Induction of short gut syndrome and transplantation in a porcine model.

UNLABELLED: Experimental models in small animals have been described for nutritional studies after small bowel transplantation for extensive resection. Herein, we compared the outcome of transplanted pigs that underwent transplantation after total small bowel resection (SBR) with controls without transplantation. METHODS: Twenty-one Landrace pigs (mean weight 30 kg) were assigned to 1 of 3 groups: group 1 (n = 6) underwent 80% SBR; group 2 (n = 9), total bowel resection; and group 3 (n = 6) total resection plus small bowel transplantation. Postoperative evaluation included biochemical analyses, weights, and evaluation of clinical status. Conventional endoscopies with graft biopsies were obtained every 4 days to assess rejection. RESULTS: Group 1 showed increased body weight after 3 weeks due to bowel adaptation, whereas groups 2 and 3 lost weight, an observation that correlated with biochemical analyses. Median survival in group 3 was 10 +/- 2 days; all hosts died of sepsis related to severe acute rejection. DISCUSSION: Short gut syndrome appeared in group 2 but not in group 1, where intestinal adaptation was observed by 4 weeks after the resection. Rejection was confirmed in group 3 using conventional endoscopy plus biopsies and at necropsy. CONCLUSION: Total bowel resection is an adequate model for short gut syndrome in pigs, rejection can be readily identified by using conventional endoscopy.

Interferon alpha-2B and liver resection to treat multifocal hepatic epithelioid hemangioendothelioma: a relevant approach to avoid liver transplantation.

BACKGROUND: Hepatic epithelioid hemangioendothelioma is a rare malignant tumor of vascular origin with frequent multifocal appearance. Liver resection may cause tumor spread. Liver transplantation has been indicated for unresectable nodules. We hypothesized that adjuvant interferon treatment is effective to prevent metastasis after liver resection. We report a case of multifocal hepatic epithelioid hemangioendothelioma successfully treated with interferon pulse therapy and bilobar hepatic resection. METHODOLOGY: CT scan and magnetic resonance imaging diagnosed three nodules in the liver (segments IV, VI and VII). Histopathology and specific immunostaining of a percutaneous nodule biopsy confirmed the diagnosis of hepatic epithelioid hemangioendothelioma. The treatment protocol included daily interferon alpha 2b 9 weeks before and 1 week after resection of liver segments IV, VI and VII. RESULTS: The postoperative outcome was complicated by a self-limited biliary fistula. The patient remains tumor free at 3 years after liver resection and currently enjoys excellent health. CONCLUSION: Interferon pulse therapy and hepatic resection was a good option to treat multifocal bilobar hepatic epithelioid hemangioendothelioma; it may prevent metastasis dissemination.

Demographic of short gut syndrome: increasing demand is not followed by referral of potential candidates for small bowel transplantation.

BACKGROUND: Despite improvements in small bowel transplantation (SBTx), early referral of patients with irreversible intestinal failure (IF) remains a major obstacle. In this study we evaluated the demand for SBTx among seven surgical pediatric centers located at least 200 km from our center. METHODS: From 1997 to 2001, 640 patients have been treated for neonatal diseases, including 248 who underwent a minor or major intestinal resection. Twenty-four patients with major resections presented with short gut syndrome, requiring total parenteral nutrition (TPN). The greatest demand was in postsurgical neonates with necrotizing enterocolitis, gastroschiesis, onphalocoeles, or midgut volvulus, and in three adults with postradiotherapy arteritis (n = 2) and mesenteric vein thromboses (n = 1). The median length of residual bowel after resection was 20 to 30 cm, without an ileocecal valve. Four patients were referred for SBTx evaluation; three died while awaiting a donor; 20 were not referred, among whom 14 died of TPN complications. RESULTS: Approximately 62 children per year require nutritional support for IF, most of whom develop complications related to TPN. Because many patients who are TPN-dependent develop complications, we believe that early referral would reduce mortality. CONCLUSIONS: Greater medical awareness about the feasibility of SBTx procedures and earlier referral may improve results and quality of life after transplant.

Factors affecting metabolic and electrolyte changes after reperfusion in liver transplantation.

