Long term outcomes of abdominal wall reconstruction using open component separation and biologic mesh in the liver, kidney, and small bowel transplant population.

PURPOSE: The aim of this study is to critically examine the multidisciplinary approach to abdominal wall reconstruction (AWR) in the solid organ transplant (SOT) population at our institution, MedStar Georgetown University Hospital, using a modified component separation technique (CST). METHODS: A retrospective review of AWR utilizing modified open CST with biologic mesh in SOT patients was performed from January 2010 to June 2018. Patient demographics, comorbidities, operative details, complications, and outcomes were recorded. Descriptive statistics, logistic and linear regression analyses were performed to appraise outcomes. RESULTS: Thirty-five patients were included; mean age was 53 years. Patient demographics and comorbidities were: 82.9% male, 45.7% history of tobacco use, and 28.6% diabetes. Fifty-one percent had undergone prior hernia repair. Transplant types were: kidney (9), liver (16), liver/kidney (1), small bowel (7), multivisceral (2). All were on an immunosuppressive regimen at time of surgery; 22.9% included steroids. Average defect size was 361 cm2. Additional soft tissue procedures were performed in 65.7% (n = 23) of patients. Median time to healing was 29.0 days. Complication rate was 31.4% (n = 11); six patients required reoperation within 90 days. Recurrence rate was 5.7% (n = 2) at mean of follow up of 3.0 years. Additional soft tissue procedures were statistically significant for healing time (p = 0.037). Steroid use was statistically significant for reoperation within 90 days (OR = 12.500; 95% CI 1.694-92.250); however, steroid use was not significant after correction for confounders. CONCLUSION: Modified open CST with biologic mesh is a safe, efficacious approach to complex AWR in the SOT population with recurrence rates comparable to the general population.

Developing trends in the intestinal transplant waitlist.

The United Network for Organ Sharing database was examined for trends in the intestinal transplant (ITx) waitlist from 1993 to 2012, dividing into listings for isolated ITx versus liver-intestine transplant (L-ITx). Registrants added to the waitlist increased from 59/year in 1993 to 317/year in 2006, then declined to 124/year in 2012; Spline modeling showed a significant change in the trend in 2006, p < 0.001. The largest group of registrants, <1 year of age, determined the trend for the entire population; other pediatric age groups remained stable, adult registrants increased until 2012. The largest proportion of new registrants were for L-ITx, compared to isolated ITx; the change in the trend in 2006 for L-ITx was highly significant, p < 0.001, but not isolated ITx, p = 0.270. New registrants for L-ITx, <1 year of age, had the greatest increase and decrease. New registrants for isolated ITx remained constant in all pediatric age groups. Waitlist mortality increased to a peak around 2002, highest for L-ITx, in patients <1 year of age and adults. Deaths among all pediatric age groups awaiting L-ITx have decreased; adult L-ITx deaths have dropped less dramatically. Improved care of infants with intestinal failure has led to reduced referrals for L-ITx.

Successful isolated intestinal transplantation in sensitized recipients with the use of virtual crossmatching.

We evaluated virtual crossmatching (VXM) for organ allocation and immunologic risk reduction in sensitized isolated intestinal transplantation recipients. All isolated intestine transplants performed at our institution from 2008 to 2011 were included in this study. Allograft allocation in sensitized recipients was based on the results of a VXM, in which the donor-specific antibody (DSA) was prospectively evaluated with the use of single-antigen assays. A total of 42 isolated intestine transplants (13 pediatric and 29 adult) were performed during this time period, with a median follow-up of 20 months (6-40 months). A sensitized (PRA ≥ 20%) group (n = 15) was compared to a control (PRA < 20%) group (n = 27) to evaluate the efficacy of VXM. With the use of VXM, 80% (12/15) of the sensitized patients were transplanted with a negative or weakly positive flow-cytometry crossmatch and 86.7% (13/15) with zero or only low-titer (≤ 1:16) DSA. Outcomes were comparable between sensitized and control recipients, including 1-year freedom from rejection (53.3% and 66.7% respectively, p = 0.367), 1-year patient survival (73.3% and 88.9% respectively, p = 0.197) and 1-year graft survival (66.7% and 85.2% respectively, p = 0.167). In conclusion, a VXM strategy to optimize organ allocation enables sensitized patients to successfully undergo isolated intestinal transplantation with acceptable short-term outcomes.

Room temperature pulsatile perfusion of renal allografts with Lifor compared with hypothermic machine pump solution.

This pilot study compared the use of the Lifor Organ Preservation Medium (RTLF) at room temperature with hypothermic Belzer machine preservation solution (CMPS) and room in vitro temperature Belzer machine preservation solution (RTMPS) in a porcine model of uncontrolled donation after cardiac death (DCD). In this study, 5 porcine kidneys for each perfusate group were recovered under a DCD protocol. The kidneys were recovered, flushed, and placed onto a renal preservation system following standard perfusion procedures. The average flow rate for CMPS was 36.2 +/- 7.2549 mL/min, RTMPS was 90.2 +/- 9.7159 mL/min, and RTLF was 103.1 +/- 5.1108 mL/min. The average intrarenal resistance for CMPS was 1.33 +/- 0.1709 mm Hg/mL per minute, RTMPS was 0.84 +/- 0.3586 and RTLF was 0.39 +/- 0.04. All perfusion parameters were statistically significant (P < .05) at all time points for the CMPS when compared with both RTMPS and RTLF. All perfusion parameters for RTMPS and RTLF were equivalent for the first 12 hours; thereafter, RTLF became significantly better than RTMPS at 18 and 24 hours. It appears that both RTMPS and RTLF have equivalent perfusion characteristic for the initial 12 hours of perfusion, but LF continues to maintain a low resistance and high flow up to 24 hours. The results of this pilot study indicate that RTLF may represent a better alternative to pulsatile perfusion with CMPS and requires validation in an in vivo large animal transplant model.

