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A 24-year-old man with short gut syndrome due to severe fistulating Crohn's disease, underwent a simultaneous isolated small bowel and abdominal wall transplantation. He had Campath-1H induction and tacrolimus as maintenance immunosuppression. On day18 postoperatively, he presented with increasing shortness of breath and a diffuse macular, blanching, erythematous eruption rash on his trunk and back (host), however sparing the transplanted abdominal wall skin (graft). A chest radiograph is shown in online supplementary …

Importance Because of the severity of disease and additional surgery, Crohn disease (CD) may result in intestinal failure (IF) and dependency on home parenteral nutrition (HPN). Defining the indication and timing for intestinal transplantation (ITx) is challenging. Objectives To determine the limitations of conventional surgery and to facilitate the decision making for transplantation. Design, Setting, and Participants Data were collected prospectively and obtained by retrospective review of medical records from all patients with CD who were assessed for ITx in Oxford, United Kingdom, and Berlin, Germany, from October 10, 2003, through July 31, 2013. Patients were considered suitable for ITx if a diagnosis of irreversible IF was established and life-threatening complications under HPN were unresolvable. Twenty patients with CD and IF, established on HPN, were evaluated for ITx. The mean (SD) age at CD onset was 17.8 (9.8) years. On first diagnosis, most patients had a stricturing CD. By the time of referral, most had a combination of stricturing and fistulizing disease. Interventions New scoring system: a modification of the American Gastroenterology Association guidelines for ITx. Modifications are related to CD-specific issues that potentially lead to a poorer outcome and are based on the findings of the study to determine the expected benefit from ITx. Main Outcomes and Measures A scoring system that would alert the physician to the severity of the patient’s CD and trigger early referral for ITx. This system may translate into better long-term outcomes for patients with CD. In addition, the Karnofsky performance status score was used to compare pretransplantation and posttransplantation outcomes. Results Ten patients underwent ITx, 4 were on the waiting list, and 4 were unavailable for follow-up. One patient was taken off the waiting list because of severe deterioration. One patient underwent conventional stricturoplasty and did not need transplantation. Among the transplant recipients, 17 (85%) had a stoma or enterocutaneous fistula, and the mean (SD) residual bowel length was 71.5 (38) cm. A total of 80% of transplant recipients had life-threatening catheter infections, and 13 (65%) had a significant decrease in the estimated glomerular filtration rate. At a mean (SD) follow-up of 27.6 (36.1) months for transplant recipients, the patient and graft survival is 80%, and their Karnofsky performance status score increased by a mean of 18.6%. Conclusions and Relevance Intestinal transplantation is a suitable treatment option for patients with CD and IF. It should be considered before any additional attempts at conventional surgery, which may cause eligible patients to miss this opportunity through perioperative complications. The suggested scoring system enables the physician to identify patients who may benefit from transplantation before HPN-associated secondary organ failure.

Transrectal ultrasound (TRUS)-guided biopsy is a very common office procedure for most urologists. Pain or discomfort associated with this procedure has been addressed recently by the use of periprostatic local anesthesia. We re-address this issue with an update of our experience and emphasize the crucial steps that contribute to the success of the technique. We also analyzed the subsequent intraoperative effects of injecting lidocaine into the area of the neurovascular bundles.Between June 1999 and December 2000, 200 patients underwent TRUS-guided biopsies of the prostate. Patients were properly consented and subjected to the procedure using periprostatic nerve block with 10 cm3 of 1% plain lidocaine. An 'ultrasonographic wheal' was created between the rectal wall and the posterior aspect of the prostate and three or four different locations along the neurovascular bundles. Pain scores were evaluated with the visual analogue scale.TRUS biopsy of the prostate was performed in 200 consecutive patients using periprostatic local anesthesia, 40 patients (20%) had undergone previous prostate biopsy without anesthesia. The age of patients ranged from 44 to 75 years (mean 67). The number of biopsies ranged from 6 to 14. Mean time from introduction of the probe per rectum to the end of the procedure was 18 min. There were no instances of clinical infection, significant bleeding, urinary retention, diaphoresis or hypotension. The visual analogue scale ranged from 1 to 3 (mean 2). Intraoperative findings in 62 patients who subsequently underwent nerve-sparing radical retropubic prostatectomy were no different from the patients who had biopsies without a local anesthetic.TRUS-guided biopsy of the prostate is the procedure of choice for diagnosing prostate cancer. This procedure can be accomplished with minimal pain with the use of periprostatic local anesthesia. It is an easy, safe, acceptable and reproducible technique that we believe should be considered for all patients undergoing TRUS biopsy regardless of age or number of biopsies.

