Guillain-Barré syndrome after solid organ transplantation.

BACKGROUND: Neurological complications occur frequently in solid organ transplant recipients. However, the peripheral nerves are usually spared significant toxicity. Guillain Barré syndrome (GBS) is the most common cause of acute neuropathy in adults. Despite numerous reports of GBS in recipients of bone marrow transplants, GBS has rarely been reported in recipients of solid organ transplants. Recent evidence supports the role of the immune system in initiating and perpetuating the ongoing neural damage in this entity. Infectious agents may initiate the immune attack, and the association of GBS with cytomegalovirus (CMV) infection has been studied extensively. METHODS: To alert clinicians to the occurrence of GBS in the latter setting, we report five new cases of GBS after solid organ transplant and summarize five other cases previously reported in the literature. RESULTS: The GBS cases (published and unpublished) have much in common: all the patients were men, most had evidence of active CMV infection at or before the onset of GBS, and all but one developed GBS within 1 year after transplantation (range 1-26 months). CONCLUSION: The association of GBS with cytomegalovirus (CMV) infection in the nontransplant population and evidence of CMV infection in almost all reported cases of GBS in solid organ transplant recipients suggest that CMV may have a role in triggering this illness.

Suprarenal or supraceliac aortic clamping during repair of infrarenal abdominal aortic aneurysms.

Suprarenal or supraceliac aortic clamping during repair of infrarenal abdominal aortic aneurysms can be complicated by renal, hepatic, and intestinal ischemia. To determine whether suprarenal or supraceliac clamping increases morbidity and mortality we retrospectively reviewed our recent nonrandomized experience. Between January 1993 and December 1998, 716 patients underwent elective (n=682) or urgent (n=34) infrarenal abdominal aortic aneurysm repair. Infrarenal clamping was used in 516 (72. 1 %) and suprarenal or supraceliac clamping in 200 (279%). The suprarenal/supraceliac group had significantly more older patients (> or = 70 years of age) (65.5% vs 477%) and a higher incidence of preoperative renal insufficiency (75% vs 5.5%). Suprarenal or supraceliac clamping was used during repair of ruptured (n=25), juxtarenal (n=7), or inflammatory abdominal aortic aneurysms (n=4); during concomitant renal or visceral revascularization (n=43); in other difficult settings (n=13); or at the surgeon's discretion (n=108). The decision for such clamping was always made during surgery In treating ruptured aneurysms, suprarenal/supraceliac clamping (25/200) was used more often than infrarenal clamping (9/516) (12.5% vs 1.74%). Operative times were similar in both groups, but transfusion requirements and length of hospital stay were slightly greater in the suprarenal/supraceliac group. Perioperative mortality was 3.1% overall, but higher in the suprarenal/ supraceliac group than in the infrarenal (75% vs 1.4%). Postoperative complications developed in 26 (13%) of patients who underwent suprarenal/supraceliac clamping. Abdominal re-exploration was required in 9 other patients. We conclude that, despite associated comorbidities, elective suprarenal/supraceliac clamping during infrarenal abdominal aortic aneurysm repair is safe, facilitates repair, and does not significantly increase mortality.

Laparoscopic mesh repair of incisional hernia following right lower quadrant renal transplantation.

The development of an incisional hernia after lower quadrant renal transplantation is an infrequent complication, but poses a difficult surgical challenge due to the proximity of the incision to the allograft and the pelvic rim. We describe the first such case of a laparoscopic repair of a recurrent incisional hernia after renal transplantation in the literature.

Right atrial bypass grafting for central venous obstruction associated with dialysis access: another treatment option.

PURPOSE: Central venous obstruction is a common problem in patients with chronic renal failure who undergo maintenance hemodialysis. We studied the use of right atrial bypass grafting in nine cases of central venous obstruction associated with upper extremity venous hypertension. To better understand the options for managing this condition, we discuss the roles of surgery and percutaneous transluminal angioplasty with stent placement. METHODS: All patients had previously undergone placement of bilateral temporary subclavian vein dialysis catheters. Severe arm swelling, graft thrombosis, or graft malfunction developed because of central venous stenosis or obstruction in the absence of alternative access sites. A large-diameter (10 to 16 mm) externally reinforced polytetrafluoroethylene (GoreTex) graft was used to bypass the obstructed vein and was anastomosed to the right atrial appendage. This technique was used to bypass six lesions in the subclavian vein, two lesions at the innominate vein/superior vena caval junction, and one lesion in the distal axillary vein. RESULTS: All patients except one had significant resolution of symptoms without operative mortality. Bypass grafts remained patent, allowing the arteriovenous grafts to provide functional access for 1.5 to 52 months (mean, 15.4 months) after surgery. CONCLUSION: Because no mortality directly resulted from the procedure and the morbidity rate was acceptable, this bypass grafting technique was adequate in maintaining the dialysis access needed by these patients. Because of the magnitude of the procedure, we recommend it only for the occasional patient in whom all other access sites are exhausted and in whom percutaneous dilation and/or stenting has failed.