Gastric contents in pediatric patients following bone marrow transplantation

Background: Graft versus host disease (GVHD) of the gut is thought to delay gastric emptying and so may increase the risk of aspirating retained contents while under anesthesia. Knowing that gastric emptying is delayed in patients with GVHD might lead one to choose to intubate the trachea for all patients with suspected GVHD, who present for diagnostic esophagogastricduodenoscopy (EGD). We are not aware of published data that gives specific guidance as to the need for intubation in the pediatric bone marrow or stem cell transplantation (BMT) population. This review was intended to evaluate the gastric contents (pH and volume) in this group of patients, to provide anesthesiologists with data that would inform their decisions about airway management for these patients. Methods: Retrospective chart review of patients ≤19 years of age undergoing EGD between 2004 and 2006. Gastric content volume and pH were measured in addition to underlying disease state and treatment. We compared BMT patients with suspected GVHD to nontransplant patients with other underlying gastrointestinal conditions. Results: Data were obtained for 77 patients post‐BMT undergoing EGD, including 40 patients whose biopsies and endoscopic findings were positive for GVHD, and 37 patients with no demonstrable GVHD. Records of 144 non‐BMT patients undergoing EGD within the same study period were also reviewed. Conclusion: Patients in the BMT group overall did not have higher volumes when compared to non‐BMT patients. A secondary comparison of BMT patients who were found to have GVHD vs BMT patients without GVHD suggests that gastric content volume may be elevated with GVHD. Patients in the BMT group had statistically significantly higher gastric pH than patients in the non‐BMT group. It is possible that the higher gastric volume in the GVHD‐positive group could put them at slightly higher risk for aspiration, but the severity of any pneumonitis, should aspiration occur, might be mitigated, by the tendency toward a higher gastric pH in the BMT patients.     

Use of a preoperative bleeding questionnaire in pediatric patients who undergo adenotonsillectomy

OBJECTIVE: To determine the efficacy of a preoperative bleeding questionnaire (POBQ) and coagulation screening in predicting hemorrhage associated with adenotonsillectomy. STUDY DESIGN: Retrospective study. SUBJECTS AND METHODS: Between January 1998 and December 2003, 7730 tonsillectomy and adenotonsillectomy patients were administered the POBQ preoperatively. Further coagulation screening was based on POBQ responses. RESULTS: A total of 232 (3.0%) of 7730 had postoperative bleeding; 184 (3.2%) of 5782 patients who had negative questionnaires bled postoperatively compared with 48 (2.5%) of 1948 patients with positive questionnaires (P = 0.126). Of 1948 patients with positive questionnaires, 141 (7.2%) had abnormal preoperative coagulation screens and 9 (6.4%) of 141 bled; of the 1807 (92.8%) with negative coagulation screens, 39 (2.2%) bled (P = 0.005). CONCLUSION: The POBQ is an effective tool for identifying patients who are at potential risk for post-tonsillectomy bleeding. Patients with both a positive POBQ and coagulation screen had a statistically higher likelihood of postoperative bleeding than other patients. The POBQ allowed the identification of individuals with bleeding disorders to be treated before surgery, likely decreasing the risk of bleeding in these patients.     

The long-term outcome of treated sensitized patients who undergo heart transplantation

Kobashigawa JA, Patel JK, Kittleson MM, Kawano MA, Kiyosaki KK, Davis SN, Moriguchi JD, Reed EF, Ardehali AA. The long‐term outcome of treated sensitized patients who undergo heart transplantation.
Clin Transplant 2011: 25: E61–E67. © 2010 John Wiley & Sons A/S. Abstract: Background: Sensitized patients prior to heart transplantation are reportedly at risk for hyperacute rejection and for poor outcome after heart transplantation. It is not known whether the reduction of circulating antibodies pre‐transplant alters post‐transplant outcome. Methods and Results: Between July 1993 and July 2003, we reviewed 523 heart transplant patients of which 95 had pre‐transplant panel reactive antibody (PRAs) >10%; 21/95 were treated pre‐transplant for circulating antibodies. These 21 patients had PRAs > 10% (majority 50–100%) and were treated with combination therapy including plasmapheresis, intravenous gamma globulin and rituximab to reduce antibody counts. The 74 untreated patients with PRAs > 10% (untreated sensitized group) and those patients with PRAs < 10% (control group) were used for comparison. Routine post‐transplant immunosuppression included triple‐drug therapy. After desensitization therapy, circulating antibody levels pre‐transplant decreased from a mean of 70.5 to 30.2%, which resulted in a negative prospective donor‐specific crossmatch and successful heart transplantation. Compared to the untreated sensitized group and the control group, the treated sensitized group had similar five‐yr survival (81.1% and 75.7% vs. 71.4%, respectively, p = 0.523) and freedom from cardiac allograft vasculopathy (74.3% and 72.7% vs. 76.2%, respectively, p = 0.850). Conclusion: Treatment of sensitized patients pre‐transplant appears to result in acceptable long‐term outcome after heart transplantation.     