Objectives. During radical prostatectomy, wide local excision of the lateral prostatic fascia and neurovascular bundle on the ipsilateral side of the tumor is advocated if nerve sparing is likely to result in a positive surgical margin. Our intent was to validate whether intraoperative T staging can predict the presence of positive surgical margins and aid in the decision of whether to perform nerve-sparing prostatectomy. Methods. One surgeon performed 100 consecutive radical prostatectomies, and one pathologist interpreted the pathologic findings. Topographic distribution of tumor within the specimen was assessed intraoperatively by palpation. The margin status was similarly assessed. This tactile clinical impression was compared with the final pathologic findings. Results. The surgical margins were positive in 39 (39%) of 100 cases. The intraoperative assessment of the margin status had a high false-negative rate and a sensitivity of only 7%. However, the specificity was 96%, because few margins were falsely positive. The overall accuracy was 62%, with a negative predictive value of 62%. The sensitivity of the intraoperative assessment of tumor location was 73%, and the positive predictive value was 65%. Conclusions. The results of our study indicate that the intraoperative assessment of the margin status is not accurate and thus cannot help determine which patients require excision of the neurovascular bundle. We believe the decision to preserve the neurovascular bundle should be based on the preoperative prognostic factors and the presence of an intact capsule covering the region of the gland adjacent to this structure.

A 28-year-old woman underwent bowel resection for Crohn's disease at the age of 9 years with 90 cm of small bowel remaining. She underwent isolated small bowel and abdominal wall transplantation and was taking tacrolimus immunosuppression therapy. She subsequently presented following an accidental burn to the composite abdominal wall allotransplant while cooking. Since she does not have nerve supply to the transplanted abdominal wall, the thermal trauma occurred without her being aware of it. This was confirmed by clinical examination of the burn and subsequent clinical assessment of …

A 41-year-old man developed an ischaemic bowelfrom a paroxysmal embolic event via patentforamen ovale (PFO). As a result he had emergencylaparotomy and had a near total enterectomy(leaving just 18 cm colon remaining) with duode-nostomy and loss of abdominal domain. His PFOwas closed and he was established on total parentalnutrition for irreversible intestinal failure.He underwent a successful isolated bowel andabdominal wall composite allograft transplant froma donor (human leucocyte antigen match: 2–2-1),one year after the ischaemic event. Postoperatively,his immunosuppression was maintained with tacro-limus therapy. Several weeks following his trans-plant he attended the outpatient clinic with a 4-dayhistory of a non-pruritic rash (shown in the image)over his transplanted abdominal graft (figure 1).The faint non-pruritic erythematous papular fol-licular eruption spread over the entire abdominalgraft. The rest of the patient ’s skin was normal. A1 mm punch biopsy was obtained which showed peri-follicularchronicinflammatory cellinfiltrate and over-lying spongiosis suggesting Banff grade II acuterejection. However, there were no signs of rejectionon endoscopic examination of the transplantedbowel, which had healthy pink mucosa throughout.He received three doses of methylprednisolone andtherashsubsequentlyresolvedwith thistreatment.

Introduction Citrulline has been successfully used as a marker for intestinal graft dysfunction after intestinal transplantation. 1 We have extended its use to direct enteral vs parenteral feeding in the early post operative period as well as during graft dysfunction presenting as high volume stoma effluent. Methods Weekly serum citrulline concentrations were used in directing nutrition in all recipients of intestinal grafts. A cut off of 13 μmol/l was used. Patients with citrulline levels Results From October 2008, nine patients underwent a small bowel transplant at the Oxford transplant centre. Mean citrulline levels week one after transplantation were 15 mmol/l (range 12–17). Endoscopic biopsies in the first week showed signs of ischaemia reperfusion with significant oedema in the submucosa of the transplanted ileum. All these patients were maintained on TPN and had enteral feed (Peptisorb) at 30 ml/h. As mean citrulline levels increased patients progressed to full feed and TPN discontinued. Four patients presented with intestinal dysfunction after discharge from the hospital. These were all commenced on TPN if the citrulline level fell below 13 mmol/l. The first, had a citrulline of 19 mmol/l on presentation and. Biopsy demonstrated acute rejection. The second, presented with a high stoma output with a citrulline level of 9 mmol/l. Biopsy results revealed increase in mitotic figures as well as apoptosis and loss of tips of villi architecture. The third patient presented with a high stomal output and a citrulline of 18 mmol/l. Citrulline fell further to 9 mmol/l. The fourth patient presented with a high output and citrulline level of 13 mmol/l, dropping further to 6 mmol/l. His biopsy revealed dense mitotic activity in the face of increased apoptosis. He recovered in a span of 30 days with subsequent citrulline showing a rise. He was then weaned off TPN and commenced on diet. Mean time to graft dysfunction from transplantation was 240 days (range 46–450). Conclusion Firstly serum citrulline is a good marker to direct nutritional therapy in the early post transplant period as well as during graft dysfunction. Competing interests None declared. Reference 1. Crenn P , et al. Postabsorptive plasma citrulline concentration is a marker of absorptive enterocyte mass and intestinal failure in humans. Gastroenterology 2000; 119 :1496.

