Isolated liver and multivisceral transplantation for total parenteral nutrition-related end-stage liver disease

Purpose

Total parenteral nutrition (TPN) has prolonged survival in children with intestinal failure; however, end-stage liver disease owing to TPN-induced cholestasis (ESLD-TPN) may preclude its use. ESLD-TPN is an indication for isolated liver transplantation (ILT) or multivisceral transplantation (MVT). Isolated liver transplantation for ESLD-TPN should only be considered in patients who have the potential for enteral autonomy.

Methods

We retrospectively reviewed the records of patients with ESLD-TPN who underwent ILT (n = 7) or MVT (n = 5) between 1994 and 2005. The median age at the time of transplantation was 10.0 months. Intestinal failure followed necrotizing enterocolitis (n = 3), gastroschisis (n = 3), gastroschisis with volvulus (n = 3), gastroschisis with atresia (n = 1), malrotation (n = 1), and megacystis microcolon intestinal hypoperistalsis syndrome (n = 1).

Results

Isolated liver transplant patients had a median length of small bowel of 70 cm and tolerated a median of 50% of enteral calories. The median length of small bowel in patients who underwent MVT was 29 cm, and none tolerated more than 30% of goal enteral feeds. Reduced-size (n = 5) and whole-liver (n = 2) allografts were used for patients undergoing ILT. Patients undergoing MVT received liver-small bowel-pancreas (n = 4) or liver-small bowel-pancreas-colon (n = 1). Overall patient survival was 57% in ILT (median follow-up = 25.1 months); 3 survivors are TPN independent, and the fourth patient requires TPN 3 days/wk. Patient survival was 40% after MVT (median follow-up = 13.0 months); 1 MVT patient died of abuse 16.9 months after transplant and was TPN independent at the time of death. Both survivors are TPN independent. Bilirubin levels are within normal range in all survivors.

Conclusion

Isolated liver transplantation for ESLD-TPN in the setting of intestinal failure is a viable option in patients who have the potential for enteral autonomy. Multivisceral transplantation is the only alternative in patients without the potential for intestinal recovery. Survival can be achieved in patients with ESLD-TPN, but mortality remains high for both procedures.     

Results of growth trophic therapy in children with short bowel syndrome

Purpose

In addition to the structural, ultrastructural, and functional changes that occur after extensive enterectomy or in utero bowel loss that results in short bowel syndrome (SBS), a complex array of humoral responses take place that may also affect adaptation of the remaining small intestine as well as nutritional status or growth. These include alterations in the levels of circulating hormones and trophic substances such as growth hormone (GH) and insulinlike growth factors (IGF-1 and IGFBP-3). The purpose of this investigation is to report on the management/treatment of 3 children with SBS (>4 years in duration) and growth failure.

Methods

Serum measures of growth factors and the response to GH stimulation after an arginine insulin tolerance test (AITT) were determined. Weight and height z-scores as well as linear growth velocity were calculated annually pre- and postinitiation of medication therapy.

Results

Patient 1 (boy, 8.5 years old, midgut volvulus, 18-cm bowel) was found to be GH deficient, whereas patients 2 (girl, 12.5 years old, gastroschisis, 70-cm bowel) and 3 (boy, 9 years old, jejunal atresia, 21 cm bowel) were found to have limited GH responsiveness. Subsequently, treatment with GH (1) and growth releasing factor (GRF; 2 & 3) was prescribed. Z-scores for both weight and height improved over time. Positive linear growth velocity was observed from initiation of therapy (<0.5 cm/yr for all) to more than 3 years of treatment (mean 1, 4.7 cm/yr; 2, 8.7 cm/yr; 3, 5.0 cm/yr [age adjusted normals >4.5, >8.5, and >4.9 cm/yr, respectively]). All patients received a regular diet with oral supplements, whereas 2 received parenteral nutrition support for about 1 year.

Conclusions

In children with medically refractory SBS, it is not only important to offer trophic factors but also essential that sufficient nutrient substrate be provided to achieve adequate growth.     

Connective tissue growth factor expression is increased in biliary epithelial cells in biliary atresia

Background/Purpose

Connective tissue growth factor (CTGF) has been implicated in the pathogenesis of hepatic fibrosis and is elevated in the serum of children with biliary atresia (BA). The objective of this study was to evaluate hepatic CTGF messenger RNA (mRNA) expression and its relationship to hepatic histology in children with BA.

