Gastrointestinal Tract Reconstruction in Adults with Ultra-Short Bowel Syndrome: Surgical and Nutritional Outcomes.

BACKGROUND: Historically, adults with ultra short bowel syndrome (USBS) have been considered candidates for lifetime parenteral nutrition (PN) or are referred for visceral transplantation. We examined the surgical and nutritional outcomes of adult patients with USBS managed at a single intestinal rehabilitation center. METHODS: We retrospectively reviewed data on 588 adult patients referred to our center between January 2013 and December 2018. USBS was defined as residual small bowel (SB) length ≤ 50 cm. RESULTS: Forty-five patients (7.6%) with a mean age of 46.7 years (range 17-78) were identified. Indications for enterectomy included mesenteric ischemia (n=17) and internal hernias (n=6), followed by large intraabdominal fibroids, trauma, and allograft enterectomies, with five cases each. Median SB length was 18.0 cm; 20 patients (44.4%) had their entire SB resected. Thirteen patients had an intact colon, of which nine had preservation of the ileocecal valve. Patients who underwent autologous reconstruction of their gastrointestinal (GI) tract required a lower total PN volume (29.0 ± 7.6 vs. 40.8 ± 13.2 ml/Kg/day, p=0.002) and presented better short- and long- term survival (p=0.005). Patients with no gut had higher mortality (p=0.036). Hormonal therapy with the glucagon-like peptide-2 analog teduglutide was used in nine patients (20%) five of whom were weaned off TPN. Excluding patients with no gut (n=20), discontinuation of total PN rate for patients with an end ostomy or tube decompression (n= 6), jejunocolostomy (n= 10), and jejunoileostomy (n=9) were 0%, 40%, and 77.7%, respectively. Eleven patients (44%) with some residual small intestine achieved nutritional autonomy in an average of 20 months after GI reconstruction. Fifteen patients were listed for transplantation (33.3%). Seven patients underwent isolated SB transplantation and achieved nutritional autonomy in an average of three months after transplantation. One-year patient and graft survival were 100%. After a 37-month median follow-up period, 36 of 42 patients followed by our center were still alive (85.7%). CONCLUSION: Nutritional autonomy can be achieved in a significant number of patients with USBS in specialized centers with surgical and/or hormonal therapy. The presence of an intact colon and ileocecal valve can significantly increase the adaptation rate. Moreover, restoration of GI tract continuity has a positive impact on medical management and survival.

Functional outcome of autologous anorectal transplantation in an experimental model.

BACKGROUND: Although anorectal transplantation is a challenging procedure, it is a promising option for patients who have completely lost anorectal function or in whom it failed to develop, as in congenital malformations. The paucity of animal models with which to test functional outcomes was addressed in this study of anorectal manometry in rats. METHODS: Wistar rats were assigned randomly to four groups: orthotopic anorectal transplantation, heterotopic transplantation, sham operation, or normal control. Bodyweight and anal pressure were measured immediately before and after operation, and on postoperative days 7 and 14. ANOVA and Tukey's test were used to compare results for bodyweight, anal manometry and length of procedure. RESULTS: Immediately after the procedure, mean(s.d.) anal pressure in the orthotopic group (n = 13) dropped from 31·4(13·1) to 1·6(13·1) cmH2 O (P < 0·001 versus both sham operation (n = 13) and normal control (n = 15)), with partial recovery on postoperative day 7 (14·9(13·9) cmH2 O) (P = 0·009 versus normal control) and complete recovery on day 14 (23·7(12·2) cmH2 O). Heterotopic rats (n = 14) demonstrated partial functional recovery: mean(s.d.) anal pressure was 26·9(10·9) cmH2 O before operation and 8·6(6·8) cmH2 O on postoperative day 14 (P < 0·001 versus both sham and normal control). CONCLUSION: Orthotopic anorectal transplantation may result in better functional outcomes than heterotopic procedures. Surgical relevance Patients with a permanent colostomy have limited continence. Treatment options are available, but anorectal transplantation may offer hope. Some experimental studies have been conducted, but available data are currently insufficient to translate into a clinical option. This paper details functional outcomes in a rat model of anorectal autotransplantation. It represents a step in the translational research that may lead to restoration of anorectal function in patients who have lost or have failed to develop it.

