J. Calvo ( University Hosp . 12 de Octubre, Madrid, Spain ) [email protected]
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Transcript of J. Calvo ( University Hosp . 12 de Octubre, Madrid, Spain ) [email protected]
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Spanish experience with intestinal (Itx) and multivisceral
transplantation (MVtx) in adultsExperiencia española con un
programa de Trasplante Intestinal y Multivisceral en adultos
J. Calvo (University Hosp. 12 de Octubre, Madrid, Spain)[email protected]
Tfno y Fax: +34913908077
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PATIENTS AND METHODS
• Between December 2004 and December 2012
• 53 patients evaluated • Most of them not eligible
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PATIENTS AND METHODS (II)
DeathsNo Indication
Patient NegativeSurg. Rescue
Intest AdaptationIn Study
Not Included
Waiting ListItx
Included
5,6% (3)7,5% (4)
5,6% (3)5,6% (3)
22,6% (12)15,1% (8)
62,3%(33)
1,8% (1)35,8% (19)
37,7% (20)
Patients Flow(n=53)
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FAP-D
T
Vascular CD
Trauma
CIPO
Mesentery Fi
bromatosis
PO Complications
Obesity
Others
29,1%(16)
12,7%(7) 9,1%
(5)3,6%(2)
5,5%(3)
5,5%(3)
5,5%(3) 3,6%
(2)
25,4%(14)Intestinal Failure (IF)
(n= 53)
PATIENTS AND METHODS (III)
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PATIENTS AND METHODS (IV)
• We have performed 21 intestinal transplants in 19 patients.
• 17 were isolated intestinal (IT) and 4 multivisceral (MVT).
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• Short bowel syndrome was found in 63 % (12/19) of the patients.
• 79% under HPN (15/19 patients). Mean = 27 ± 40 months HPN preItx • 86 % (13/15 patients) had HPN related
complications.
RESULTS
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HPN COMPLICATIONS
• Thrombosis: 33,3% (7); SVC: 9,5%• CRI: 38% (8); x= 0,6 ± 0,8 episodes/year • Non CRI: 43% (9); x= 1,3 ± 1,5 replacements• Metabolic: 62% (13); PNLD: 43% (9)• Intestinal Obstruction: 19% (4)
RESULTS (I)
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FAP-DT 33,3% (7 patients)Vascular 19% (4 patients)Crohn´s Disease 4,8% (1 patient)Miscelanous• Trauma• Retransplant• GIST• Schistosomiasis• Polycitemia Vera• Bariatric Surgery Complications
43% (9 patients) 9,5% (2 patients) 14,3% (3 patients) 4,8% (1 patient) 4,8 (1 patient) 4,8% (1 patient) 4,8% (1 patient)
IF in Transplanted Patients21/19
RESULTS (II)
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Itx MVtx0
5
10
15
20
17
4
Chart Title
Series1
RESULTS (III)
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1. Intraoperative Complications2. Medical Complications3. Surgical Complications4. Immune Complications (Rejection)5. PTLD
RESULTS (IV)
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1. Introperative Complications2. Medical Complications3. Surgical Complications4. Immune Complications (Rejection)5. PTLD
RESULTS (V)
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Complications Type Compl0
5
10
15
20
4
15
31
Yes No Coagulopathy Explant
RESULTS (VI)
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1. Intraoperative Complications2. Medical Complications3. Surgical Complications4. Immune Complications (Rejection)5. PTLD
RESULTS (VII)
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Infection Neurologic C-V Haemathol Metabolic0%
10%20%30%40%50%60%
51,3%
10%3,7%
8,7%
26,3%
Chart Title100% of our patients suffered any type of medical complication (total of 80 events)
RESULTS (VIII)
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INFECTIONS (I)• General Incidence: 5,1 episodes/1000 transplant days
Bacterial Infections: 3,38/1000 transplant days
Viral Infections: 1,22/1000 transplant days (0,81 due
to CMV)
Fungal Infections: 0,54/1000 transplant days
RESULTS (IX)
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37%
24%
5%
10%
15%7% 2%
Chart Title
Catheter Mesh Urinary Tract Pneumonia Enteritis Intraabd. Soft Tissue
RESULTS (X)INFECTIONS (II)
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57%
35%
4% 4%
Chart Title
Renal Failure H-E Disorders PNLDSALF
RESULTS (XI)METABOLIC COMPLICATIONS
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• 68,4 % (13/19 Itx) had RF/Impaired Renal function
• 15,6% of all medical complications
• Multifactorial
• Dyalisis in 3 patients in the early PO period
• One patient awaiting Kidney Transplantation
• Loop Ileostomy Closure done in 5 of 12 living patients.