Hypothesis Protocol Doppler ultrasonography of the liver (DUSL) is useful for detecting early hepatic artery thrombosis (HAT). Urgent exploration based on DUSL findings and immediate revascularization of the liver may avoid HAT-related sequelae, namely, biliary complications and retransplantation after pediatric liver transplantation. Design Case-control study. Setting University hospital. Patients Group 1 included 96 liver transplantations performed in 75 pediatric patients from June 1, 1994, to August 31, 1999. Group 2 included 43 liver transplantations performed in 39 pediatric patients from September 1, 1999, to September 30, 2001. Intervention In group 1, DUSL was performed on the first posttransplantation day or on request. Angiographic confirmation of suggested HAT was treated with thrombolysis, angioplasty, or thrombectomy. In group 2, protocol DUSL was performed every 12 hours in the first week and every 24 hours in the second week. The suspicion of HAT warranted urgent surgery without the patient undergoing angiography. Main Outcome Measures Incidence of HAT, biliary complications, and retransplantation. Graft and patient survival. Hospital stay, and number of admissions and operations after undergoing HAT. Results The incidence of HAT was 10.4% (10 of 96 transplantations) in group 1 and 7.0% (3 of 43 transplantations) in group 2. The incidence of biliary complications after HAT was 100% in group 1 and 0% in group 2 (P= .02). The incidence of retransplantation after HAT was 90.0% (9 of 10 patients) in group 1 and 0% in group 2 (P= .01). Of the 10 patients who experienced HAT in group 1, 5 patients underwent early retransplantation (mean length of time, 13.2 days). All 5 patients who did not undergo early retransplantation had biliary complications. Four of these 5 patients underwent retrasplantation at a later time (mean length of time, 687 days). In group 2, DUSL identified early HAT in 3 patients (7.0%). Emergent thrombectomy and arterial reconstruction were undertaken. All 3 (100%) have their original graft and are alive. None experienced biliary complications. One-year graft and patient survival is 72.0% and 84.0%, respectively, in group 1 and 80.0% and 85.0%, respectively, in group 2. Shorter hospital stay, fewer readmissions, and surgery after HAT were noted in group 2. Conclusions Protocol DUSL detects early HAT and urgent revascularization based on DUSL can significantly reduce the incidence of biliary complication and graft loss requiring retransplantation in pediatric liver transplantation.

We analyze the optical properties of two commercial contact tips in air and saline: a silica conical tip manufactured by Heraeus Laser- Sonics and a sapphire rounded tip manufactured by SLT, together with a set of seven laboratory-fabricated silica tips. A statistical comparison (Dunnett's test) was used to determine the significance of the rounded sapphire contact tip compared to a set of five sculpted silica contact tips when used in a tissue mass ablating experiment using excised rat liver. A regression test was performed to determine a model for the relationship between mass ablation and energy. In addition, seven contact tips were assessed for an evaluation of laser-induced damage in excised rat liver. The tissue damage was assessed using histological sections, stained with hematoxylin and eosin, and examined using a light microscope. Dunnett's test showed that with a level of significance of P P < 0.05, a first-degree linear model applies to mass ablation and energy input. The results of the histological investigation indicate that no relationship exists between tissue damage and the geometrical profiles for the various contact tips.

The development of sapphire tips, coupled to the distal end of silica fibers, introduced the use of a new surgical power delivery system known as contact tip surgery. An alternative medium to sapphire tips is the use of silica optical fibers with molded distal ends. We investigated a number of possible approaches for the fabrication of a variety of distal end configurations on silica fibers using an oxy-propane gas torch, arc fusion, Nd:YAG radiation, and CO 2 radiation. We fabricated seven silica contact tips that included a clear and frosted microlens, a clear and frosted ball lens, a clear and frosted conical lens, and a flat end lens. The most reliable method found to fabricate silica contact tips used a CO 2 laser because it offered complete control over the manufacturing process.