Allometric growth patterns in hatchery-reared larvae of the catfish Lophiosilurus alexandri (Pisces: Pseudopimelodidae) / Padrões de crescimento alométrico em larvas criadas em cativeiro do pacamã Lophiosilurus alexandri (Pisces: Pseudopimelodidae)

The aim of the present study was to characterize the relationships that occur between morphometric variables of larvae of Lophiosilurus alexandri Steindachner, 1876 through their allometric growth analysis. Total length, head length and body height were correlated with standard length, head height and body height, as well as eye diameter and head height with head length. The results revealed allometric positive relation during the initial development, where the b coefficient varied between 1.10 and 2.81. The variable pre-anal distance in relation to the standard length and the snout length in relation to the head length revealed an allometric negative relation, where the b coefficient was 0.85 and 0.94, respectively.

O objetivo do presente estudo foi caracterizar os tipos de relações que ocorrem entre as variáveis morfométricas das larvas de Lophiosilurus alexandri Steindachner, 1876, por meio da análise de seu crescimento alométrico. As variáveis comprimento total, comprimento da cabeça e altura do corpo foram correlacionadas com o comprimento padrão; a altura da cabeça com a altura do corpo; e o diâmetro do olho e a altura da cabeça com o comprimento da cabeça. Os resultados revelaram relações alométricas positivas durante o desenvolvimento inicial, quando o coeficiente b variou entre 1,10 e 2,81. A variável distância pré-anal em relação ao comprimento padrão e a variável comprimento do focinho em relação ao comprimento da cabeça revelaram relação alométrica negativa quando o coeficiente b foi 0,85 e 0,94, respectivamente.

Posterior reversible encephalopathy syndrome in liver transplant patients: clinical presentation, risk factors and initial management.

Posterior reversible encephalopathy syndrome (PRES) is an uncommon but well-known complication after transplantation diagnosed by characteristic radiological features. As limited data on this complex syndrome exist we sought to better define the incidence, clinical presentation and risk factors for PRES in liver transplant (LTx) patients. We conducted a retrospective analysis of 1923 adult LTx recipients transplanted between 2000 and 2010. PRES was diagnosed radiologically in 19 patients (1%), with 84% of cases occurring within 3 months post-LTX. We compared this cohort of PRES patients to 316 other LTx recipients also requiring radiographic imaging within 3 months after LTx for neurological symptoms. Seizure was the most common clinical manifestation in the PRES group (88% vs. 16%, p< 0.001) and 31% had an intracranial hemorrhage. Those with hemorrhage on imaging were more likely to be coagulopathic. PRES patients were significantly more likely to have had alcoholic liver disease and infection/sepsis. These factors may be related to a common pathway of vascular dysregulation/damage that appears to characterize this complex syndrome. Intracranial bleeding and seizures may be the end result of these phenomena. The relationship of these associated factors to the hypothesized pathophysiology of PRES is discussed.

Motives and decision making of potential living liver donors: comparisons between gender, relationships and ambivalence.

The motives and decision making of potential living liver donors are critical areas for transplant clinicians evaluating these candidates to understand, yet these topics remain relatively unstudied. Thus, we surveyed 77 prospective living liver donors at the point of donation evaluation using structured instruments to gather more information on their approach to and concerns about donation. We collected information on donation decision making, motives for donation and anticipated social and physical concerns about postdonation outcomes. We examined three additional characteristics of donors: gender, the relationship of the donor to the intended recipient and the presence of ambivalence about donation. Women had more concerns about their family/social responsibilities. Those donating to nonimmediate family were more likely to have been asked to donate but less likely to feel they had to donate. However, ambivalent donors were the most distinct having difficulties and concerns across most areas from their motivations for donating, to deciding to be tested and to donate, to concerns about the postdonation outcomes. We discuss the clinical relevance of these findings to donor evaluation and preparation.

