Partial abdominal evisceration and intestinal autotransplantation to resect a mesenteric carcinoid tumor

<p>Abstract</p> <p>Background</p> <p>Midgut carcinoids are neuroendocrine tumors that commonly metastasize to the intestinal mesentery, where they predispose to intestinal obstruction, ischemia and/or congestion. Because of their location, many mesenteric carcinoid tumors are deemed unresectable due to the risk of uncontrollable bleeding and prolonged intestinal ischemia.</p> <p>Case Presentation</p> <p>We report the case of a 60-year-old male with a mesenteric carcinoid tumor obstructing his superior mesenteric vein, resulting in intestinal varices and severe recurrent GI bleeds. While his tumor was thought to be unresectable by conventional techniques, it was successfully resected using intestinal autotransplantation to safely gain access to the tumor. This case is the first described application of this technique to carcinoid tumors.</p> <p>Conclusions</p> <p>Intestinal autotransplantation can be utilized to safely resect mesenteric carcinoid tumors from patients who were not previously thought to be surgical candidates. We review the literature concerning both carcinoid metastases to the intestinal mesentery and the use of intestinal autotransplantation to treat lesions involving the mesenteric root.</p

Heat Stroke as a Cause of Liver Failure and Evaluation of Liver Transplant

Heat stroke is a multiple organ dysfunction syndrome of poorly understood pathogenesis. Exertional heat stroke with acute liver failure is a rarely reported condition. Liver transplant has been recommended as treatment in cases of severe liver dysfunction; however, there are only 5 described cases of long-term survival after this procedure in patients with heat stroke. Here, we present 2 cases of young athletes who developed heat stroke. Both patients developed acute liver failure and were listed for liver transplant. Liver function tests of one patient improved, and he was discharged on postoperative day 13. The other patient showed no signs of improvement and liver biopsy showed massive necrosis. The patient underwent combined kidney-liver transplant and was discharged on postoperative day 17. After a follow-up of longer than 6 years, both patients are doing well with normal liver function and no neurologic sequelae. We also reviewed all published cases of hepatic failure associated with heat stroke and found 9 published cases of liver transplant for heat stroke in the English literature. Conservative management appears to be justified in heat stroke-associated liver failure, even in the presence of accepted criteria for emergency liver transplant

Heat Stroke as a Cause of Liver Failure and Evaluation of Liver Transplant

Heat stroke is a multiple organ dysfunction syndrome of poorly understood pathogenesis. Exertional heat stroke with acute liver failure is a rarely reported condition. Liver transplant has been recommended as treatment in cases of severe liver dysfunction; however, there are only 5 described cases of long-term survival after this procedure in patients with heat stroke. Here, we present 2 cases of young athletes who developed heat stroke. Both patients developed acute liver failure and were listed for liver transplant. Liver function tests of one patient improved, and he was discharged on postoperative day 13. The other patient showed no signs of improvement and liver biopsy showed massive necrosis. The patient underwent combined kidney-liver transplant and was discharged on postoperative day 17. After a follow-up of longer than 6 years, both patients are doing well with normal liver function and no neurologic sequelae. We also reviewed all published cases of hepatic failure associated with heat stroke and found 9 published cases of liver transplant for heat stroke in the English literature. Conservative management appears to be justified in heat stroke-associated liver failure, even in the presence of accepted criteria for emergency liver transplant

The value of pre-transplant coronary angiography findings in kidney transplant candidates at high risk for cardiovascular disease

IntroductionCardiovascular disease is a significant cause of mortality after kidney transplantation. Whether pre-transplant screening for coronary artery disease (CAD) in asymptomatic kidney transplant candidates (KTCs) is beneficial is unclear.MethodsWe conducted a retrospective cohort study evaluating post-transplant cardiovascular events in 192 high-risk KTCs who underwent pre-transplant CAD evaluation. The study aimed to identify risk factors associated with finding severe CAD on pre-transplant angiography, and to assess the relationship between screening strategies and post-transplant cardiovascular events.ResultsAt five years post-transplant, cardiovascular events occurred in 23.9% of subjects. Prior CAD history and left ventricular ejection fraction (LVEF) &lt; 50% were associated with higher odds of finding severe CAD on pre-transplant angiography. Severe CAD on angiography was associated with a higher risk of early cardiovascular events within six months of transplantation. However, coronary intervention in KTCs with severe CAD was not associated with lower rates of post-transplant cardiovascular events.ConclusionPre-transplant coronary angiography to identify severe CAD is of highest yield in KTCs with a history of CAD or an LVEF &lt; 50%. Our findings indicate that the identification of severe CAD in KTCs has prognostic significance for the early post-transplant period. Optimization of medical therapy in these high-risk KTCs may improve post-transplant cardiovascular outcomes

