Halff, G

Hall, R

Starzl, TE

Todo, S

English

PubMed

GLENN HALFF

SATORU TODO

ROBERTA HALL

THOMAS E. STARZL

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LATE COMPLICATIONS WITH GALLBLADDER CONDUIT BILIARY RECONSTRUCTION AFTER LIVER TRANSPLANTATION

D-Scholarship@Pitt

• , • • September 1989 BRIEF COMMUNICATIONS 537 determined by correlating the recipient's serum reactivity against the T and B lymphocyte and monocyte populations as well as the use of HLA-specific monoclonal blocking antibodies. Thus, a procedure is now available for better prediction of graft survival in the recipient. The usefulness of this new procedure is particularly important in patients with high levels of sensi-tization. Investigators have noted that finding a serologically compatible kidney for these individuals is very difficult (I5). Since the modified flow cytometric procedure can make the distinction between deleterious and irrelevant antibodies, some potential recipients may still be considered for transplantation with an available kidney despite a positive B cell crossmatch result. In conjunction with the CDC assay, we intend to use this modified flow cytometric cross match technique to study antibodies reactive with donor leukocytes in order to improve the success rate of renal transplantation. In summary, we have described a modified flow cytometric crossmatch technique that utilizes donor peripheral blood leu-kocytes. The use of leukocytes provides a wider spectrum of antigens and has the potential to distinguish between antibod-ies that are detrimental and those that have no effect on graft survival. The procedure can also be performed in a shorter period of time than lymphocytotoxicity and previous flow cy-tometry crossmatch procedures. Three cases were described in which the modified crossmatch procedure was useful in char-acterizing the antibody responsible for the positive B cell CDC crossmatch. The application of this procedure in renal trans-plantation allows for the use of extended phases of crossmatch testing, thus enhancing the probability of graft survival. At the same time, some potential allograft recipients are not excluded from consideration for transplantation solely on the basis of a positive crossmatch result. TIMOTHY J. FARLEY THOMAS C. SHANAHAN WILLIAM R. BARTHOLOMEW! Department of Microbiology and lmmurwlogy State University of New York at Buffalo Histocompatibility Laboratory Erie County Medical Center Buffalo, New York 14215 'Address correspondence to: William R. Bartholomew, Ph.D., As· sistant Director, Division of Clinical Microbiology and Immunology, Erie County Medical Center, 462 Grider St., Buffalo, N.Y. 14215. REFERENCES 1. Russ GR, Nicholls C, Sheldon A, Hay J. Positive B lymphocyte cross match and glomerular rejection in renal transplantation. Transplant Proc 1987; 19: 785. 2. Ahern A, Anruc S, Della Pell P, et a1. Hyperacute rejaction of HLA-AB identical renal allografts associated with B lymphocyte and endothelial reactive antibodies. Transplantation 1982; 33: 103. 3. Morris PJ, Ting A, Oliver DO, Williams K, Dunhill MS. Renal transplantation and a positive serological crossmatch. Lancet 1977; 1: 1288. 4. d'Apice A, Tait BD. Improved survival and function of renal transplants with positive B cell crossmatches. Transplantation 1979; 27: 324. 5. Ozturk G, Terasaki PI. Non-HLA lymphocyte cytotoxins in various diseases. Tissue Antigens 1979; 14: 52. 6. lePage V, Gluckman JC, Bedrosian J. Anti-B celllymphocytotoxic antibodies in kidney transplant recipients. Transplantation 1978; 25: 255 . 7. Pellegrino MA, Belvedere M, Pellegrino AG, Ferrone A. B periph-eral lymphocytes express more HLA antigens than T peripheral lymphocytes. Transplantation 1978; 25: 93. 8. Kissmeyer·Nielsen F. Olsen F, Peterson F, Fjeldborg O. Hypera-cute rejection of kidney allografts associated with preexisting humoral antibodies against donor cells. Lancet 1966; 2: 662. 9. Mohanalrumar T, Rhodes C, Mendez-Picon G, Goldman M, Mon-cure C, Lee H. Renal allograft rejection associated with presen· sitization to HLA-DR antigens. Transplantation 1981; 31: 93. 10. Garovoy MR, Rheinschmidt MA. Bigos M, et a1. FI<,>w cytometry analysis: a high technology crossmatch technique facilitating transplantation. Transplant Proc 1983; 15: 1939. 11. Iwaki Y, Cook OJ, Terasaki PI, et al. Flow cytometry crossmatch-ing in human cadaver transplantation. Transplant Proc 1987; 19: 761. 12. Talbot 0, Guran BK, Shenton BK, et al. Value of the flow cyto-metric crossmatch in renal transplantation. Transplant Proc 1987; 19: 4315. 13. Hopkins KA, MacQueen JM. Basic microlymphocytotoxicity test. In: AACHT lab manual, section II pI-I. 1981. 14. Willoughby PB, Ward FE, MacQueen JM. Modifications of the microcytotoxicity test. In: AACHT lab manual, section II p 2·1. 1981. 