Skeletal integrity and visceral transplantation.

Despite continuous improvement in long-term survival, there is no knowledge about risk of bone health impairment and management strategies before and after intestinal transplantation. Therefore, 147 adults were retrospectively studied via chart review; 70 long-term survivors, 53 candidates and 24 recipients with longitudinal follow-up. Evaluation process included measurement of bone mineral density (BMD) and allied biochemical markers. Both long-term survivors and candidates showed low bone mass with lower (p < 0.05) z-scores at hip, femoral neck and spine. Vitamin D deficiency and secondary hyperparathyroidism were observed in both groups. Prevalence of osteoporosis was 44% among long-term survivors and 36% in candidates with age, BMD, duration of parenteral nutrition, type of immunosuppression and rejection being significant risk factors. Fragility fractures occurred at a higher (p = 0.02) rate among long-term survivors (20%) compared to candidates (6%). The longitudinal study documented acceleration (p = 0.025) of bone loss after transplantation with a decline of 13.4% (femoral neck), 12.7% (hip) and 2.1% (spine). Alendronate reduced (p < 0.05) but did not prevent bone loss. In conclusion, intestinal transplant recipients are at risk of osteoporosis secondary to bone loss before and after transplantation. Accordingly, current management includes comprehensive preventive measures with prompt therapeutic intervention utilizing intravenous bisphosphonates or subcutaneous human PTH.

An innovative sphincter preserving pull-through technique with en bloc colon and small bowel transplantation.

This report describes a new innovative pull-through technique of hindgut reconstruction with en bloc small bowel and colon transplantation in a Crohn's disease patient with irreversible intestinal failure. The approach was intersphincteric and the anastomosis was established between the allograft colon and the recipient anal verge with achievement of full nutritional autonomy and anal continence.

Cholesterol-lowering properties of whole cowpea seed and its protein isolate in hamsters.

Hypercholesterolemic hamsters were fed for 4 wk on diets rich in saturated fatty acids and cholesterol, differing only in protein source (20 %): casein (control group, HC), whole cowpea seed (HWS), and cowpea protein isolate (HPI). Hamsters fed on HWS and HPI presented significant reductions in plasma total cholesterol and non-HDL cholesterol. HPI and HC presented similar protein digestibility, which were significantly higher than that of HWS. Animals fed on HWS presented significantly higher levels of bile acids and cholesterol in feces than did the animals fed on casein or HPI diets. Histological analyses of the liver showed that HC diet resulted in steatosis widely distributed throughout the hepatic lobule, while HWS and HPI diets promoted reductions in liver steatosis. The effectiveness of HWS for modulating lipid metabolism was greater than that of HPI, as measured by plasma cholesterol reduction and liver steatosis.

Systemic and regional hemodynamic effects of enalaprilat infusion in experimental normotensive sepsis.

Angiotensin-converting enzyme inhibitors have been shown to improve splanchnic perfusion in distinct shock states. We hypothesized that enalaprilat potentiates the benefits of early fluid resuscitation in severe experimental sepsis, particularly in the splanchnic region. Anesthetized and mechanically ventilated mongrel dogs received an intravenous infusion of live Escherichia coli over a period of 30 min. Thereafter, two interventions were performed: fluid infusion (normal saline, 32 mL/kg over 30 min) and enalaprilat infusion (0.02 mg kg(-1) min(-1) for 60 min) in randomized groups. The following groups were studied: controls (fluid infusion, N = 4), E1 (enalaprilat infusion followed by fluid infusion, N = 5) and E2 (fluid infusion followed by enalaprilat infusion, N = 5). All animals were observed for a 120 min after bacterial infusion. Mean arterial pressure, cardiac output (CO), portal vein blood flow (PVBF), systemic and regional oxygen-derived variables, and lactate levels were measured. Rapid and progressive reductions in CO and PVBF were induced by the infusion of live bacteria, while minor changes were observed in mean arterial pressure. Systemic and regional territories showed a significant increase in oxygen extraction and lactate levels. Widening venous-arterial and portal-arterial pCO2 gradients were also detected. Fluid replacement promoted transient benefits in CO and PVBF. Enalaprilat after fluid resuscitation did not affect systemic or regional hemodynamic variables. We conclude that in this model of normotensive sepsis inhibition of angiotensin-converting enzyme did not interfere with the course of systemic or regional hemodynamic and oxygen-derived variables.

