Long-Term Outcomes of Renal Function After Adult Intestinal Transplantation at a Single Small-Volume Center: 2 Cases of Renal Transplantation

PurposeRenal dysfunction more frequently occurs after intestinal transplantation (ITx) than after heart, lung, or liver transplantation. We provide a clinical analysis of renal function after adult ITx.MethodsWe retrospectively analyzed 8 adult ITx patients who survived for at least 6 months between 2004 and 2018. Glomerular filtration rate (GFR) measurements were performed at baseline, at 3 and 6 months post-transplantation, and yearly. The median follow-up duration was 53.5 months.ResultsAll cases were isolated ITx; 3 received living-donor ITx, and 5 received deceased-donor ITx. The mean baseline GFR was 97 mL/min/1.73 m². The GFR had decreased by more than 50% of baseline at 1 year post-transplant. Renal dysfunction was observed in 4 patients. Two patients developed acute kidney injury due to acute rejection and sepsis. One of these patients fully recovered renal function, but the second patient died. Another 2 patients developed chronic kidney disease and required hemodialysis (HD) within 6 and 3 years, respectively. The first living-donor ITx patient lost renal function progressively over 6 years after ITx. She received a renal graft from the same living donor as for the ITx after 3 years of HD. The other patient (deceased-donor ITx) received a kidney from his daughter at 5 months after HD.ConclusionsTo obtain an accurate assessment of renal function, frequent direct measurements of GFR should be performed to facilitate early diagnosis of renal impairment and to determine subsequent strategies to improve renal function after ITx.     

Liver Transplantation Following Life-threatening Abdominal Trauma: A Case Series of 5 Patients at a Single Institution

Managing traumatic liver injury (TLI) is always challenging and demands precise clinical judgment. Currently, treatment of TLI in most circumstances is non-operative; however, surgical therapy might be required for severe TLI, particularly those that result in extensive blood loss. In the current institutional study carried out from June 1995 to April 2017, we describe our experience with 5 patients who received an orthotopic liver transplant for severe TLI. One patient passed away postoperatively from cerebral edema; 1 patient died of renal failure 4 years after the liver transplantation, and 3 patients are still alive. Based on our experience, we conclude that in patients with TLI, especially those with uncontrollable bleeding or those who develop liver failure, liver transplantation should be taken into consideration.     

Prevention of Bleeding After Islet Transplantation: Lessons Learned from a Multivariate Analysis of 132 Cases at a Single Institution

Islet transplantation is being offered increasingly for selected patients with unstable type 1 diabetes. Percutaneous transhepatic portal access avoids a need for surgery, but is associated with potential risk of bleeding. Between 1999 and 2005, we performed 132 percutaneous transhepatic islet transplants in 67 patients. We encountered bleeding in 18/132 cases (13.6%). In univariate analysis, the risk of bleeding in the absence of effective track ablation was associated with an increasing number of procedures (2nd and 3rd procedures with an odds ratio (OR) of 9.5 and 20.9, respectively), platelets count <150,000 (OR 4.4), elevated portal pressure (OR 1.1 per mm Hg rise), heparin dose > or =45 U/kg (OR 9.8) and pre-transplant aspirin (81 mg per day) (OR 2.6, p = 0.05). A multivariate analysis further confirmed the cumulative transplant procedure number (p < 0.001) and heparin dose > or =45 U/kg (p = 0.02) as independent risk factors for bleeding. Effective mechanical sealing of the intrahepatic portal catheter tract with thrombostatic coils and tissue fibrin glue completely prevented bleeding in all subsequent procedures (n = 26, p = 0.02). We conclude that bleeding after percutaneous islet implantation is an avoidable complication provided the intraparenchymal liver tract is sealed effectively.     

