PubMed · 10637692
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H Pichlmaier. 1999. [Palliative surgery].. https://doi.org/10.1007/pl00002575
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BACKGROUND: Intestinal transplantation (Itx) remains the most difficult form of transplantation. This is due to the high immunogenicity of the bowel that currently obligates Itx patients to heavy immunosuppression, which causes infection, posttransplant lymphoproliferative disease (PTLD), and drug toxicity. Wider application of Itx depends on the development of tolerogenic strategies to promote engraftment while reducing the need for immunosuppression. We applied a strategy to clinical Itx that combines intraportal donor-specific blood transfusion with a deliberately low immunosuppression protocol (no high-dose steroids; lower tacrolimus level). METHODS: A 55-year-old patient received a combined liver/Itx. Donor-specific whole blood was taken from the donor during procurement and transfused in the recipient portal vein after graft reperfusion. For induction immunosuppression, no intravenous bolus of steroids was given; only two doses of anti-interleukin 2 receptor antibody were administered. The patient received posttransplantation maintenance immunosuppression with lower tacrolimus levels than average (15 ng/ml first month; 5-10 ng/ml thereafter), low-dose azathioprine (1 mg/kg first to third months; 0.5 mg/kg thereafter), and low-dose steroids (Medrol 8 mg twice daily first and second months; 4 mg twice thereafter). The patient was monitored for rejection, graft-versus-host disease, infection, and PTLD. Protocol biopsy specimens were taken from the distal ileum (2 per week). RESULTS: Clinical, endoscopic, and histologic signs of rejection did not develop. Chimerism was identified at day 28. Graft-versus-host disease was absent clinically. Chimerism was self-limiting and disappeared without modifying baseline immunosuppression and without observing a change in graft function. The patient remained free of systemic opportunistic infections, PTLD, and drug toxicity. Total parenteral nutrition was stopped at 7 weeks after transplantation. The patient remains free of total parenteral nutrition and free of rejection at 14 months after transplantation. CONCLUSIONS: We describe an Itx patient who remained rejection free despite receiving significantly lower immunosuppression than average. We hypothesize that intraoperative immunomodulation via intraportal donor-specific blood transfusion in the absence of nonspecific overimmunosuppression promoted Itx acceptance.
PURPOSE: To evaluate the efficacy and safety of percutaneous treatment of biliary strictures complicating orthotopic liver transplantation (OLT). METHODS: Between October 1990 and May 2000, 619 patients underwent 678 liver transplants. Seventy of the 619 (11%) patients were found to be affected by biliary strictures by July 2000. Bilioplasty was performed in 51 of these 70 (73%) patients. A cohort of 33 of 51 (65%) patients were clinically followed for more than 12 months after the last percutaneous treatment and included in the survey results. RESULTS: After one to three treatments 24 of 33 (73%) patients were stricture-free on ultrasound and MR cholangiography follow-up. A delayed stricture recurrence required a fourth percutaneous bilioplasty in two of 33 (6%) patients. A surgical bilioenteric anastomosis was performed in six of 33 (18%) patients. Retransplantation was performed due to ischemic damage in one of 33 (3%) patients. CONCLUSION: Interventional radiology is an effective therapeutic alternative for the treatment of most biliary strictures complicating OLT. It has a high success rate and should be considered before surgical interventions. Elective surgery may be necessary in a few failed cases or those with more severe and extensive biliary strictures.
The early detection of cholestatic liver disease is one of the major challenges facing pediatricians when evaluating the jaundiced infant. Early recognition of liver disease greatly facilitates the care and outcome of infants, because several serious life-threatening disorders may have cholestasis as a major presenting sign of underlying neonatal liver disease. A key component of the work-up is measurement of serum conjugated bilirubin levels, which if elevated should prompt the clinician to initiate a work-up to determine the cause of neonatal cholestasis. In general, if a patient is developing progressive jaundice soon after birth, is still jaundiced at 2 weeks of life, or develops jaundice within the first month of life, a work-up for neonatal cholestasis should begin. A number of previously undiagnosed causes of neonatal cholestasis are beginning to be assigned genetic and infectious etiologies, with significant implications for the work-up and management of cholestatic infants.