Management of asymptomatic cholelithiasis for patients awaiting renal transplantation

Background There is no consensus regarding the most appropriate management of asymptomatic cholelithiasis in patients awaiting renal transplantation. Cholecystectomy is considered before renal transplantation because of potential worsened complications from cholelithiasis with posttransplantation immunosuppression. This study reviewed the outcomes for operative and nonoperative management of asymptomatic cholelithiasis in patients awaiting renal transplantation.Methods A retrospective chart review of all patients who received renal transplant at the authors’ institution during the period 1994 to 2000 was completed. All patients underwent pretransplantation abdominal ultrasound.Results Of the 411 patients receiving renal transplants (242 men and 169 women with a mean age of 45.7 years), 32 had cholelithiasis at the pretransplantation workup (7.8%), and 35 had gallbladder abnormalities (8.5%): polyps, thickened wall, sludge, bile duct dilation. Before transplantation, 12 of the 32 patients (38%) with cholelithiasis underwent uncomplicated cholecystectomy. None of the remaining 19 patients with cholelithiasis required cholecystectomy after renal transplantation (mean follow-up period 6.2 years). Of the 35 patients with gallbladder abnormalities, 2 required post transplantation elective cholecystectomy.Conclusions No evidence was found for increased morbidity related to cholelithiasis or gallbladder abnormalities after renal transplantation. As in the general population, the risks associated with asymptomatic cholelithiasis do not appear to warrant prophylactic cholecystectomy for patients awaiting renal transplantation.Society of American Gastrointestinal and Endoscopic Surgeons(SAGES) 2004 oral presentation, program #2003     

Prognostic value of serum carcinoembryonic antigen levels in patients who undergo lung transplantation

BACKGROUND: Potential candidates for lung transplantation undergo a rigorous evaluation before transplant. Serum carcinoembryonic antigen (CEA) levels are used as a screening tool for occult malignancy in many lung transplant centers. We reviewed the pre-transplant CEA levels in lung transplant recipients in our institution to determine their prognostic significance. MATERIALS AND METHODS: We performed a retrospective database review of the first 200 patients that had undergone lung or heart-lung transplant at our institution (dates were 1/20/92-7/25/98). Data extracted included CEA levels (in ng/ml) at the time of lung transplant evaluation, demographic data, and survival. Patients had one of the following diagnoses: alpha-1-anti-trypsin deficiency, cystic fibrosis, chronic obstructive pulmonary disease, Eisenmenger's syndrome, idiopathic pulmonary fibrosis, primary pulmonary hypertension, sarcoidosis, or other. RESULTS: After excluding re-transplants, CEA results were available for 174 of 193 (90.2%) patients. CEA levels were elevated in 85 patients (48.9%) with a mean value of 3.15 +/- 2.55 (normal < 2.5). Solid organ cancers developed in 6 patients, at a median follow-up of 27.5 months after transplant. Their mean pre-transplant CEA level was similar to the rest of the group (3.52 +/- 2.05). Pre-transplant CEA levels did not predict post-transplant survival. Patients with idiopathic pulmonary fibrosis had the highest pre-transplant CEA levels, whereas patients with primary pulmonary hypertension and Eisenmenger's syndrome had the lowest (5.36 +/- 4.59, 0.83 +/- 0.56, and 1.43 +/- 0.81, respectively; p = 0.0001). CONCLUSIONS: CEA levels are high in patients with end-stage lung disease, especially IPF. Their levels appear to be a marker of the underlying disease and do not predict the post-transplant survival or development of malignancy.     