Methods

Connective tissue growth factor mRNA expression was evaluated by in situ hybridization in 26 liver biopsies from 11 patients with BA, 11 with other diseases, and 4 autopsy controls. Serial sections were immunostained with cell-specific markers to characterize the cells expressing CTGF. Biopsies were scored for CTGF expression (0-4) and inflammation and fibrosis (1-4).

Results

High levels of CTGF expression were observed in 9 of 11 BA with localization to biliary epithelial cells and vascular endothelial cells. Connective tissue growth factor mRNA expression was correlated with fibrosis in BA and all livers. In the 11 patients with other liver diseases, 7 had CTGF expression limited to hepatic stellate cells and vascular endothelial cells. None of the 4 livers in children without liver disease had significant levels of CTGF.

Conclusions

In BA livers, novel biliary epithelia CTGF mRNA expression is high and correlates with severity of fibrosis. These data support a role for biliary epithelial cell signaling in fibrogenesis.     

Intestinal transplantation for total intestinal aganglionosis: a series of 12 consecutive children

Background

Management of patients with total intestinal aganglionosis (TIA) is a medical challenge because of their dependency on parenteral nutrition (PN). Intestinal transplantation (ITx) represents the only alternative treatment for patients with irreversible intestinal failure for achieving intestinal autonomy.

Methods

Among 66 patients who underwent ITx in our center, 12 had TIA. They received either isolated ITx (n = 4) or liver-ITx (LITx, n = 8) after 10 to 144 months of total PN. All grafts included the right colon.

Results

After a median follow-up of 57 months, the survival rate was 62.5% in the LITx group and 100% in the ITx patients. The graft survival rate was 62.5% in the LITx group and 75% in the ITx group. All the surviving patients were fully weaned from total PN, after a median of 57 days. Pull through of the colon allograft was carried out in all patients. Fecal continence is normal in all but one of the surviving children.

Conclusion

These results suggest that ITx with colon grafting should be the preferred therapeutic option in TIA. Early referral to a transplantation center after diagnosis of TIA is critical to prevent PN-related cirrhosis and thereby to permit ITx, which is associated with a good survival rate.     

Outcome After Steroid Withdrawal in Heart Transplantation

Background

There is a lack of consensus and insufficient data to assess the impact of late steroid withdrawal after heart transplantation (HTx). The aim of the study was to investigate the security and feasibility of corticosteroid withdrawal at 1 year after transplantation.

Methods and Results

Steroid withdrawal was attempted after at least 12 months of treatment in 86 HTx patients who fulfilled the criteria. At 1 and 3 months after drug discontinuation, patients underwent 2 endomyocardial biopsies (EMB). After a mean follow-up of 25 ± 13 months, 63% of the patients remained steroid free. In 30 patients (35%) corticosteroids were reinitiated, in 15 cases because of acute rejection (7%), 5 (6%) because of worsening renal function, 5 (6%) because of malignancy, 3 (4%) because of adverse effects of immunosuppressive drugs, and 2 because of severe allograft coronary artery disease. Four patients (5%) died after drug discontinuation. There was a significant decrease in total cholesterol (198 ± 35 to 181 ± 38 mg/dL; P < .001) and low-density lipoprotain (LDL) cholesterol levels (113 ± 30 to 105 ± 30 mg/dL; P < .001). There were no differences in mortality between patients with and without corticosteroids.

Conclusion

Steroid withdrawal is feasible and safe in HTx patients. In our study, it was successfully maintained in 63% of the patients. EMB is helpful to identify patients with acute rejection at 1 and 3 months after withdrawal. Short- to mid-term metabolic benefits are significant reductions in serum total and LDL cholesterol.     

Graft serosectomy in adult small bowel transplantation without vascular reconstruction in rats improves graft survival by induction of vascular endothelial growth factor

Purpose

The aim of this study was to assess whether adult small bowel grafts (ASBGs) can survive transplantation without vascular reconstruction if graft serosectomy (SS) is performed.