Mechanisms of action of hypertonic saline resuscitation in severe sepsis and septic shock.

Small volumes of 7.5% NaCl (2400mOsm/L) have been extensive evaluated in animal models of hemorrhagic shock and in clinical trials of post-traumatic hypotension and as volume support for complex cardiovascular procedures. Hypertonic solutions promote immediate blood volume expansion, restore cardiac output and regional blood flows, improve microcirculation and modulate immune responses, thereby decreasing inflammatory responses triggered by shock and trauma. A large number of very interesting in vivo and in vitro experiments highlighted that hypertonic saline resuscitation may decrease susceptibility to post-traumatic sepsis, modulate trauma and sepsis-induced immune dysfunction, inflammatory response and apoptosis. All those long-term benefits associated with hypertonic resuscitation may be of potential relevance for the management of severe sepsis and septic shock In this review, we describe the mechanisms of action of hypertonic saline based on experimental studies as well as its efficacy and safety based on its clinical use. We believe those studies support the need for additional experimental and clinical studies before the widespread use of hypertonic solutions for the treatment of severe sepsis and septic shock.

Severe pulmonary disease due to multisystemic eosinophilic epitheliotropic disease in a horse.

Multisystemic eosinophilic epitheliotropic disease was diagnosed histologically in a 17-year-old Quarter Horse intact mare that was presented with a chronic history of respiratory distress. At necropsy, the lungs were poorly collapsed and the pulmonary parenchyma contained innumerable, discrete, spherical nodules in a miliary pattern. A few similar nodules were scattered in the liver and the renal lymph nodes. Histologically, these nodules consisted of fibrosing eosinophilic granulomas. Based on histologic findings and the absence of an etiologic agent, a diagnosis of multisystemic eosinophilic epitheliotropic disease was made.

Short-lasting systemic and regional benefits of early crystalloid infusion after intravenous inoculation of dogs with live Escherichia coli.

We investigated the systemic and regional hemodynamic effects of early crystalloid infusion in an experimental model of septic shock induced by intravenous inoculation with live Escherichia coli. Anesthetized dogs received an intravenous infusion of 1.2 x 10(10) cfu/kg live E. coli in 30 min. After 30 min of observation, they were randomized to controls (no fluids; N = 7), or fluid resuscitation with lactated Ringer's solution, 16 ml/kg (N = 7) or 32 ml/kg (N = 7) over 30 min and followed for 120 min. Cardiac index, portal blood flow, mean arterial pressure, systemic and regional oxygen-derived variables, blood lactate, and gastric PCO2 were assessed. Rapid and progressive cardiovascular deterioration with reduction in cardiac output, mean arterial pressure and portal blood flow (approximately 50, approximately 25 and approximately 70%, respectively) was induced by the live bacteria challenge. Systemic and regional territories showed significant increases in oxygen extraction and in lactate levels. Significant increases in venous-arterial (approximately 9.6 mmHg), portal-arterial (approximately 12.1 mmHg) and gastric mucosal-arterial (approximately 18.4 mmHg) PCO2 gradients were also observed. Early fluid replacement, especially with 32 ml/kg volumes of crystalloids, promoted only partial and transient benefits such as increases of approximately 76% in cardiac index, of approximately 50% in portal vein blood flow and decreases in venous-arterial, portal-arterial, gastric mucosal-arterial PCO2 gradients (7.2 +/- 1.0, 7.2 +/- 1.3 and 9.7 +/- 2.5 mmHg, respectively). The fluid infusion promoted only modest and transient benefits, unable to restore the systemic and regional perfusional and metabolic changes in this hypodynamic septic shock model.