Open lung biopsy in pediatric bone marrow transplant patients

Purpose: The aim of this study was to evaluate the clinical benefits of open lung biopsy in the diagnosis and treatment of pulmonary infiltrates in children who have undergone bone marrow transplantation. Methods: The authors retrospectively reviewed the medical records of all patients in whom pulmonary infiltrates developed within 6 months after bone marrow transplantation. Of 528 patients who received bone marrow transplants (313 allogeneic, 215 autologous) at St Jude Children's Research Hospital between June 1991 and December 1998, 83 (16%) had radiographic evidence of pulmonary infiltrates after the procedure. Of these, 43 (52%) underwent bronchoalveolar lavage (BAL), 19 (23%) underwent open lung biopsy (OLB), 6 (7%) underwent needle biopsy, and 5 (6%) underwent transbronchial biopsy; 21 received medical therapy alone. The authors evaluated the outcome, culture results, histopathologic findings, radiographic findings, and clinical features of those who underwent OLB. Results: The 19 patients ranged in age from 0.9 to 19.8 years (median, 11.4 years). Histopathologic studies indicated an infectious process in 6 patients (30%), bronchiolitis obliterans organizing pneumonia (BOOP) in 5 (26%), interstitial pneumonitis (IP) in 4 (21%), gangliosidosis in 1, and lymphocytic infiltrate in 1. Although the clinical plan was changed on the basis of the histopathologic diagnosis for 17 of the 19 patients (90%), improvement in outcome was seen in only 8 (47.5%) of these patients. Postoperative morbidity (30 days) was 47% and included prolonged intubation (7 patients), pneumothorax (2 patients), and pleural effusion (1 patient). The 30-day survival rate was 63.2% [plusmn] 10.6%. No patient with multisystem organ failure (MSOF), ventilator dependence, or a postoperative complication survived after OLB. Conclusions: Histopathologic analysis of OLB specimens is very accurate in determining the cause of pulmonary infiltrates in pediatric patients who have undergone BMT, but OLB may not improve patient outcome. Because the postoperative morbidity and mortality rates associated with OLB are high, careful patient selection is necessary. The mortality rates of patients with MSOF or ventilator dependence are particularly high; therefore, less-invasive alternatives for diagnosis of pulmonary lesions should be considered before OLB is performed.     

Importance of bone marrow cell dose in bone marrow transplantation

The importance of the size of the infused marrow cell dose (MCD) was investigated in 274 patients undergoing allogeneic BMT between 1975 and 1990. Among those, 65 had acute myelogenous leukemia (AML), 79 acute lymphoblastic leukemia (ALL), 58 chronic myelogenous leukemia (CML) and 25 severe aplastic anemia (SAA). MCD was analyzed in bivariate and multivariate analysis together with 6 other clinical factors. In multivariate analysis a low MCD was significantly associated with increased incidence of acute graft-versus-host disease (GvHD) in all patients (p = 0.005) and in ALL patients (p = 0.02) whereas in CML a high dose was instead correlated to acute GvHD. A low MCD was also correlated to an increased incidence of symptomatic cytomegalovirus (CMV) infection (p = 0.001). A low MCD was also correlated to death in acute GvHD in all patients (p = 0.01) and to a poor survival in all patients (p = 0.04) (AML, p = 0.07).     

Management of pediatric patients who have swallowed foreign objects

The clinical management of children who have swallowed foreign bodies presents a great challenge for both pediatricians and pediatric surgeons. Our 7-year experience of treating 141 patients with a history of foreign body ingestion is reported. In 114 patients, there were 122 foreign bodies present in areas from the esophagus to the rectum, as located by plain chest and abdominal x-ray examination. In two patients, a plastic toy and the plastic cap of a razor were passed with stool a few days later. In the remaining 25 patients, nothing was found. In babies under one year of age, button batteries were the most commonly swallowed foreign bodies, while coins were the most frequently swallowed objects in children over the age of three years. Seventeen foreign bodies in the esophagus were removed: seven by balloon catheter, four endoscopically, and one by a magnet tube. Four were dislodged into the stomach. Twenty nine of the 78 items present in the stomach were button batteries and 23 of the items were removed using a magnet tube. One was removed endoscopically and 5 batteries that had moved beyond the pylorus were excreted within 48 hours. Twenty four coins in the stomach were managed conservatively. Surgical intervention was required in two patients; one patient had a previous history of pyloromyotomy, and a magnet tag measuring 1.5 cm in diameter did not pass through the pylorus for 7 weeks. The other patient had swallowed a sewing needle that moved into the descending colon and abdominal pain ensued.     