BACKGROUND: The metabolic and electrolyte changes were evaluated after various durations of cold and warm ischemia times to correlate ASA status with hemodynamic changes that may affect the severity of the reperfusion syndrome. PATIENTS AND METHODS: Sixty-one patients who underwent liver transplantation (OLT) were monitored by arterial pH, PaO2, PaCO2, HCO2, BE, K+, Ca2+, Na+, GL, and serial Ht at three specific times: after the skin incision (baseline), 10 minutes before reperfusion (T2), and 10 minutes after reperfusion (T3). Changes in metabolic parameters were correlated with ASA status, hemodynamic changes, time of OLT, as well as cold and warm ischemia times. RESULTS: The pH in ASA IV patients was significantly lower at T1 and T3, and PCO2 higher in ASA V at T1. A significant correlation was observed between pH, PaCO2, HCO3-, BE, Na+, Ca2+, and glucose with the phase of the procedure. The pH and HCO3- decreased significantly from T1 and T2, increasing during T3. Ca2+ fell from T1 to T2 increasing in T3. Mean glucose and sodium levels increase from T1 to T3. Mean BE dropped from T1 to T2 and increased at T3 without a significant correlation between the metabolic parameters in any phase of the study and the cold or warm ischemia times. Patients with a high ASA status showed an increased risk for cardiovascular collapse after reperfusion. CONCLUSIONS: Patients with advanced ASA status are more prone to metabolic and acid-base disturbances during reperfusion, without any relation to the cold or warm ischemia times. High ASA status shows an increased risk for cardiovascular collapse after reperfusion.

[Intestinal transplantation in the rat. Surgical technique]. / Trapianto d'intestino nel ratto. Tecnica chirurgica.

Small bowel transplant (SBT) is a still open challenge in the field of transplantation. Immunological problems make it a technique not yet completely reliable for patients with irreversible chronic intestinal failure and, thus, accepted at the moment only for those who present potentially life threatening complications of total parenteral nutrition (TPN). Recently, new immunosuppression protocols have greatly improved the results, however research for new regimens to prevent rejection is still going on. The rat represents an invaluable model for studying small bowel transplant. The simplicity of the technique and the use of inbred species allow to study both rejection and graft versus host disease. The technique of rat small bowel transplant in the rat is presented and illustrated by a very didactic and explicable series of images.

Correlation between allograft survival and chimeric state after bone marrow infusion in rat small bowel transplantation.

Methods to enhance natural microchimerism, which occurs after any successful organ transplant, are currently explored using unmodified donor bone marrow both in experimental and in clinical trials. Because of the potential immunomodulatory effects of donor bone marrow cells, we performed this study to evaluate the effect of single and multiple donor-specific bone marrow infusions (DSBMI) on chimerism and small bowel allograft survival in a fully histoincompatible rat model. Forty-five male DA rats and 45 female Lewis rats were used as donors and recipients, respectively, for a heterotopic small bowel transplant. Animals were separated into 10 groups according to the number of bone marrow infusions and immunosuppressive protocol used. Control groups (groups 1 and 2) did not receive any bone marrow infusion, groups 3 and 4 received one infusion at day 0 (150 x 10(6) cells), groups 5 and 6 received two infusions at days 0 and 4 (75 x 10(6) cells each), groups 7 and 8 received two infusions at days 4 and 10 (75 x 10(6) cells each), and groups 9 and 10 received five infusions at days 4, 10, 15, 20 and 25 (30 x 10(6) cells each). Animals in groups 1, 3, 5, 7 and 9 were immunosuppressed with 0.5 mg/kg FK506 while the remaining groups were immunosuppressed with 1 mg/kg FK506, from day 0 to 4 after transplant. Every 15 days, the chimeric state was determined by flow cytometry in order to detect cells expressing DA rat class I antigen, and small bowel biopsies were obtained from ileostomies. Animals in all groups showed minimal to moderate acute rejection at day 15 after transplant, however, vascular rejection (vasculitis, arteritis) was observed in only bone marrow groups (100% in 0.5 mg/kg and 42.1% in 1 mg/kg FK506 groups). On day 30, 58.3% of bone-marrow-infused animals and 66.6% of controls showed severe acute and early chronic rejection. The chimeric levels varied from 0 to 12% after transplant and were significantly higher in bone-marrow-infused groups compared with controls (p < 0.05). We conclude that modulation of immune response with short-course immunosuppression and a single or multiple DSBMI did not improve allograft or recipient survival. The inability to achieve a stable chimeric state did not allow us to determine the effect of chimerism on graft and recipient survival after small bowel transplantation.

Splenic artery aneurysm rupture.

This is the report of a case with an atherosclerotic splenic artery aneurysm ruptured into the peritoneal cavity which presented with hypovolaemic shock. The patient underwent successfully emergency laparotomy and splenectomy. A brief review of the the literature follows.