Could Sentinel Skin Transplants Have Some Utility in Solid Organ Transplantation?

Accurate diagnosis of allograft rejection can be hazardous and challenging. A strategy that has emerged from experience with vascularized composite allografts (VCAs) is the use of sentinel skin transplants (SSTs)-portions of donor skin transplanted synchronously to an allograft. Work in nonhuman animal models and experience with VCAs suggest concordance between rejection occurring in the primary allograft and the SST, and that appearance of rejection in the SST may precede rejection in the primary allograft, permitting early therapeutic intervention that may improve outcomes with lower rates of chronic rejection. The encouraging findings reported in VCA transplantation raise the possibility that SST may also be useful in solid organ transplantation. Some evidence is provided by experience with abdominal wall transplantation in some intestinal and multivisceral transplant recipients. Results from those reports raise the possibility that rejection may manifest in the skin component before emergence in the intestinal allograft, providing a "lead time" during which treatment of rejection of the abdominal wall could prevent the emergence of intestinal rejection. It is plausible that these findings may be extrapolated to other solid organ allografts, especially those for which obtaining an accurate diagnosis of acute rejection can be hazardous and challenging, such as the lung or pancreas. However, more data are required to support widespread adoption of this technique.

Abdominal Wall Transplantation: Skin as a Sentinel Marker for Rejection.

Abdominal wall transplantation (AWTX) has revolutionized difficult abdominal closure after intestinal transplantation (ITX). More important, the skin of the transplanted abdominal wall (AW) may serve as an immunological tool for differential diagnosis of bowel dysfunction after transplant. Between August 2008 and October 2014, 29 small bowel transplantations were performed in 28 patients (16 male, 12 female; aged 41 ± 13 years). Two groups were identified: the solid organ transplant (SOT) group (n = 15; 12 ITX and 3 modified multivisceral transplantation [MMVTX]) and the SOT-AWTX group (n = 14; 12 ITX and 2 MMVTX), with the latter including one ITX-AWTX retransplantation. Two doses of alemtuzumab were used for induction (30 mg, 6 and 24 h after reperfusion), and tacrolimus (trough levels 8-12 ng/mL) was used for maintenance immunosuppression. Patient survival was similar in both groups (67% vs. 61%); however, the SOT-AWTX group showed faster posttransplant recovery, better intestinal graft survival (79% vs. 60%), a lower intestinal rejection rate (7% vs. 27%) and a lower rate of misdiagnoses in which viral infection was mistaken and treated as rejection (14% vs. 33%). The skin component of the AW may serve as an immune modulator and sentinel marker for immunological activity in the host. This can be a vital tool for timely prevention of intestinal graft rejection and, more important, avoidance of overimmunosuppression in cases of bowel dysfunction not related to graft rejection.

Modified liver-free multivisceral transplantation for a metastatic small bowel neuroendocrine tumor: a case report.

Neuroendocrine tumors originating from the small bowel frequently metastasize to the lymph nodes and/or liver. Although surgical extirpation of the primary tumor and locoregional metastases epitomizes the management of patients with such tumors, this is not always possible with conventional surgical techniques. Nonresectable, slow-growing tumors involving the mesenteric root represent a generally accepted indication for deceased donor intestinal and multivisceral transplantation. Furthermore, vascularized sentinel forearm flaps offer opportunities for monitoring graft rejection and tailoring immunosuppression regimens. Here, we report the first documented case of modified liver-free multivisceral transplantation preceded by neoadjuvant 177-lutetium peptide receptor radionuclide therapy in a patient with a small bowel neuroendocrine tumor and extensive lymph node metastases in the mesenterium. At a follow-up of 21 months the patient is biochemically and radiologically disease-free.

Selective embolization for massive upper gastrointestinal bleeding deriving from gastric angiodysplasia.

Transcatheter arterial embolization is a valuable, minimally invasive method, used as treatment for upper gastrointestinal bleeding, after failed primary endoscopic approach. It is a safe and effective procedure, but it's use is limited because of relatively high rates of rebleeding and mortality. The aim of this paper is to present a case of severe, massive upper gastrointestinal bleeding deriving from gastric angiodysplasia, which was treated successfully with superselective embolization. The patient recovered from the haemorrhagic shock and avoided emergency surgical intervention.

Mechanical bowel preparation before elective colorectal surgery: is it necessary?

AIM: To present the worldwide accepted guidelines concerning the use of mechanical bowel preparation (MBP) before elective colorectal surgery (ECS). PATIENTS AND METHODS: We conducted a retrospective review of the Pubmed Databases for randomized controlled trials (RCTs) and meta-analyses, which included adult patients who underwent elective colorectal surgery. We compared the patients who had a preoperative MBP with those who did not. Significant factors that were taken into account were postoperative septic complications and anastomotic dehiscence. RESULTS: Our search revealed 5 RCTs and 2 meta-analyses that met our criteria. Patients who underwent emergency colorectal surgery were excluded from the study. We identified the recommendations for 6 different types of elective colorectal surgery. CONCLUSION: MBP has been for many years a standard clinical procedure for patients undergoing elective colorectal surgery. However, many recent researches suggest the omission of MBP, since there are no significant differences regarding postoperative infectious complications, such as anastomotic dehiscence and superficial surgical site infections. Furthermore, MBP is a time-consuming, expensive procedure and causes severe discomfort to the patient. More importantly, the application of MBP has been associated with serious complications in both healthy patients and patients with existing cardiac or renal disease, such as electrolyte and volume disturbances.

Laparoscopic sigmoidectomy for colon cancer.