Bronchiectasis in bone marrow transplantation

Two patients are described with clinical and radiographic bronchiectasis which occurred after allogeneic bone marrow transplantation for haematological malignancy. Both had evidence of chronic graft versus host disease in other organs. Increased immunosuppression with corticosteroids resulted in clinical response, although both patients persisted with chronic mucopurulent sputum production and one had progressive airflow obstruction. Bronchiectasis may be an under-recognised manifestation of chronic graft versus host disease of the lung.


     

Subjective xerostomia in long-term surviving children and adolescents after pediatric bone marrow transplantation

BACKGROUND: The aim of the present investigation was to evaluate whether the subjective symptoms of dry mouth in long-term-surviving pediatric bone marrow transplant (BMT) patients are associated with low unstimulated salivary secretion rates (USSR) and with stimulated whole salivary secretion rates (SSSR). METHODS: Fifty-three patients surviving > or =2 years after pediatric allogeneic BMT were included. USSR, SSSR, and the change in salivary secretion rates since the previous year were estimated. A questionnaire regarding subjective symptoms of xerostomia was answered. RESULTS: The mean USSR and SSSR were 0.24+/-0.17 and 0.90 +/- 0.58 ml/min, respectively. Salivary gland dysfunction, defined as USSR < or =0.1 ml/min or SSSR < or =0.5 ml/min, was present in 35% of the patients. Seventy-nine percent of the patients expressed one or more symptom of dry mouth, and 49% gave at least two answers indicating dry mouth. The number of complaints increased with age at examination (P<0.05). Both USSR (P<0.01) and SSSR (P<0.01) were inversely correlated to the total number of complaints of xerostomia. A reduction in SSSR compared with the year before was correlated to two or more complaints of xerostomia (P<0.01). The presence of dry mouth at night or on awakening was indicative of both low USSR (P<0.01) and SSSR (P<0.001). Patients reporting dryness during the day had significantly lower SSSR (P<0.05). CONCLUSION: The expression of subjective complaints of xerostomia among long-term surviving pediatric BMT patients is correlated to salivary gland dysfunction and age. It is very important to identify these patients with salivary gland dysfunction to relieve their symptoms and prevent secondary complications.     

Postoperative management of patients who undergo aortic surgery

Because patients with occlusive or aneurysmal disease of the aorta frequently have coexisting disease in other important organ systems, complications after aortic surgery usually relate to the heart, lungs and kidneys. Postoperative care thus requires attention, in an intensive-care milieu, to respiratory, cardiac, renal and gastrointestinal systems, coagulation and, in rare instances, psychiatric problems.     

Lymphocytotoxic antibodies in leukemic patients treated with bone marrow transplantation

Lymphocytotoxic antibodies were studied sequentially in a series of 42 patients with leukemia who received a bone marrow graft. Of these patients, 38% had cytotoxic antibodies before bone marrow transplantation (BMT). After BMT the antibody status changed with time, but 62% of the patients had antibodies at some time after BMT. During the first 10 weeks after BMT, 40% of the patients had antibodies. Thereafter the frequency rose to 50% and remained at that level beyond one year after BMT. In successful grafts the gamma globulins are of donor origin six months after BMT; thus donor B cells are capable of forming lymphocytotoxic antibodies even when the immune system is suppressed by cyclosporine. The antibodies had recognizable HLA specificity in about half the cases before and after BMT. When donor and patient were HLA-identical, HLA specificity did not correspond to donor/recipient antigens. In two cases in which the donor was matched for only one haplotype, antibodies formed by recipient cells, active against donor HLA antigens, were found.     