Active spleno-femoral shunt avoids splanchnic congestion during portal triad occlusion: an experimental study.

UNLABELLED: Portal triad occlusion (PTO) is often performed during hepatic resections for trauma or malignancies to minimize intraoperative blood loss. The pringle maneuver is also regularly required during liver transplantation. This maneuver leads to temporary hepatic ischemia and may be associated with splanchnic blood flow congestion, promoting undesirable hemodynamic disturbances in some patients. Veno-venous bypass is a useful, easily performed technique that may avoid those deleterious hemodynamic effects of PTO. We tested the hypothesis that an active spleno-femoral shunt maintains hemodynamic stability and promotes complete decompression of the mesenteric bed, avoiding intestinal mucosal blood congestion, during PTO. METHODS: Seven dogs (17.2 +/- 0.9 kg) were subjected to 45 minutes of hepatic ischemia during which there was an active spleno-femoral shunt. Systemic hemodynamics were evaluated through Swan-Ganz and arterial catheters. Splanchnic perfusion was assessed by portal vein blood flow and hepatic artery blood flow (PVBF and HABF, ultrasonic flowprobe), intestinal mucosal-arterial pCO(2) gradient (D(t-a)pCO(2), tonometry), and regional O(2)-derived variables. RESULTS: No significant changes in systemic and regional parameters were observed during the ischemia period. During reperfusion, a significant decrease in mean arterial pressure, PVBF, and arterial pH was observed. A significant increase in ALT and D(t-a)pCO(2) (4.8 +/- 2.5 to 18.9 +/- 3 mm Hg) was also observed following hepatic blood flow restoration. CONCLUSION: Spleno-femoral shunt maintains systemic hemodynamic stability, with an effective decompression of the splanchnic bed during portal triad occlusion. The deleterious hemodynamic and metabolic effects observed during reperfusion period, such as transitory hypotension, high D(t-a)pCO(2), and acidemia, were associated with an isolated hepatic ischemia-reperfusion injury, not with the blood congestion in the splanchnic bed.

Hepatic arterial buffer response fails to restore hepatic oxygenation after temporary liver dearterialization in canines.

BACKGROUND: Hepatic artery thrombosis is a rare but extremely troublesome condition after liver transplantation. Recently, urgent arterial revascularization has been used as rescue therapy, leading to improved graft and patient survivals. Hepatic artery ligation produces a progressive reduction in portal vein blood flow. Theoretically, a hyperemic response may be expected following hepatic artery reperfusion (hepatic artery buffer response, HABR). In this study, we tested the hypothesis that HABR can maintain adequate liver oxygenation after temporary liver dearterialization. METHODS: Seven dogs (19.7 +/- 1.2 kg) subjected to 60 minutes of hepatic artery occlusion were observed for 120 minutes thereafter. Systemic hemodynamics was evaluated through Swan-Ganz and arterial catheters, and splanchnic perfusion by portal vein and hepatic artery blood flows (PVBF and HABF) via an ultrasonic flowprobe. Liver enzymes (ALT and LDH) and systemic and hepatic oxygen delivery (DO2hepat) were calculated using standard formulae. RESULTS: Hepatic artery occlusion induced a progressive reduction in PVBF and DO2hepat. A complete restoration of HABF after hepatic artery declamping was observed; however, the DO2hepat (33.3 +/- 5.9 to 16.5 +/- 5.9 mL/min) did not return to the baseline levels. CONCLUSION: Temporary hepatic artery occlusion induced a progressive decrease in portal vein blood flow during ischemia, an effect that continued during the reperfusion period. The hepatic artery blood flow was promptly restored after declamping. However, HABR was not able to restore hepatic oxygen delivery to baseline levels during the reperfusion period.

Effects of intra-aortic balloon occlusion on intestinal perfusion, oxygen metabolism and gastric mucosal PCO2 during experimental hemorrhagic shock.