Methods

Syngeneic ASBG transplants were performed in 85 Lewis rats. The entire serosa was removed just before transplantation in the SS group (n = 50) and left intact in the nonserosectomy group (n = 35). Transplanted ASBG was harvested 1, 3, 5, 7, 14, 21, or 28 days after transplantation and studied using staining with hematoxylin-eosin, immunohistochemistry for protein gene product 9.5, S-100, CD34 and vascular endothelial growth factor (VEGF), and quantification of VEGF messenger RNA (mRNA). Adult small bowel graft viability was assessed blindly using a mucosal surface expansion score (0, no mucosa; 1, mucosa on one fourth of graft; 2, mucosa on one half of graft; 3, mucosa on three fourths of graft; and 4, circumferential mucosa on graft).

Results

No rejection was identified in any ASBG. Average mucosal surface expansion score and VEGF mRNA expression were significantly higher in the SS group (both P < .01). Vascular endothelial growth factor protein was detected in enterocytes from day 3 posttransplant in the SS group. Distribution of protein gene product 9.5 and S-100 was normal in SS-group ASBG.

Conclusions

Our results suggest that SS allows VEGF mRNA and, subsequently, VEGF protein in ASBG to be induced very soon after transplantation, which may contribute to the survival of ASBG transplanted without vascular reconstruction.     

The significance of serum hepatocyte growth factor levels in planning follow-up of postoperative jaundice-free patients with biliary atresia

Purpose

The aim of this study was to clarify the significance of serum hepatocyte growth factor (HGF), interleukin (IL)-6, and IL-1 receptor antagonist (ra) levels in the evaluation of disease status in jaundice-free survivors with biliary atresia after Kasai operation.

Patients and Methods

Serum concentrations of HGF, IL-6, and IL-ra were measured in 31 long-term jaundice-free patients with biliary atresia after Kasai operation and 29 controls. Patients were divided into 4 groups: group A (n = 8), normal liver function; group B (n = 9), mild liver dysfunction without portal hypertension; group C (n = 9), moderate liver dysfunction with controllable portal hypertension; and group D (n = 5), receiving liver transplantation.

Results

Serum IL-6 levels were significantly higher in patients than in controls. There was no difference in serum IL-6 levels among groups B, C, and D. Serum IL-1ra levels were elevated according to liver dysfunction. Serum HGF levels in group D were significantly higher than in controls and the other groups. Serum hyarulonic acid levels were positively correlated with serum levels of IL-1ra and HGF.

Conclusions

Elevation of serum IL-1ra and HGF levels correlated with the progression of liver fibrosis and dysfunction. In particular, serum HGF levels could be used as a predictor for requiring liver transplantation.     

Surgical complications after intestinal transplantation in infants and children—UK experience

Surgical complications have a significant impact on morbidity and mortality following intestinal transplantation (ITx). Birmingham Children's Hospital commenced intestinal transplantation in 1993 and the following surgical strategies evolved: (a) pretransplant abdominal tissue expanders, 1998; (b) combined en-bloc reduced liver and intestinal transplantation (CRLITx), 1998; (c) staged abdominal closure, 2001; (d) preservation of graft duodenal artery, 2005.

Aim

An internal audit was performed to document the surgical complications after ITx and to evaluate strategies in the management and prevention of complications.

Methods

A retrospective analysis of the medical records from January 1993 to June 2007 was conducted to identify surgical complications, evaluate management strategies, and report outcome following ITx.

Results

Forty-six children underwent 49 ITx (9 isolated intestinal, 39 combined liver and intestinal [CLITx], and 1 multivisceral transplant). Twenty three children had CRLITx since 1998, although there were none before 1997. The median donor: recipient weight ratio in CLITx was 2.2:1 (range, 0.67:1-6.70:1). Twenty-six children experienced 29 (59%) surgical complications: portacaval shunt thrombosis (n = 2, none alive); graft duodenal stump leakage (n = 3, 2 alive); spontaneous bowel perforation(n = 6, 2 alive); sub-acute bowel obstruction (n = 6, all alive); abdominal compartment syndrome ([ACS], n = 4, 2 alive); pancreatic leak (n = 3, 2 alive); biliary complications (n = 22, 17 alive ) failed staged abdominal closure with wound sepsis requiring skin grafting into the bowel (n = 1, alive), wound dehiscence (n = 1, alive), anastomotic leak (n = 1, alive) and intra-abdominal bleeding (n = 1,alive), primary nonfunction (n = 1, 1 died). Following the complications of ACS in children with primary abdominal closure and graft duodenal stump leaks in 2004, we modified our strategies in 2005 to include staged abdominal closure with recipient to donor weight mismatch, and preservation of the gastroduodenal artery during donor organ procurement in addition to pre transplant abdominal tissue expansion. Fifteen children with recipient and donor weight mismatch subsequently required staged closure of the abdomen and none of them developed ACS. Twelve children had gastroduodenal artery preserved and none developed graft duodenal stump leaks. Twenty-four of the 46 (52%) are alive 6 months to 10 years post transplant.