Heparin-induced thrombocytopenia in patients who undergo open heart surgery

To determine whether heparin-dependent antiplatelet antibodies (HAAb) have an effect on morbidity and/or mortality rates, we reviewed the cases of 3438 patients who underwent open heart surgery from 1981 to 1989. Forty-six patients (1.3%) had HAAb. The patients were divided into two groups: those patients who were known to have HAAb before surgery (group I) and those patients who were diagnosed with HAAb after surgery (group II). Group I patients (n = 5) were pretreated with platelet-inhibiting drugs before reexposure to heparin during cardiopulmonary bypass and were maintained with strict abstinence from heparin afterward. Their lowest observed platelet counts ranged from 42,000/mm3 to 89,000/mm3 (median, 63,00/mm3). Thromboembolic complications did not occur, and all patients survived. Group II patients (n = 41) who were diagnosed to have HAAb after surgery had not been pretreated with platelet-inhibiting drugs before surgery. Lowest platelet counts ranged from 11,000/mm3 to 128,000/mm3 (median, 42,000/mm3). Bleeding complications occurred in 21 patients (51%), and thromboembolic complications occurred in 13 patients (32%). Hospital mortality in group II patients was 37%. Late recognition of HAAb was associated with an increase in morbidity and mortality rates. Thromboembolic complications of HAAb, which had been diagnosed before surgery, were eliminated, and bleeding was reduced by pretreatment with platelet-inhibiting drugs and strict abstinence from heparin after surgery.     

Management of pediatric patients with refractory constipation who fail cecostomy

Background

Antegrade continence enema (ACE) is a recognized therapeutic option in the management of pediatric refractory constipation. Data on the long-term outcome of patients who fail to improve after an ACE-procedure are lacking.

Purpose

To describe the rate of ACE bowel management failure in pediatric refractory constipation, and the management and long term outcome of these patients.

Methods

Retrospective analysis of a cohort of patients that underwent ACE-procedure and had at least 3-year-follow-up. Detailed analysis of subsequent treatment and outcome of those patients with a poor functional outcome was performed.

Results

76 patients were included. 12 (16%) failed successful bowel management after ACE requiring additional intervention. Mean follow-up was 66.3 (range 35–95 months) after ACE-procedure. Colonic motility studies demonstrated colonic neuropathy in 7 patients (58%); abnormal motility in 4 patients (33%), and abnormal left-sided colonic motility in 1 patient (9%). All 12 patients were ultimately treated surgically. Nine patients (75%) had marked clinical improvement, whereas 3 patients (25%) continued to have poor function issues at long term follow-up.

Conclusions

Colonic resection, either segmental or total, led to improvement or resolution of symptoms in the majority of patients who failed cecostomy. However, this is a complex and heterogeneous group and some patients will have continued issues.     

Lung transplantation after allogeneic marrow transplantation in pediatric patients: the Memorial Sloan-Kettering experience.

BACKGROUND: Chronic lung disease and pulmonary failure are complications that can occur after bone marrow transplantation (BMT) and are associated with severe morbidity and mortality. METHODS: We report on four patients who developed chronic, progressive, and irreversible lung disease 1 to 3 years after allogeneic BMT in childhood. These patients had chronic graft-versus-host disease (n=3) or radiation-related pulmonary fibrosis (n=1). Three patients underwent double lung transplants and one patient underwent a single lung transplant 2 to 14 years after BMT. RESULTS: All four patients tolerated the lung transplantation procedure well and showed significant clinical improvement with normalization of pulmonary function tests by 1 year posttransplant. One patient died from infectious complications 3 years after lung transplantation, and one patient died after chronic rejection of the transplanted lungs 6 years posttransplant. Two patients remain alive without significant respiratory impairment 2 and 7 years after lung transplantation. CONCLUSION: We conclude that lung transplantation offers a viable therapeutic option for patients who develop respiratory failure secondary to BMT.     

Renal involvement in bone marrow transplantation

Bone marrow transplantation (BMT) is an effective therapeutic strategy for leukaemic malignancies and depressed bone marrow following cancer. However, its side effects on kidneys have been reported. Some drugs and irradiation are also suggested to be nephrotoxic. It is well known that haemolytic uraemic syndrome (HUS) after BMT develops as late-onset BMT nephropathy. Cyclosporine A (CsA) is a possible cause. Radiation nephropathy shows changes that are similar to the histology of HUS. These findings suggest that endothelial damage is closely associated with the pathogenesis of post-BMT nephropathy. Recently, some patients have developed glomerulonephritis accompanied by graft-versus-host disease (GVHD) after BMT. In these patients immune deposits are found mainly in subepithelium and mesangium equal to those of secondary membranous glomerulonephritis. A murine experimental model of GVHD manifests similar symptoms and histological changes to those of actual patients and may suggest the pathogenesis of glomerulonephritis.