The presence of recipient lymphocytes in grafts is thought to equate with rejection. Thus, we wished to follow the fate of lymphocytes after transplant of the small bowel. Three complete small-bowel transplants, two with the liver from the same donor also transplanted, were done successfully. Patients were immunosuppressed with FK 506. 5 to 11% of lymphocytes in the recipients' peripheral blood were of donor origin during the early postoperative period when there were no clinical signs of graftversus-host disease. However, donor cells were no longer detectable after 12 to 54 days. Serial biopsy specimens of the grafted small bowel showed progressive replacement of lymphocytes in the lamina propria by those of the recipient's HLA phenotype. Lymphoid repopulation was complete after 10 to 12 weeks but the epithelial cells of the intestine remained those of the donor. The patients are on enteral alimentation after 5, 6, and 8 months with histopathologically normal or nearly normal intestines. Re-examination of assumptions about the rejection of intestinal grafts and strategies for its prevention are required following these observations.Little is known about the fate and function of lymphocytes in intestinal grafts, partly because long-term survival after transplant of the small intestine has been difficult to achieve. The first successful complete small-intestine transplant in man 1 was accomplished with continuous intravenous infusion of cyclosporin. The patient briefly had donor lymphocytes in peripheral blood during the early postoperative phase and at the same time had symptoms of graft-versushost disease (GVHD). We have followed the fate of host and donor lymphocytes in three patients treated with FK 506-one after small-bowel transplant and two after combined liverintestine grafting.Patient 1 lost the entire small bowel and most of the colon 5 months before transplant after a gun shot wound of the superior mesenteric artery; liver function was normal. Patients 2 and 3 had had total small-bowel resection several years earlier because of necrotising enterocolitis and thrombosis of the superior mesenteric artery, respectively, and both had liver failure following parenteral hyperalimentation. All grafts received arterial blood from the aorta, and intestinal venous outflow was through the liver of patient 1 or through the liver grafts of patients 2 and 3. FK 506 for immunosuppression was given intravenously at first (0·1 mg/kg per day) and later enterally (0·3 mg/kg per day in divided doses). Maintenance doses of FK 506 were lower. Prednisolone was given initially and later stopped (patients 2 and 3) or reduced (patient 1). Patients were maintained on intravenous nutrition for at least 2 months before starting jejunostomy and, ultimately, oral feeding. continuity restored, and patient 3 is still being fed through a nasogastric tube with its tip advanced into the graft jejunum.Peripheral blood lymphocytes were isolated with 'Ficoll-Hypaque' (Pharmacia LKB) and stored in liquid nitrogen until tested. Lymphoc...
68-year-old woman presented with abdominal pain and vomiting. After initial conservative therapy, laparotomy showed multiple ulcers of the ileum, one of which had perforated and adhered to the uterus. The affected segment of the ileum was resected. Numerous cytomegalic cells, corresponding to endothelia and macrophages, with intranuclear inclusion bodies, were found in microscopic sections of the ulcerated lesions. These findings were consistent with cytomegalic vasculitis and enteritis. Cytomegalovirus infections of the alimentary tract have been reported mainly in severely immunocompromised patients or those with predisposing disorders such as ulcerative colitis; their prognosis is usually poor. In our patient, there was no obvious immunocompromised state or other gastrointestinal disorders. The postoperative course has been uneventful for 2 years after surgery. The prognosis of Cytomegalovirus-associated lesions in the alimentary tract may be quite good in the immunocompetent patient.
With advances of combined modality therapy, prognoses in esophageal cancer have been improving. After resection of esophageal cancer, the development of gastric tube cancer is a risk. While such cancer in an early stage can be cured endoscopically, total gastric tube resection is indicated in advanced stages. A 68-year-old man underwent subtotal esophagectomy reconstructed with a gastric tube through the retrosternal route. Gastric cancer was found one and a half years postoperatively. The gastric tube was resected without sternotomy. This is the first report of a patient undergoing resection of the gastric tube reconstructed through the retrosternal route without sternotomy.
Background: Staplers make it possible to create a gastrointestinal anastomosis quickly, easily, and securely. Staplers have undergone several improvements. We herein evaluate the effect of a new stapler with unique surface gripping technology that provides a superior tissue grip without trauma during firing. Methods: Porcine small bowel was used. The stapling devices compared were the ECHELON FLEX TM with White (E) and GST System White (G). The number of total malformed staples, severely malformed staples, staples malformed to the cutting side, and the absolute value of the degree of malformation were evaluated. Results: The number of malformed staples and the absolute value of the degree of malformation were significantly lower in group G. The number of occurrences of total malformations <0 was greater in group G. Comparing the inner, middle, and outer staple rows, the number of occurrences of malformations were lower on the outer row in group E. Comparing the front, middle, and back parts malformation was lower in the front. UNDER PEER REVIEW 2 Conclusions: We found that a new stapler is superior to a standard stapler with regard to a reliable "B" shape formation of staples. Future directions include studying the correlation between staple malformation and the strength of the suture line.
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