15. AlariC L, Rodriguez R, Blackburn S, Kight JA. Influence of pre-transplant antibodies on early renal allograft rejection. Received 14 July 1988. Accepted 7 March 1989. LATE COMPLICATIONS WITH GALLBLADDER CONDUIT BILIARY RECONSTRUCTION AFTER LIVER TRANSPLANTATION! The preferred techniques for biliary tract reconstruction with liver transplantation are duct-to-duct anastomosis over a T-tube stent or anastomosis of the graft common duct to a defunctionalized Roux limb of jejunum (1-3). A more complex but occasionally useful procedure is the gallbladder conduit operation, which was recommended by Waddell and Grover (4) for use in liver transplantation and adapted by CaIne (5) for this purpose. In our own experience with almost 2000 liver transplanta-tions, the Waddell-Calne option for biliary reconstruction has 'This work was supported by Research Grants from the Veterans Administration and by Project Grant DK29961 from the National Institutes of Health, Bethesda, MD. been exercised on only 10 occasions. In most ofthe 10 patients (Table 1), multiple previous operations had caused extensive scarring, and/or there had been the loss of a large portion of the small bowel, either from construction of multiple Roux limbs or because of extensive intestinal resections for other reasons. The use of the gallbladder conduit under these circum-stances either obviated the need for extensive dissections, per-mitted the use of a short residual Roux limb, or allowed both advantages. The biliary reconstructions were performed exactly as de-scribed by Caine (5). In essence, the donor common duct is anastomosed to the base of the donor gallbladder (Hartman's pounch) and the fundus of the gallbladder is anastomosed to 538 TRANSPLANTATION Vol. 48, No.3 TABLE 1. Complications of gallbladder conduit biliary reconstruction Age at Date of Multiple 01" No. transplantation transplantation previous operations 235 45 8/8/82 Yes 250 3 8/22/82 Yes 768b 22 10/5/88 Yes 1277 2 10/28/87 Yes 1305 44 10/20/87 No 1321 20 12/8/87 Yes 1371 Ph 1/17/88 Yes 1402 3 2/13/88 Yes 1601 54 7/6/88 Yes 1732 53 10/11/88 Yes ·OT, orthotopic transplantation. b Retransplantation-first transplantation was 4/21/86. FIGURE 1. Biliary reconstruction with a gallbladder conduit. The T-tuhe pasaetl through the proximal and distal anastomosis and out through the gallbladder wall to the skin. the recipient bowel or to the recipient common bile duct. The proximal limb of aT-tube is passed through the choledocho-cholecystostomy anastomosis and the distal T-Iimb is passed through the anastomosis of the gallbladder fundus to the intes-Time to Complication revision Status No complication No revision Alive and well Gallstone/chol- 5 Years Alive and well angitis No complication No revision Died 3 weeks pOStoP· Gallstone/chol- 1 Years Alive and well angitis No complication No revision Alive and well No complication No revision Alive and well No complication No revision Alive and well Siudge/cholan- 6 Months Alive and well gitis Increased liver 3.5 Months Alive and well enzymes/ gall-stone No complication No revision Died 9 weeks pOStoP. FIGURE 2. Transhepatic cholangiogram 5 years after transplanta-tion and biliary reconstruction with gallbladder conduit. tine or recipient common duct. The T-limb of the T-tube is brought through the gallbladder wall to the skin (Fig. 1). Eight of the 10 patients survived chronically after operation and have been followed for 6 months to 6- lh years. The other two died after 3 and 4 weeks. The bile duct reconstruction was not a factor in their deaths. Of the 8 who are alive. 4 developed biliary tract stones, sludge, or strictures, and usually all 3 (Table 1 ). A typical late complication is shown in Figure 2. The stricture occurred at the site of the anastomosis between the donor duct and the gallbladder. The stones were found in the donor duct, the gallbladder. or both places (Fig. 2). Reoperation was re-quired in each instance with conversion to a choledochojeju-nostomy 0.3, I, 3.5, and 5 years after the transplantation. The symptoms leading to operation were life-threatening in 3 pa-tients with severe cholangitis. The fourth patient had silent obstructive jaundice. Reoperation was successful in all 4 cases. • , , I September 1989 BRIEF COMMUNICATIONS 539 By 1974. the devastating effect of biliary tract complications after liver transplantation had been recognized and the need for improved techniques was obvious (6). The options settled upon in our program were either choledochojejunostomy or choledochocholedochostomy with aT-tube stent (1-3). The alternative technique of reconstruction with a donor gallbladder conduit has the advantages of providing a double passage of bile from the new liver via the common duct and cystic duct. as well as easy access for postoperative irrigation through a carefully placed T -tube. In addition. dangerous dissections and loss of additional jejunal length can be avoided in patients with multiple previous operations. With this method. the rate of complications in the Cambridge program was substantially reduced (7). However. it has not been appreciated that sludge and stone formation would be a common late complication. particularly in pediatric recipients. In our small series of only 10 patients, reoperation became necessary as early as 3.5 months after transplantation, and as late as 5 years. The potential hazards as well as the inconvenience inherent in this method of biliary tract reconstruction should preclude its use except for those specific indications already mentioned. In summary, the Waddell-Caine method of biliary tract re-construction using a gallbladder conduit was associated with a 50% incidence of late biliary tract'sludge or stone formation, with obstruction and frequent cholangitis. This procedure should not be used for the biliary tract reconstruction of liver transplantation except under extremely specific and very rare circumstances. GLENN HALFF SATORU TODO ROBERTA HALL THOMAS E. STARZL2 The Department of Surgery University of Pittsburgh Health Center University of Pittsburgh Pittsburgh, Pennsylvania 2 Reprint requesta should be sent to Thomas E. Starzl. M.D .