An Analysis of Resection vs Transplantation for Early Hepatocellular Carcinoma: Defining the Optimal Therapy at a Single Institution

Background The reported survival after liver transplantation (OLT) for early hepatocellular carcinoma (HCC) is superior to the results of liver resection (LR), but few analyses have considered long waiting times and patient drop-offs due to tumor progression. Methods From 1995–2005, 347 patients with HCC were evaluated at our institution and underwent either LR (n = 174) or placed on the OLT waiting list (n = 173). Patients who only underwent ablation were not included. After eliminating patients with 1) incidental tumors after OLT, 2) tumors outside of Milan criteria, 3) preoperative vascular invasion prior to LR and 4) Child-Pugh Class C cirrhosis prior to OLT, 261 patients (LR = 121; OLT = 140) were included in this analysis. Results Median follow-up time was 35 months. Median waiting time for OLT was 7.7 months; during this time, 30 patients were taken off the waiting list. Overall survival (OS) from time of listing or LR was not different between the two groups; 1, 3, and 5 year OS after LR was 89%, 75%, and 56% compared with 90%, 70%, and 64% for OLT (P = .84). Only patients who waited <4 months for OLT (n = 67) had better survival than those who underwent LR (P = .05). Patients who waited longer that four months for OLT had a 2.5× higher risk of death in a Cox multivariate model [odds ratio (OR) 2.5; 95% confidence interval (CI): 1.3–5; P = .007]. Conclusion Unless waiting time is short (<4 months), the survival of patients with early HCC is similar between LR and LT. Presented at the 2006 Seventh International Hepato-Pancreato-Biliary Association, Edinburgh, Scotland, September 3–7, 2006.     

Thrombotic Microangiopathy Following Intestinal Transplantation: A Single Center Experience

Background

Transplant-related thrombotic microangiopathy (TMA) is a well-recognized complication of all types of transplantations. Despite its known relationship with immunosuppressive therapy, only a few cases have been reported following intestinal transplantation.

Methods

We retrospectively reviewed the medical files of nine consecutive intestinal transplant patients between 2000 and 2008.

Results

The diagnosis of TMA was established in 3 patients (33%). At diagnosis the immunosuppressive therapy consisted of tacrolimus (n = 3), combined with azathioprine (n = 1) or sirolimus (n = 2) and steroids (n = 2). The median time between transplantation and TMA was 104 days (range, 55-167 days). Levels of ADAMTS13, a von Willebrand protease, were within normal ranges in all 3 patients. Treatment consisted of stopping/tapering of tacrolimus, together with initiation of plasma therapy, leading to complete remission in all 3 patients. During further follow-up, all 3 patients showed severe graft rejection necessitating more profound immunosuppressive therapy, leading to graft loss in 1 patient and infection-related death in the 2 others. At a median follow-up of 52 months (range, 9-100 months) all remaining TMA-free patients (n = 6) were alive with functioning grafts under minimal immunosuppression.

Conclusion

Herein we have described 3 intestinal transplant patients who were diagnosed with transplantation-related TMA. Despite excellent disease control the final outcomes were dismal, which clearly contrasts with the outcome among TMA-free patients, who were all well with functioning grafts at last follow-up.     

Retroperitoneal Soft Tissue Sarcomas: Experience at a Single Institution in Mexico

Background  

Retroperitoneal soft tissue sarcomas (RSTS) are a rare and uncommon entity with a poor 5-year overall survival (OS) of approximately 50%, even though they rarely metastasize. The aim of the present study was to analyze the survival of patients with RSTS treated at our institution.     

Clinical Significance of Splenic Hilar Dissection with Splenectomy in Advanced Proximal Gastric Cancer: An Analysis at a Single Institution in Japan

Background

Significance of splenic hilar node dissection with splenectomy is now denied for advanced gastric cancer of upper one-third of the stomach without invasion to the greater curvature by the Japan Clinical Oncology Group 0110, a pivotal randomized study from Japan. However, a question remains for tumors which involve the greater curvature, as this study excluded such tumors.

Methods

We retrospectively analyzed 421 consecutive patients with gastric cancer who underwent curative total gastrectomy with splenectomy from 1992 to 2009. The survival curves, state of lymph node (LN) metastasis, and index of the estimated benefit from LN dissection of each station were evaluated according to the tumor location.

