cadaver pancreas recovery technique. Impact on islet recovery and in vitro function.

Previous studies in rodent and canine animal models have suggested a detrimental impact on islet recovery and function when pancreas excision is preceded by in situ vascular flushing with cold preservation solutions. We studied the efficacy of islet isolation from 19 consecutive cadaver pancreases procured alternately by initial pancreatectomy before in situ flush (group 1, our standard procurement technique, n = 9) or pancreas removal following in situ vascular flushing with cold University of Wisconsin solution (group 2, n = 10). Once procured, pancreases were weighed, the main pancreatic duct was cannulated, and 150 ml of collagenase solution was injected. The pancreases were transported to the isolation laboratory and processed within 2 hr. Islets were counted and sized after dithizone staining, and the islet equivalents were calculated. Aliquots of isolated islets were cryopreserved using established techniques. Islet function of both freshly isolated and frozen-thawed islets was assessed using a glucose-stimulated perifusion system. Significantly more pancreas was harvested after University of Wisconsin flush (90.6 +/- 6.9 g for group 1 versus 66.7 +/- 4 for group 2, P < 0.05). The quantity of islets per gram of processed pancreas released during enzymatic digestion from each of the experimental groups did not differ significantly (4.5 +/- 0.6 x 10(3) islet equivalents per gram for primary pancreatectomy versus 4.0 +/- 0.4 x 10(3) University of Wisconsin flush). Similarly, following Ficoll purification, the overall yields of islets did not differ significantly. Total islet yield in the primary pancreatectomy group was 181 +/- 25 x 10(3) islet equivalents (2.7 +/- 0.3 x 10(3) IE/g) versus 217 +/- 41 x 10(3) for the University of Wisconsin flush group (2.9 +/- 0.8 x 10(3) islet equivalents/g; P not significant). No differences were observed in in vitro viability. Perifusion stimulation indexes (peak/basal insulin release) were 5.9 +/- 1.3 for group 1 and 7.1 +/- 1.5 for group 2. These results conflict with published results in animal models and indicate that large numbers of viable islets can be recovered from cadaver pancreas utilizing either procurement technique. The decreased operating time, simplicity, and safety favor the use of total pancreatectomy after limited in situ vascular flushing as the method of choice for pancreas procurement for subsequent islet isolation.