The aim of this study is to report our experience with laparoscopic sigmoidectomy due to cancer. Between 2007 and 2009, laparoscopic sigmoidectomy for cancer was performed in 3 patients. The average operative time was 176 min. The average hospital stay was 10.2 days. There was one anastomotic leak. The patient was subjected to laparotomy and a Hartmann's procedure and drainage of the peritoneal cavity was performed. In conclusion, laparoscopic sigmoidectomy for cancer is a safe and efficient procedure.

Anastomotic leakage following low anterior resection for rectal cancer.

AIM: Aim of this study is to present the incidence of anastomotic leakage after anterior resection for rectal cancer and to demonstrate the therapeutic approach for the treatment of this complication. PATIENTS AND METHODS: Between 1990 and 2009, 170 patients underwent low anterior resection with total mesorectal excision (TME). RESULTS: A total of 14 (8.2%) anastomotic leaks were confirmed. Reoperation was carried out in six patients with major leaks. Eight patients with minor leaks were treated conservatively by nutritional support and antibiotic therapy. CONCLUSION: The incidence of anastomotic leakage after anterior resection of the rectum for rectal cancer is relatively low.

Progress in rectal cancer staging and treatment.

Colorectal cancer poses a worldwide major health issue. Rectal cancer has somewhat distanced itself from colonic cancer as a different oncologic entity, due to differences in diagnosis and treatment. Several developments over the last years have improved screening, diagnostics, pre-operative therapy, surgical techniques and postoperative patient care. The multidisciplinary approach to rectal cancer, mainly through the co-operation of surgeons, oncologists and radiologists, seems to be one of the most important steps in the management of that disease.

Defunctioning ileostomy closure following low anterior resection by chemotherapy.

AIM: The aim of this study is to review the time between formation and closure of loop ileostomies following total mesorectal excision in patients with rectal cancer. PATIENTS AND METHODS: A retrospective study of 170 patients who underwent low anterior resection for rectal cancer, between 1990 and 2009. Loop ileostomies were created in 8 patients. RESULTS: Of the 8 patients with defunctioning loop ileostomies, 4 received adjuvant chemo-radiotherapy, 3 received neo-adjuvant chemo-radiotherapy and 1 did not receive anything. There was 12.5% morbidity. The time from formation to closure for the patient with no adjuvant therapy was 3 months and for those with adjuvant therapy was 7 months. This was a significant delay. CONCLUSION: Time between formation and closure of loop ileostomy following anterior resection of rectum is significantly delayed by adjuvant chemotherapy.

Brain metastases in colorectal cancer.

AIM: The aim of this study is the presentation of brain secondaries associated with colorectal cancer. PATIENTS AND METHODS: In the period between 1990 and 2009, 670 patients with colorectal cancer were treated. RESULTS: From 670 patients, 5 patients were identified with brain metastases. The incidence was 0.73%. The median interval between the colorectal cancer and the development of the brain secondaries was 7.5 months. Median survival after the diagnosis of brain metastases was 4.3 months. CONCLUSION: Brain metastases associated with colorectal cancer are relatively rare, but also a frequent cause of death.

Large bowel obstruction due to endometriosis.

We report on three cases of premenopausal female patients with large bowel endometriosis causing intermittent obstruction.

The handsewn anastomosis after colon resection due to colonic cancer.

AIM: The purpose of our study is to present the results of the handsewn single-layer interrupted extramucosal anastomosis following colon cancer. PATIENTS AND METHODS: In the period between 1989 and 2009, 276 intestinal anastomoses were fashioned following colon resection using single-layer interrupted extramucosal 3/0 Vicryl. RESULTS: The mean hospital stay was 8.2 days. Twenty-three patients had postoperative complications, and the total morbidity was 8.3%. Seven anastomotic leakages occurred (2.5%). The mortality rate was 2.5%. CONCLUSION: The single-layer anastomosis with interrupted extramucosal sutures after colon resection is safe and effective.

Circumferential stapled procedure for bleeding ano-rectal varices.

AIM: Aim of this study is to demonstrate that the circumferential stapled procedure for rectal varices is a feasible and suitable method of controlling bleeding varices. PATIENTS: Between 2004 and December 2007, four patients underwent the procedure as an emergency, with the intention of controlling haemorrhage. RESULTS: Four patients underwent this procedure, with successful control of bleeding achieved in all. No further rebleeding was observed in the follow-up period. CONCLUSION: The stapled disruption of bleeding rectal varices in patients with portal hypertension seems a very useful and effective procedure.

Metachronous colorectal cancer.

AIM: In this study, we present our patients with metachronous colorectal cancer. PATIENTS AND METHODS: In the period between 1990 and 2009, 670 patients with colorectal cancer were treated. RESULTS: Metachronous cancer was developed in 4 (0.6%) patients. The time interval between index and metachronous cancer was 28 months to 22 years (mean 146 months). CONCLUSION: Metachronous colorectal cancer is a potential risk that proves the necessity of postoperative colonoscopic control of all patients with colorectal cancer.

Laparoscopic right hemicolectomy due to colon cancer.

AIM: The aim of this study is to present our patients with laparoscopic right hemicolectomy due to cancer. PATIENTS AND METHODS: Between 2005 and 2009, laparoscopic right hemicolectomy for cancer was performed in 9 patients. RESULTS: The average operative time was 168 min. The average hospital stay was 5.3 days. There was one conversion (11.1%) to an open procedure. There were no postoperative complications. All the patients remain so far with no signs of tumor recurrence. CONCLUSION: Laparoscopic right hemicolectomy for cancer in the hands of an experienced laparoscopic surgeon is a safe and efficient procedure.