Results

The incidence of No. 10 metastasis was 9.3 % (39/421), with 15.9 % in patients with tumors involving the greater curvature (Gre group, n = 132) and 6.2 % in those without (non-Gre group, n = 289) (P = 0.032). The 5-year overall survival (OS) of patients with and without No. 10 metastasis was 35.4 and 43.1 % (P = 0.135) in the Gre group and 32.8 and 66.5 % (P = 0.0006) in the non-Gre group, respectively. The index of No. 10 LN dissection was 5.6 and 2.0 in the Gre and non-Gre groups, respectively. In the Gre group, the index was relatively higher in patients aged < 65 years, within pT3, and with Borrmann type 4 tumors.

Conclusions

Splenectomy may have a survival benefit when a tumor shows involvement with the greater curvature, especially in relatively young patients and those without serosal exposure.

     

Robotic Versus Open Pancreaticoduodenectomy: A Comparative Study at a Single Institution

Background  

Minimally invasive pancreaticoduodenectomy (PD) remains one of the most challenging abdominal procedures, and its application is poorly reported in the literature so far. To date, few data are available comparing a minimally invasive approach to open PD. The aim of the present study is to compare the robotic and open approaches for PD at a single institution.     

20-Year Analysis of Kidney Transplantation: A Single Center in Japan

Background

Patient and graft survival after successful kidney transplantation (KT) have improved despite an increase in the number of challenging cases. Various factors have evolved during the long history of kidney transplantation.

Methods

Between 1988 and 2012, a total of 292 living donor and 56 deceased donor KTs were performed at Niigata University Hospital. Long-term patient and graft survival and changes in background during a 20-year period in a single center were retrospectively analyzed.

Results

Excellent patient survival rates of 95.1% at 20 years for living donor KT and 96.2% at 15 years for deceased donor KT were observed. Graft survival rates at 1, 5, 10, 15, and 20 years were 96.8%, 95.4%, 83.1%, 61.8%, and 56.2% in living donor KT, respectively. In contrast, graft survival rates at 1, 5, 10, and 15 years in deceased donor KT were 89.0%, 80.3%, 77.3%, and 33.8%, respectively. These survival rates have dramatically improved since 2002 (91.7% for living and 80.9% for deceased donor KT at 10 years post-transplantation). The number of elderly recipients (older than 60 years) and the percentage of grafts donated from spouses have increased. The rejection rate decreased and the cytomegalovirus antigenemia–positive rate increased during the 20-year period assessed. The percentage of pre-emptive KTs progressively increased, with graft survival in this group tending to be better than non-preemptive KTs. The causes of graft loss were chronic allograft dysfunction (54.7%), acute rejection (11.1%), and malignancies (9.4%). After living donor KT, the principal predictors of graft loss were if the recipient was younger than 30 years, if the donor was older than 50 years, and if the rejection episodes occurred after living donor KT. In contrast, the only risk factor in the case of deceased donor KT occurred after transplantation from donors who were older than 50 years.

Conclusions

A summary of the long-term outcome of KT over 20 years in a single center has been reported. Along with the changes in patient backgrounds, immunosuppressive drugs, and our knowledge of transplantation, patient and graft survival outcomes have also changed. Investigation into such outcomes during a different transplantation era is required to fully appreciate advances in KT.     

Clinicopathologic Characteristics and Prognosis of Diffuse Sclerosing Variant of Papillary Thyroid Carcinoma in Japan: An 18-Year Experience at a Single Institution

Background  Diffuse sclerosing variant (DSV) is a variant of papillary thyroid carcinoma that has diffuse involvement in one or both thyroid lobes without forming a dominant mass. We investigated the biological characteristics of DSV in Japan. Methods  We investigated biological behaviors and prognoses of DSV in 35 patients who underwent surgical treatment between 1989 and 2007. Results  After excluding papillary microcarcinoma, DSV accounts for 0.7% of papillary carcinoma. DSV occurs more frequently in younger patients and is clinically apparent as lymph node metastasis and lung metastasis more frequently than other papillary carcinomas, but the incidence of extrathyroid extension did not differ between the metastases. Routine radioiodine ablation therapy after initial surgery was not performed unless distant metastasis was clinically apparent at surgery. The disease-free survival rate of DSV was significantly worse than that of a pair-matched control group. However, only two patients, one with lung metastasis at surgery and another who underwent only palliative surgery, have died of carcinoma to date. Conclusions  Although cause-specific survival of DSV was good, its disease-free survival was worse than that of the control group because of the unavailability of routine radioiodine ablation therapy. Therefore, DSV requires careful surgical resection to minimize the carcinoma recurrence.     

