A 36-year-old woman, previously healthy.
a surgical procedure was performed 72 cm after ileocodeal resolution of an acute gastrointestinal disorder with extensive necrosis of the small intestine. Massive resection was performed from 30 cm of the Treitz angle to 10 cm of the ileostomy
Biopsy showed transmural hemorrhagic infarction and intestinal submucosal thrombosis, without morphological elements of vasculitis.
Thrombophilia study showed lupus anticoagulant (+), C protein 72% (normal value (VN) 66-160%), S protein 78% (VN >58%), activated protein C resistance (activated protein C > 0.58)
The patient presented with thrombosis of the portal and superior mesenteric veins and an enterocutaneous fistula of the duodenal stump.
It was managed with low molecular weight heparin (LMWH) and home total parenteral nutrition (TCPN).
Later he presented multiple infections and thrombosis of the central venous accesses.
She required multiple hospitalizations for metabolisers, including an episode of acute renal failure, with a clearance of 60 ml/min.
Consequently, the patient was referred to our IT program in April 2004.
Pretransplant study:
Weight 46 kg, height 1.54 m, body mass index 19 kg/m2, Bill Rh Group (+).
Histocompatibility study: HLA A2 A68 B62 B35 DR4.
Antibodies IgG class I and II positive, panel-reactive antibody (PRA) 20%.
Normal cardiological, pulmonary, gynecological, otorhinolaryngological and endocrine evaluations.
Digestive endoscopic and contrast study showed normal esophagus and stomach, highly dilated duodenal stump, 25 cm long and normal colon to the cecum.
Intestinal transplantation procedure.
In November 2004, IR was performed with a cadaver donor, identical blood group, and cross lymphocytes T and B negative.
Compatibility: 1MM A, 1MM B, 1MM DR.
Histocompatibility of the Public Health Institute.
Search: in the donor, 50 mg EV thymog-lobulin (Aventis Pasteur) was used to reduce lymphocyte load and preservation of the graft with aortic perfusion solution from the University of Wisconsin (ViaSpan).
Cold ischemia time: 6 h.
Surgery: Approach by supra and infraumbilical midline laparotomy, dissection of the aorta and infrarenal vena cava.
The mesenteric artery graft was anastomosed to the infrarenal aorta and the mesenteric vein was anastomosed to the infrarenal vena cava of the receiver.
It was reperfused optimally.
Traffic was reconstituted using total small intestine (adequately 6 m), performing duodenojejunal anastomosis proximal and ileoileal distal.
A loop ileostomy of the graft was left at 15 cm from the distal anastomosis for endoscopic and histological control of the intestine.
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The immunosuppression scheme consisted of induction with alemtuzumab (Campath 1H, Berlex) 30 mg and methylprednisolone 1 g prior to peo-declamation.
She received a second dose of Campath® 30 mg on the third day.
Prednisone, tacrolimus (Prograf, Pharma isolation/Fujisawa), sirolimus (Rapamune, Wyeth) and myco-late mofetil (Myfortic, Novartis) were used.
Antibiotic prophylaxis for 10 days with ceftriaxone, metronidazole and vancomycin; prophylaxis against cytomegalovirus (CMV) with antifungal prophylaxis for 17 days weekly followed by Merck gammaglobulin (CMV) for 30 days;
Anticoagulant therapy with conventional heparin for 2 weeks, followed by LMWH, and from the second month with Neosintrón®, maintaining an internationalnormalizedratio (INR) between 2.5 and 3.5.
Immunological follow-up of the graft was performed with serial endoscopic and histological control weekly for 3 months and then monthly until the seventh month post-transplant.
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Post-operative Ev.
The recipient restarted intestinal transit on the third day, on the fifth postoperative day she underwent placement of semi-elemental formula (Vnex, Novartis), administered continuously enterally by nasojejunal tube.
On the eighth day oral feeding was initiated.
The gastrostomy was closed on day 14 post-transplant.
In the fourth week, parenteral nutrition was permanently discontinued.
At day 42 post-transplantation she was exclusively fed by mouth with a hypofatal regime.
The intestinal transit was reconstructed seven months after transplantation.
Complications:
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At 29 months post-transplant follow-up, the patient maintained normal oral intake, and manic seizure consistent with prednisone, mycophenolate mofetil and tacrolimus.
It should be noted that this has been the only attempt of intestinal transplantation performed by this group to date.
