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Presenter: Douglas, Farmer, Los Angeles, United States
Authors: Bernard Dubray, Jr., Wethit Dumronggittigule , Cheng Cheng, Elizabeth Marcus, Robert Venick, Ronald Busuttil, Douglas Farmer
Bernard J. Dubray, Jr.1, Wethit Dumronggittigule 1, Cheng Y. Cheng1, Elizabeth A. Marcus2, Robert S. Venick2, Ronald W. Busuttil1, Douglas G. Farmer1.
1Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States; 2Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
Introduction: Temporary enterostomy (OST) formation at the time of intestinal transplantation (ITx) has traditionally been the standard of therapy. The lack of reliable non-invasive monitoring of ITx allograft relegates frequent endoscopy/biopsy via OST as the standard method to diagnose pathology. While complications related to OST formation/takedown procedures are well described in general surgery, the ITx OST has never been reported.
Methods: A retrospective review of a prospectively maintained single-center ITx database from Nov 1991 to August 2016 was performed. Demographic, surgical and outcome variables were recorded. The assessment of OST was divided into two parts – the formation and takedown. OST types were end-ileostomy, loop-ileostomy or blow-hole ileostomy. Criteria for OST takedown included at least 3 months s/p ITx, low dose steroids, stable graft function and no rejection. A standard pre-takedown workup included endoscopy/biopsy and contrast radiography. Overall survival (OS) and graft survival (GS) were assessed. Standard statistics was undertaken.
Results: 123 recipients (age 7.66 yrs (0.62-61.87); weight 23 kg (6.9-96)) received 145 ITx. Allograft types were isolated intestine (23%), liver/intestine (53%), multivisceral (17%), modified multivisceral (7%). OST types at ITx were end (22%), loop (10%), distal blow-hole (56%), proximal blow-hole (8%), and none (4%). 76 OST (54%) underwent takedown.
OST formation: 25 Complications occurred in 24 formations (17%): 10 prolapse (40%), 7 ischemia (28%), 8 other (32%). 12 (50%) were required OST revision. Complications were more likely with liver/intestinal ITx, end type and a history of more reoperations post-ITx. OST takedown rates were significant lower among patients with complication of OST formation (p=0.005). There was no different of GS between patients with and without OST complication (p=0.50).
OST takedown: Median time to takedown: 422 days (18-3928). 16 complications occurred in 13 takedowns (17%): 5 abscess (31%), 5 SBO (31%), 2 hernia (13%), 4 other (25%). With complications, trend toward longer time between ITx and takedown (p=0.07). There were no deaths or graft loss as a result of complication. GS of patients with OST takedown complication was not different from patients without complication (p=0.25).
Conclusions: The first analysis of OST after ITx reveals
1. Most recipients can undergo successful OST formation/takedown
2. Complication rates are surprisingly similar to those seen in general surgery patients despite the higher complexity of ITx patients
3. Complications did not lead to worse outcomes
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