• Improved Renal Function (3/5) and avoided progression in other 2.
• 7 still with Ileostomy: 1 KTx, 4 RF +/- N and 2 PTCRF.
RESULTS (XII)RENAL FAILURE
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1. Intraoperative Complications2. Medical Complications3. Surgical Complications4. Immune Complications (Rejection)5. PTLD
RESULTS (XIII)
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RESULTS (XIV)SURGICAL COMPLICATIONS Itx (%/number)
Mesh Infection 37% (13)Intraabdominal Fluid Collections 11,4% (4)
Haemoperitoneum 14,2% (5)Intestinal Leak/Perforation 11,4% (4)
Pancreatitis 5,7% (2)Urinary Fistula 5,7% (2)
Haematoma 2,8% (1)Gallbladder Perforation 2,8% (1)
Arterial Graft Mycotic Pseudoaneurism 2,8% (1)Desmoid Recurrence 5,7% (2)
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RESULTS (XV)REOPERATIONS in Itx (%/number)
Mesh Removal 33,3% (19)Intestinal Perforation/Leak 12,2% (7)
Explant 8,7% (5)Haemoperitoneum 12,2% (7)
Intraabdominal Collections Drainage 7% (4)Tracheostomy 7% (4)
Ileostomy Closure 10,5% (6)Mucormicosis 1,7% (1)Pancreatitis 1,7% (1)
Bowell Obstruction 1,7% (1)Mycotic Pseudoaneurism 1,7% (1)
Desmoid Recurrence Resection 1,7% (1)
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Severe AR PTLD-PH-CMV PTLD Technical0
1
2
3
4
5Chart Title
Causes of Graft Explantation
5/21 explanted grafts (23,8%)7/21 grafts loss (33%)
RESULTS (XVI)
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1. Intraoperative Complications2. Medical Complications3. Surgical Complications4. Immune Complications (Rejection)5. PTLD
RESULTS (XVII)
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• Induction: Alemtuzumab (anti-CD 52)
• Manteinance IS: TAC
• 14/21 grafts AR (66,6 %); Total: 145 rejection diagnosed (IR)
• 22 rejection episodes in patients who suffered it
x=1,1 ± 0,9 episodes/patient (0-3); 50% > 2 episodes
• 64,2% before 3 months (AR < 90 days);
x=28 ± 25 days (1-81)
• IR: 51% (74); AR-I: 20% (29); AR-II: 16 % (23); AR-III: 11,7% (17)
RESULTS (XVIII)
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IR AR-I AR-II AR-III HR CR0
1020304050607080
74 cases
29 cases23 cases
17 cases
1 case 1 case
71% mild episodes of AR (IR/AR)27,5% moderate-severe AR (17,6% de Refractory Rejection)
RESULTS (XIX)
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1. Intraoperative Complications2. Medical Complications3. Surgical Complications4. Immune Complications5. PTLD
RESULTS (XX)
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• 2 PTLD (B-cell Lymphomas) (10,5%) • 8 PTLD in 7 patients (36,8%)
Six PH reactive/policlonal + 2 Lymph.• 62,5% CR (in 3 was found in resected
specimen and intestinal biopsies)• One skin cancer (Melanoma)
RESULTS (XXI)
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• 21 Itx in 19 patients.• 12 patients alive and 7 died• Living Patients have complete HPN
Independence• All resumed daily activities (jobs, studies…)• Overall Survival: 63%; Overall Mortality: 37%• Patients Follow up: 35,3 ± 30 months (1-94)• Grafts Follow up: 32,7 ± 32 months (0-94)
RESULTS (XXII)
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• Mean Patient Survival: 61,7 ± 9,6 months (42,8-80,5)• Patients Actuarial Survival at 1, 3, 5 and 7 years:
85%; 66,3%; 58% and 58% respectively• Mean Graft Survival: 59,3 ± 9,6 months (40,5-78)• Grafts Actuarial Survival at 1, 3, 5 and 7 years:
71,4%; 65,5%; 57,3% and 57,3% respectively
RESULTS (XXIII)
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MORTALITY POSTRANSPLANT TIME (months)
PTLD Ischemic Enteritis 13 months
AR-III + PH + CMV Infection 12,5 months
AR-III + PH + CMV Infection + CR 22 months
Severe Acute Pancreatitis –MOF (MV tx) 1,2 months
MOF-Invasive Aspergillosis 2,5 months
MOF-Bronchoaspiration 6 months
Massive Brain Hemorrage (Severe Thrombopenia)
41 months
RESULTS (XXIV)
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These preliminary results appear encouraging.All surviving patients are TPN free.Patient and graft survival results are
comparable to high volume and experienced centers.
Careful patients selection must be done.
CONCLUSIONS