Urinary reconstruction after kidney transplantation: pyeloureterostomy or ureteroneocystostomy

PURPOSE: Ureteroneocystostomy (UCN) is the most widely used urinary reconstruction technique during kidney transplantation. Disadvantages of this technique include a high incidence of hematuria and reflux, plus the potential for obstruction resulting from distal ureteral fibrosis. Pyeloureterostomy (PU) avoids these complications but increases the technical complexity. METHODS: Between January 1990 and December 2005, 1066 adults patients underwent kidney transplantations; 768 patients (72.1%) had urinary reconstruction by PU and 298 (27.9%) underwent UNC. RESULTS: Patients in the PU group underwent simultaneous ipsilateral native nephrectomy. The operative time was longer in the PU group compared with the UNC group: 210 +/- 36 min versus 182 +/- 24 min (P \u3c 0.001). Overall surgical complications in the PU group were comparable to those in the UNC group (9.5% versus 12.3%). The urinary complication rate was also comparable in both groups: 3.2% (25 of 768) in the PU group and 5% (15 of 298) in the UNC group. However, urinary obstruction comprised 60% of urinary complications in the UNC group, compared with 32% in the PU group (P \u3c 0.01). We treated most urinary complications non-operatively. However, 24% of patients (six of 25) in the PU group needed operative intervention or revision for ureteral reconstruction, compared with 46.6% (seven of 15) in the UNC group (P \u3c 0.01). CONCLUSIONS: Pyeloureterostomy is a safe and effective method for urinary tract reconstruction in renal transplantation. Pyeloureterostomy should be part of every transplant surgeon\u27s armamentarium

Biliary reconstruction and complications after living-donor liver transplantation

AbstractBackgroundThe technique of biliary reconstruction remains controversial in living-donor liver transplantation (LDLT). The objective of this study was to assess the incidence of biliary complications after LDLT based on the reconstruction technique.MethodsBetween 1997 and 2007, 30 patients underwent LDLT. The type of allograft was the right lobe in 15, left lobe in 4 and left lateral sector in 11 patients. There were 18 adult and 12 paediatric recipients. The mean follow-up was 48 months (range 18–120 months). Biliary complications were defined as leak or stricture requiring intervention.ResultsBiliary reconstruction was achieved with Roux-en-Y choledochojejunostomy (RYCJ) in 17 patients and duct-to-duct (DD) anastomosis in 13 patients. An external biliary stent was placed in all patients (except one) in the RYCJ group and reconstruction over a T-tube was done in 6 out of 13 patients in the DD Group. Twenty-five (83.3%) patients had one biliary anastomosis and the remaining five (16.7%) had multiple anastomoses (one in the RYCJ group and four in the DD group).The overall incidence of biliary complications was 30%.; 29.4% in the RYCJ group and 38.4% in the DD group (P= 0.6). Biliary complications occurred equally in patients with and without an external stent or T-tube stenting (12.5% vs. 18.8%). The incidence of biliary leakage was 23.5% for RYCJ and 15.3% for DD (P= 0.4). Although the incidence of biliary stricture was significantly higher in the DD (23.1%) compared with the RYCY group (5.9 %) (P < 0.01), all DDCC strictures were successfully managed endoscopically. Need for operative revision of biliary anastomoses was significantly higher in patients with RYCY compared with DD reconstruction; 17.7% vs. 7.7% (P < 0.01).ConclusionsAlthough there was a higher rate of biliary stricture formation in the DDCC group, we feel that because of physiological bilioenteric continuity, comparable incidence of leakage and easy endoscopic access, DD reconstruction is the preferred approach for biliary drainage in LDLT. After LDLT, the endoscopic approach has been shown to provide effective treatment of most biliary complications