Conclusion

Evolving strategies may avoid or reduce surgical complications commonly seen after intestinal transplantation and thus contribute to an improved outcome.     

Immediate Antibody-Mediated (Hyperacute) Rejection in Small-Bowel Transplantation and Relationship to Cross-Match Status and Donor-Specific C4d-Binding Antibodies: Case Report

Background

The role of preformed donor-specific antibodies (DSAs) as a barrier to isolated intestinal transplantation (ITx) remains ambiguous; thus, a positive cross-match has not been a contraindication to ITx.

Objective

To report the case of a patient with Crohn's disease who underwent ITx and developed immediate antibody-mediated rejection on reperfusion of the allograft.

Methods

Percent reactive antibody testing was performed using pretransplantation serum samples and at transplantation using bead-based assays (Luminex, Luminex Corp, Austin, Tex) and flow cytometry solid-phase assays (FlowPRA single-antigen beads (One Lambda, Inc, Canoga Park, Calif). Serologic tests, flow cytometry cross-matching, and flow cytometry assays of C4d-binding serum antibodies were also performed. Histologic and immunofluorescent analysis of biopsy specimens was performed.

Results

HLA typing revealed no sharing of class I or II antigens between donor and recipient. Pretransplantation donor-specific antibodies (DSA) were present at transplantation. Cross-matching (performed during surgery) was positive for class I and II by serologic testing and flow cytometry. After reperfusion, the graft immediately developed severe ischemic injury and arteritis on mucosal biopsy specimens, with immunoglobulin deposition. The DSA C4d binding antibodies were also present. After intense immunosuppression and plasmapheresis, the graft and the biopsy histologic findings showed marked improvement (day 2). By day 7 posttransplantation, patient and graft status were stable. The patient has remained clinically stable for more than a year after transplantation.

Conclusions

Pretransplant DSA in ITx can be a risk factor for immediate (hyperacute) but potentially reversible antibody-mediated rejection. Thus, pretransplantation DSA and cross-match results are critical components to be considered in patients awaiting or undergoing ITx.     

Timing, route, and dose of administration of heparin-binding epidermal growth factor-like growth factor in protection against intestinal ischemia-reperfusion injury

Purpose

We have previously demonstrated that heparin-binding epidermal growth factor-like growth factor (HB-EGF) is an intestinal cytoprotective agent. The current study examined whether HB-EGF is effective as salvage therapy as well as prophylactic therapy for intestinal ischemia-reperfusion (I/R) injury, whether intravenous administration is as effective as intraluminal administration, and whether increased benefits are seen with increasing dose.

Methods

Total midgut I/R injury in rats was achieved by occlusion of a first-order branch of the superior mesenteric artery for 60 minutes, followed by reperfusion for 6 hours. Rats were treated with HB-EGF 5 minutes before ischemia, halfway through the ischemic event, or 5 minutes after ischemia. Route of administration was tested by administering HB-EGF either intraluminally or intravenously. Seven different doses of HB-EGF were tested.

Results

Heparin-binding, EGF-like growth factor protected the intestine from injury when administered before injury and was also effective when administered during ischemia or even after injury. Intraluminal administration of HB-EGF was superior to intravenous administration. Increasing doses of HB-EGF resulted in a greater cytoprotective effect.

Conclusion

These data demonstrate that HB-EGF acts as an effective intestinal cytoprotective agent when administered intraluminally not only before injury, but also during injury and, most importantly, even after intestinal injury has already occurred. These findings support a basis for the prophylactic use of intraluminal HB-EGF in high-risk patients, as well as for the administration of HB-EGF to salvage patients in whom an intestinal insult has already occurred.     

The Bianchi procedure: a 20-year single institution experience

Background/Purpose

The emergence of improved outcomes for small bowel (SB) transplantation has raised questions regarding the utility of autologous intestinal lengthening for patients with short bowel syndrome (SBS). Chronic immunosuppression, multiple hospitalizations, and posttransplant lymphoproliferative disease are significant adverse factors. The purpose of this study is to evaluate the 20-year single institution experience with the Bianchi procedure and analyze its role in the management of pediatric SBS.