Clinicopathological Features and Prognostic Factors of Adenocarcinoma of the Esophagogastric Junction According to Siewert Classification: Experiences at a Single Institution in Japan

Background

Treatment strategy for adenocarcinoma of the esophagogastric junction (AEG) remains controversial. The aims of this study are to evaluate results of surgery for AEG, to clarify clinicopathological differences according to the Siewert classification, and to define prognostic factors.

Methods

We retrospectively analyzed 179 consecutive patients with Siewert type I, II, and III AEG who underwent curative (R0) resection at the National Cancer Center Hospital East between January 1993 and December 2008.

Results

Patients with AEG were divided according to tumor: 10 type I (5.6%), 107 type II (59.8%), and 62 type III (34.6%). Larger, deeper tumors and nodal metastasis were more common in type III than type II tumors. No significant differences were seen in 5-year survival rates among the three types: type I (51.4%), type II (51.8%), and type III (62.6%). Multivariate analysis showed that depth of tumor and mediastinal lymph node metastasis were independent prognostic indicators. The recurrence rate for patients with mediastinal lymph node metastasis was 87.5%. The risk factors for mediastinal lymph node metastasis were length of esophageal invasion and histopathological grade.

Conclusions

Mediastinal lymph node metastasis and tumor depth were significant and independent factors for poor prognosis after R0 resection for AEG. Esophageal invasion and histopathological grade were significant and independent factors for mediastinal lymph node metastasis.     

Chordoma: Natural History and Results in 28 Patients Treated at a Single Institution

Background: The natural history of chordoma is characterized by a high failure rate and a poor functional outcome. The purpose of this study was to review the long-term outcome of our institutional experience.Methods: The clinical features, type of treatment, pathologic assessment, and follow-up of 56 consecutive patients with chordoma were reviewed.Results: Fifty sacral and six mobile spine chordomas (median size, 13 cm; range, 2–30 cm) were treated at our center between January 1933 and December 2000. Twenty-eight patients affected by sacrococcygeal chordoma and operated on after 1977 form the basis of our study. Surgical margins were rated as wide in 11 cases, marginal in 13 cases, and intralesional in 4 cases. The median follow-up was 71 months (range, 15–200 months). Seventeen patients disease recurred. Ten patients died as a result of disease. Nine patients remained continuously free of disease. The estimated 5- and 10-year overall survival was, respectively, 87.8% and 48.9%; disease-free survival was 60.6% and 24.2%. Radiotherapy was considered for marginal and intralesional resections.Conclusions: High sacral amputation can achieve a good rate of wide-margin resections for sacrococcygeal chordomas. Adjuvant radiotherapy may offset the negative effect in the prognosis of marginal resections.     

Treatment of the Adenocarcinoma of the Esophagogastric Junction at a Single Institution in Mexico

BACKGROUND: Adenocarcinoma of the esophagogastric junction (EGJ) is rapidly increasing in the west. Our aim is to define the prognostic factors and treatment of EGJ carcinoma in Mexico, particularly the location after the Siewert's classification. METHODS: A retrospective cohort of patients suffering from EGJ adenocarcinoma treated from 1987 to 2000. The Kaplan-Meier and the Cox's models were used to define prognostic factors. RESULTS: Two hundred and thirty-four patients were included, 90 females and 144 males. Surgical resection was possible in 68 cases only (29%). Significant prognostic factors were tumor node metastasis (TNM) stage [stages I-II: risk ratio (RR) is 1; stage III RR is 1.3, 95% confidence interval (CI) 0.75-2.4; stage IV RR, 2.04, 95% CI 1.1-3.7], gender (male RR = 1.47, 95% CI 1.05-2.05), metastatic lymph node ratio (no resection: RR = 1; ratio 0.2-1 RR=0.67, 95% CI 0.39-1.14; ratio 0-0.19 RR = 0.42, 95% CI 0.23-0.76) and seralbumin (3 mg/dL or less RR = 2.05 95% CI 1.3-3.2; 3.1-3.4 mg/dL RR = 1.9 95% CI 1.2-3.03; 3.5-3.8 mg/dL RR = 1.3 95% CI 0.8-1.9; 3.9 mg/dL or more: RR = 1) (model P = 0.0001). CONCLUSIONS: EGJ adenocarcinoma is a highly lethal neoplasia and the location after the Siewert' classification is not a prognostic factor. In Mexico, TNM clinical stage, serum albumin, gender, surgical resection and metastatic lymph node ratio are significant prognostic factors. Curative treatment is infrequent but radical resection is associated to longer survival. Consequently, the management must consider quality of life and surgical morbidity.     