BACKGROUND: Aortic occlusion has been suggested for the initial treatment of severe uncontrolled hemorrhagic shock. Our objective is to determine the impact of aortic occlusion, during hemorrhagic shock, on splanchnic mucosal perfusion and to correlate these findings with other systemic and regional markers of splanchnic ischemia. METHODS: Fourteen dogs (17 +/- 1.7 kg) anesthetized with pentobarbital were bled to a mean arterial pressure (MAP) of 40 mm Hg. After 30 min, the animals were randomly assigned to controls (no aortic occlusion, n = 7) and transfemoral aortic occlusion (TAO) at T9 level (n = 7). Superior mesenteric artery blood flow (SMABF, ultrasonic flow probe), gastric mucosal PCO2 (gastric tonometry) and splanchnic oxygen extraction ratio (O2ERsplanc) were evaluated for 120 min. RESULTS: Hemorrhage caused a marked reduction in SMABF and increases in PCO2-gap and O2ERsplanc in both groups. TAO significantly improved MAP and further increased the PCO2-gap and O2ERsplanc, with a decreased SMABF. After reperfusion, SMABF, MAP and O2ERsplanc returned to pre-occlusion values, although the PCO2-gap remained higher in the TAO group. CONCLUSION: Aortic occlusion promotes blood pressure restoration with an additional insult to mucosal perfusion, which could be adequately predicted by global and/or splanchnic oxygen-derived variables during ischemia, but not during the early reperfusion period.

Radioisotope blood volume measurement in uncontrolled retroperitoneal haemorrhage induced by a transfemoral iliac artery puncture.

Standard-of-care, large volume crystalloid infusion, in the setting of uncontrolled bleeding, has been challenged and it is not known if fluid resuscitation increases retroperitoneal hemorrhage. We developed an experimental model of retroperitoneal haemorrhage to correlate haemodynamic and metabolic alterations with the blood volume loss. Anaesthetised, spontaneously breathing dogs (17.1+/-0.56 kg) were randomised to unilateral (UL, n=11) or bilateral (BL, n=11) iliac artery puncture, using a metallic device introduced through the femoral arteries and followed for 120 min. Initial and final blood volumes were determined using radioactive tracers, 99mTC and 51Cr, respectively. UL was associated with a stable arterial pressure and a moderate decrease in cardiac output and oxygen delivery. BL induced an abrupt and sustained decrease in mean arterial pressure, from 131.9+/-5.9 to 88.6+/-10.8 mmHg, and a much greater reduction in cardiac output, oxygen delivery and consumption than UL throughout the experiment. Total retroperitoneal blood loss after BL was 36.8+/-3.2 ml/kg, while after UL was 25.1+/-3.4 ml/kg (P=0.0262). We conclude that a transfemoral bilateral iliac artery puncture produces a clinically relevant model of uncontrolled retroperitoneal haemorrhage, with hypotension and low flow state, while a unilateral iliac artery lesion causes a compensated shock state.

Initial management of severe hemorrhage with an oxygen-carrying hypertonic saline solution.

We tested the hypothesis that the combination of polymerized bovine hemoglobin (PBHg) with hypertonic saline may be beneficial for the initial management of hemorrhagic shock in 22 mongrel dogs (15 +/- 1 kg) bled to a mean arterial pressure (MAP) of 40 mm Hg in 5 min and maintained at this level for 45 min (shed blood volume approximately 50 ml/kg). Animals were treated with a 4 ml/kg bolus over 4 min of one of the following fluids: whole blood, 7.5% NaCl (HS), 13 g/dl of PBHg, or 7.5% NaCl combined with polymerized bovine hemoglobin (HS-PBHg). No additional intervention was performed, and the animals were followed for 60 min after treatment. PBHg and HS-PBHg produced a sustained, significant increase in MAP. Cardiac output was transiently increased only after HS and HS-PBHg. A partial increase in superior mesenteric artery blood flow was observed, particularly after HS-PBHg. We concluded that small volumes of PBHg alone restore MAP, but not blood flow. The combination of PBHg with hypertonic saline provides improvements in cardiac output and mesenteric blood flow, suggesting a potential benefit for the initial management of major blood loss.