• Ph.D., Department of Surgery, 3601 Fifth Avenue. Falk Clinic, Pittsburgh, PA 15213. REFERENCES 1. Starzl TE, Iwatsuki S, Van Thiel DH, et a1. Evolution of liver transplantation. Hepatology 1982; 2: 614. 2. Iwatauki S, Shaw BW Jr, Stanl TE. Biliary tract complications in liver transplantation under cyc1osporin-steroid therapy. Trans-plant Proc 1983; 15: 1288. 3. Lerut J. Gordon RD, Iwatsuki S, et al. Biliary tract complications in human orthotopic liver transplantation. Transplantation 1987; 43: 47. 4. Waddell WR, Grover FL. The gallbladder as a conduit between the liver and intestine. Surgery 1973; 74: 524. 5. Caine RY. A new technique for biliary drainage in orthotopic liver transplantation utilizing the gallbladder as a pedicle graft conduit between the donor and recipient common bile ducts. Ann Surg 1976; 184: 605. . ~" 6. Stanl TE, Ishikawa M. Putnam CW, et aI. Progress in and deter-rents to orthotopic liver transplantation, with special reference to survival. resistance to hyperacute rejection and biliary duct reconstruction. Transplant Proc 1974; 6: 129. 7. RoUes K. In: Caine RY. edt Biliary tract complications. Liver Transplantation. London: Grune & Stratton, 1987: 473. Received 27 February 1989 Accepted 28 March 1989. NONTROPICAL PYOMYOSITIS IN A RENAL ALLOGRAIT RECIPIENT Pyomyositis (pyomyositis tropicans) is an abscess-forming bacterial infection of skeletal muscle. This illness usually occurs in tropical climates. where it is well recognized, but is infre-quently diagnosed in nontropical climates. It is, however, being recognized with increasing frequency in the United States. Although trauma, parasitic and viral infections, nutritional and other metabolic factors have been implicated, the exact patho-physiologic mechanisms leading to bacterial infection of skel-etal muscle are unknown. Staphyiococcu.s aureu.s is almost always the offending organism but the disease can be caused by virulent streptococci and other species. The disease occurs most often in males and in younger patients. Pyomyositis carries an important morbidity and mortality if not diagnosed properly and treated aggressively with antibiotics, as well as surgical intervention (1-8). We present the first published case of nontropical pyomyo-sitis occurring in a renal allograft recipient and comment on the presenting features, diagnosis, and therapy of the disease in this paper. The patient is a 53-year-old white male with end-stage renal disease secondary to chronic glomerulonephritis. He underwent a cadaver donor renal transplant in 1978 which was lost to chronic rejection in 1985'. He returned to dialysis at that time and underwent a second cadaver donor renal transplant in December 1987. Since that time he has enjoyed excellent allo-graft function (baseline serum creatinine 1.4-1.7 mg/dl). His maintenance immunosuppressive medications are prednisone 10 mg/day and cyclosporine A 250 mgjday (3.2 mgjkg/day). His past medical history is also significant for chronic hepatitis B infection with probable cirrhosis, hypertension, goutyarthri-tis, and lower extremity venous thrombosis. There is no history of previous derma to logic problems or intravenous drug abuse. He has never traveled outside the continental United States. On July I, 1988 he developed pain in the right elbow which became progressively worse, especially at night, and he pre-sented for evaluation in Transplant Clinic on July 5. There was no history of trauma to the arm or any other difficulty. At that time he was afebrile. Examination of the right arm revealed moderate swelling with tenderness to palpation and motion in the area of the right elbow. The musculature of the arm ap-peared normal. His laboratory parameters were within normal limits. Because of a past history of gouty arthritis an empiric trial of colchicine and indomethacin was begun. After initial improvement the pain began to worsen dramatically and be-came constant, with subjective fever and increased swelling in the upper arm. The patient was hospitalized for further evaluation on July 22, 1988. At that time physical examination showed the tem-perature to be 38.2·C, blood pressure 118/78, respirations of 14 per minute, and pulse of 88. The patient was in moderate distress from right arm pain. The right upper arm was edema-tous and the inner aspect of the upper arm was exquisitely 

Late com plications with gallbladder conduit biliary reconstruction after liver transplantation

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Late complications with gallbladder conduit biliary reconstruction after liver transplantation

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Late com plications with gallbladder conduit biliary reconstruction after liver transplantation

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