Methods

Medical records for 19 consecutive patients who underwent the Bianchi procedure from 1984 to 2004 were reviewed. Patients were categorized into 3 groups: less than 5 years, 5 to 9.9 years, and 10 years or more after surgery. Various outcome variables were evaluated. Data are presented in tabular format as the number of patients (%) or average (range).

Results

Nineteen patients were included in the study. Of 16 patients weaned from total parenteral nutrition (TPN), 7 (44%) responded to Bianchi procedure alone and 9 patients (56%) required SB transplant at an average of 4.09 years (range, 0.7-13.64 years) post-Bianchi. Four patients (21%) died, 1 received SB transplant and died of unrelated causes, and 3 were still on TPN and had not received SB transplantation.

Conclusion

The Bianchi procedure facilitated weaning from TPN and eliminated the need for supplemental nutrition in select patients. Although the role of surgery is primarily adjunctive in the treatment of SBS, it offers therapeutic benefit in decreasing parenteral nutrition requirements and promoting intestinal adaptation. In particular, the Bianchi procedure has significant potential to improve the prognosis of pediatric patients with SBS.     

Comprehensive Surgical Intestinal Rescue and Transplantation Program in Adult Patients: Bologna Experience

Introduction

Surgical approaches to complicated benign intestinal failure are accepted worldwide, especially in the pediatric population. Intestinal transplant surgery is thought to rescue patients in whom complications of total parenteral nutrition (TPN) develop.

Objective

To report our experience with surgical intestinal rescue in an adult population with intestinal failure.

Patients and Methods

An intestinal rehabilitation program initiated at our institution included comprehensive medical rehabilitation, surgical bowel rescue, and transplantation. From 2000 to 2009, of 81 adult patients referred by our gastroenterologists for bowel rehabilitation, 42 (51,8%) underwent 43 transplantations (32 isolated intestinal grafts and 11 multivisceral grafts). Underlying diseases were primarily short-bowel syndrome, Gardner syndrome, and intestinal pseudo-obstruction. Thirty-nine patients (48,2%) underwent surgical rescue (40 cases) consisting of bowel resection, adhesiolysis, stricturoplasty, liver transplantation with portocaval hemitransposition (6 cases in 5 patients). Underlying diseases were primarily intestinal fistulas, stenosis, or perforations, short-bowel syndrome, cocoon syndrome, and complete portal thrombosis.

Results

After a mean (SD) follow-up of 1043 (1016) days, in the transplantation population, 21 patients (50%) are alive, with a 1-, 3-, 5-year patient survival of 76%, 59%, and 52%, respectively, and graft survival of 66%, 54%, and 48%, respectively. After 901 (404) days in the rescue population, 32 patients (82%) are alive (2 died, and 5 were lost to follow-up); in 75%, TPN 25% was discontinued, and are receiving oral feeding with TPN support. The 1- and 3-year survival rate was 100% and 83%, respectively.

Conclusions

Deaths occurred primarily in the transplantation population. Intestinal surgical rescue, when possible, is optimal.     

Evaluation of Epstein-Barr virus load in saliva before and after renal transplantation

Introduction

Posttransplant lymphoproliferative disorders (PTLD) arising in solid organ transplant patients show a strong correlation with Epstein-Barr virus (EBV) infection. The aim of our study was to evaluate the frequency of EBV DNA levels before and after transplantation among saliva samples of Iranian kidney transplant patients.

Materials and Methods

In 40 kidney transplant recipients and their healthy donors, we evaluated the EBV DNA levels in saliva samples by quantitative polymerase chain reaction method using samples obtained 1 hour before transplantation surgery. In addition, 3 months after transplantation we evaluated EBV DNA levels in recipients for comparison with preoperative levels. Exclusion criteria included hepatitis B, hepatitis C, and human T-cell leukemia virus infections before transplantation as well as HIV-positive patients under highly active antiretroviral therapy, graft rejection requiring dialysis and active viral infection of oral cavity.

Results

Before renal transplantation, there was no significant difference in saliva EBV DNA levels between kidney donor and recipient patients (P = .8). The levels increased significantly to 67.6% in the recipient group after transplantation (P = .01).

Conclusion

We observed that EBV was more frequently present in the oral mucosa after renal transplantation. Thus, we can follow these patients for EBV infection using saliva examinations as a simple screening method.     