Diaphragmatic Hernia After Hepatic Resection: Case Series at a Single Western Institution

Background

Diaphragmatic hernia (DH) after hepatic resection (HR) is a rare and not well-described complication. We report our experience with DH following a high volume of HRs in a tertiary center.

Methods

Records of patients undergoing major HR for liver tumors between April 1992 and November 2011 were reviewed. The definitive diagnosis of DH was made based on radiologic studies. Primary repair was used for defects <10?cm in size. Transthoracic repair was used in patients with recurrent or complex hernias. Univariate analysis was performed to determine risk factors associated with posthepatectomy DH.

Results

DH developed in 10 out of 993 patients (1?%) at a median time interval of 15?months after HR. DH was not associated with old age (m?=?48.5?years), gender (male?=?50?%), or high body mass index (m?=?24.5). However, mean tumor size was large (m?=?9.2?cm). The majority of patients presented with symptoms (80?%), small (60?%) and right-sided (80?%) hernias, and underwent elective repair via an abdominal approach (70?%). Large defects (>10?cm; 30?%) were successfully repaired with prosthetic mesh. Increased incidence of DH was associated with diaphragmatic resection at the time of HR (5.4 vs. 0.7?%, p?=?0.001). At a median follow-up of 36?months (range, 10?C167?months) after hernia repair, recurrence occurred in one patient.

Conclusion

Diaphragmatic resection at the time of HR and large tumor size may put patients at risk of developing posthepatectomy DH. Early detection and prompt treatment is associated with low recurrence and offers the advantage of primary repair.     

Myxofibrosarcoma: Prognostic Factors and Survival in a Series of Patients Treated at a Single Institution

Background

First described in 1977, myxofibrosarcoma is one of the most common sarcoma subtypes of the elderly. Until some years ago, myxofibrosarcoma was diagnosed as “myxoid malignant fibrous histiocytoma.” The aim of this retrospective case series analysis was to investigate prognostic factors and the clinical outcome of a cohort of patients with myxofibrosarcoma treated at a single institution.

Methods

We reviewed 158 patients with localized myxofibrosarcoma who underwent surgery at the Istituto Nazionale Tumori of Milan, Italy, over 15 years. Local recurrence, distant metastases, and survival were analyzed.

Results

One hundred twenty patients had primary tumors, while 38 patients had locally recurrent tumors. Five-year overall survival was 77%. Tumor size, grade, and margins were statistically significant predictors of survival. Five-year local recurrence and distant metastases rate were 18% and 15%, respectively. Surgical margins were the only statistically significant prognosticator of local relapses. Patients treated with radiotherapy had the same prognosis as nontreated patients, but likely they had worse local presentations. The histological grade correlated with distant recurrences but not with local relapses. The value of adjuvant chemotherapy could not be determined.

Conclusions

Patients with myxofibrosarcoma have a better disease-specific survival than other sarcoma subtypes, but also a higher local relapse rate. This is likely related to the peculiar local growth pattern of these tumors. Adequate surgery should be pursued, while the role of adjuvant therapies need to be investigated.     

Management of De Novo Mycobacterial Infection After Lung Transplantation Without Rifampicin: Case Series of a Single Institution

Background and Objectives

To treat organ transplant patients with mycobacterial infection, physicians need to pay attention to interaction between drugs used against mycobacteria and immunosuppressants. The purpose of this report is to describe the clinical features of and treatment for mycobacterial infection in lung transplant (LTx) recipients.