Evaluation of lyophilized platelets as an infusible hemostatic agent in experimental non-compressible hemorrhage in swine.

INTRODUCTION: Human lyophilized platelets hold promise as a novel hemostatic infusion agent for the control of traumatic hemorrhage. Rehydrated, lyophilized platelets (Stasix) were investigated as an infusible hemostatic agent in experimental non-compressible hemorrhage, using a porcine liver injury model. METHODS: Yorkshire swine underwent a grade III liver injury and uncontrolled bleeding. After 15 min, animals were infused with Stasix (n = 10) or normal saline vehicle (n = 10). At 2 h, the liver was repaired, and the animals were monitored for another4 h. Resuscitation, including blood transfusion, was administered during the hospital phase. Laboratory data, including arterial blood gas, complete blood count, thromboelastography (TEG), and coagulation parameters, were collected. All animals underwent necropsy with complete histopathologic examination. RESULTS: Overall survival in the Stasix group [8/10 (80%)] was significantly higher than in the control group [2/10 (20%)] (P = 0.023). Mean total blood loss index (g kg(-1)) was lower in Stasix-treated animals (22.2 +/- 3.5) than in control animals (34.7 +/- 3.4) (P = 0.019). Hemodynamic parameters were improved in the Stasix group, and a trend towards higher hemoglobin and lower lactate was observed. Coagulation and TEG parameters were not different between the groups. One surviving animal in the Stasix group had evidence of thrombi on necropsy. CONCLUSIONS: This is the first reported study to evaluate rehydrated, lyophilized platelets as an infusible hemostatic agent for non-compressible hemorrhage. Stasix improved survival and reduced blood loss in a liver injury porcine model. However, evidence of thrombotic complications warrants further investigation prior to human use in the setting of traumatic hemorrhage.

Surgical and ablative treatment for metastatic adenocarcinoma to the liver from unknown primary tumor.

Metastatic adenocarcinoma to the liver from an unknown primary tumor (UPT) carries a poor prognosis, with a median survival of 5 months. Chemotherapy has not significantly improved outcome, and effective treatment is yet to be established in these patients. We examined our experience with surgical resection and ablation of this disease to determine clinico-pathologic characteristics and treatment outcomes. We undertook a retrospective chart review of 157 patients who were treated for metastatic disease to the liver with resection or radiofrequency ablation (RFA) between 1999 and 2003. Seven patients were identified with unknown primary malignancy. Evaluation of the seven patients included complete history and physical examination, complete blood count, routine chemistries, stool Hemoccult test, chest radiograph, and computed tomography (CT) of the abdomen and pelvis. In addition, the three female patients had breast examinations and mammography. Adenocarcinoma histology was determined via CT-guided liver biopsy in all patients. Other diagnostic tests, including whole-body positron emission tomography to the measurement of various serum tumor markers, were performed in the majority of the patients. There were nine total lesions treated; six with RFA and three with hepatic resection. Median diameter of the lesions was 5.4 cm (range, 1.3-15). Two patients were treated with adjuvant and three patients with neoadjuvant and adjuvant chemotherapy. Extrahepatic sites of metastases, adrenal and skeletal, were discovered in 1 patient prior to treatment. With a median follow-up of 9 months, 1 patient is currently alive with no evidence of disease, 4 patients are alive with disease, and 2 patients died of disease. Median disease-free-interval following treatment was 6.5 months. To date, optimal treatment for metastatic adenocarcinoma to the liver UPT remains unclear. Localized treatment involving RFA or hepatic resection may be a promising addition to chemotherapy in the management of this disease.

The role of the community psychiatric nurse.

The community psychiatric nurse is an essential element in a comprehensive mental health service. At present each nurse is expected to be a trained counsellor and psychotherapist, a skilled behaviour therapist and an expert assessor of clinical status. This superhuman role is unrealistic; a more appropriate one is outlined.

Excretion patterns of glycosaminoglycans and glycoproteins in normal human urine.

Glycosaminoglycans and glycoproteins in the urine of 100 healthy, active, human subjects were examined by cellulose acetate electrophoresis and salt gradient, ion-exchange, column chromatography. The cetylpyridinium chloride (CPC) turbidity and uronic acid:creatinine ratio was also studied. Fractions were identified by electrophoretic mobility, staining reactions, susceptibility to enzyme digestion, identification of amino- and neutral sugars, hexosamine, uronic acid, and sulphate assays, and optical rotation. The CPC turbidity is relatively high in childhood, falling to lower levels in adults, but rising again to relatively high levels in old age. The uronic acid: creatinine ratio is high in children, falling to a low level in adult life, and rising only slightly in old age. Three major electrophoretic fractions, corresponding with glycoprotein, heparan sulphates, and chondroitin sulphates, were identified in every urine sample. Hyaluronic acid was identified in some samples. A small amount of keratan sulphate was present in the ;heparan sulphate' fraction. Chondroitin sulphate excretion is high in children. Adults excrete relatively less chondroitin sulphate and more heparan sulphate. In old age, the proportion of glycoprotein increases. The excretion pattern in the first few days of life resembles that of the adult. It is stressed that extreme caution must be exercised in interpreting the urinary glycosaminoglycan pattern of a child.