Evaluation of Thyroid Disease in Kidney Transplantation Candidates: Management and Follow-up

Introduction

Diagnosis of thyroid disease is fundamental in the evaluation of patients awaiting kidney transplantation. We analyzed the incidence of thyroid disease in patients with end-stage renal disease (ESRD) and evaluated its evolution before and after kidney transplantation.

Patients and Methods

Between January 2000 and May 2008, we evaluated 323 candidates for kidney transplantation. In all patients, serum concentrations of free triiodothyronine, free thyroxine, and thyroid-stimulating hormone were determined and a ultrasonography of the neck was performed. Patients with thyroid cancer were considered eligible for kidney transplantation after at least 2 years since treatment.

Results

One-hundred-four patients with ESRD (44%) had functional or morphologic changes in the thyroid gland. Forty-one patients (17.4%) underwent fine-needle aspiration cytology; 3 demonstrated showed papillary carcinoma; 3, follicular adenomas; 8, uncertain cytologic lesions; and 27, a nodular goiter. Seventeen patients underwent surgery. Six of 11 patients with thyroid cancer underwent transplantation: two patients underwent laterocervical lymph node dissection because of local recurrence within 2 years after successful transplantation; the other 4 patients are alive with a functioning graft. Of the 184 transplant recipients, 10 underwent surgery to treat thyroid disease: 8 with multinodular goiter, 1 with micropapillary carcinoma, and 1 with follicular adenoma. All 10 patients are alive with a well-functioning graft and no signs of disease recurrence.

Conclusions

Thyroid diseases are common in patients with ESRD. Early diagnosis and treatment significantly decreased morbidity and mortality in patients awaiting transplantation.     

Serum levels of interleukin-9 during acute rejection in liver transplantation

Introduction

Interleukin-9 (IL-9) has been cast as a player in autoimmunity, but its role in liver transplantation remains to be clarified. The aim of our study was to investigate the time course of IL-9 serum levels during hepatic allograft rejection.

Methods

IL-9 serum levels were determined in 34 healthy subjects and 50 hepatic transplant recipients. The patients were divided into two groups: group I was composed of 15 patients with acute rejection episodes, and group II, 35 patients free of this problem. Samples were collected on days 1 and 7 after liver transplantation and on the day of liver biopsy.

Results

The concentrations of IL-9 were similar in the rejection and nonrejection groups over the entire postoperative period. The whole transplant group, including those with stable graft function, showed higher IL-9 serum levels than the controls at all times after liver transplantation.

Conclusions

These preliminary results suggest a lack of participation of IL-9 in human liver allograft rejection.     

Serum measurements of testosterone, insulin-like growth factor 1, and insulin-like growth factor binding protein-3 in the diagnosis of prostate cancer among Korean men

Aim： To investigate the relationships of serum testosterone, insulin-like growth factor （IGF）- 1 and IGF-binding protein （IGFBP）-3 levels with prostate cancer risk and also with known prognostic parameters of prostate cancer in Korean men who received radical retropubic prostatectomy （RRP） for clinically-localized prostate cancer. Methods： Serum levels of total testosterone, free testosterone, IGF-1 and IGFBP-3 were determined in 592 patients who subsequently received prostate biopsy. Results were compared between patients who eventually received RRP for prostate cancer （n = 159） and those who were not diagnosed with prostate cancer from biopsy （control group, n = 433）. Among the prostate cancer only patients, serum hormonal levels obtained were analyzed in relation to serum prostate specific antigen （PSA）, pathological T stage and pathological Gleason score. Results： Prostate cancer patients and the control group demon- strated no significant differences regarding serum levels of total testosterone, free testosterone, IGF-I and IGFBP-3 across the different age groups. Among the cancer only patients, no significant associations were observed for serum levels of total testosterone, free testosterone, IGF-1 and IGFBP-3 levels with pathological T stage, pathological Oleason score and preoperative PSA. Conclusion： Our data indicate that simple quantifications of serum testosterone and IGF-1 along with IGFBP-3 levels might not provide useful clinical information in the diagnosis of clinically localized prostate cancer in Korean men. Also, our results suggest that serum levels of testosterone, IGF-1 and IGFBP-3 might not be significantly associated with known prognostic factors of clinically localized prostate cancer in Korean men. （Asian J Androl 2008 Mar; 10： 207-213）     

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.