A Novel Approach to Recalcitrant Postoperative Chylous Ascites in Liver Re-Transplantation: A Case Report

In this report we have discussed our experience with a special home-made platelet-rich plasma (PRP)-fibrin glue (FG) as a last resort for treatment of a challenging case of postoperative CA. A 25 years old, ill woman was admitted with severe ascites and hepatic encephalopathy in our center. She was a known case of autoimmune hepatitis and cirrhosis who had undergone liver transplantation 5 years ago and developed chronic rejection. During the surgery an old organized thrombosis in the portal vein was detected, accordingly an iliac vein graft was used to bypass the superior mesenteric vein. After surgery the patient developed chylous ascites. Having no other choice, based on our experience with PRP-FG in similar situations, we decided to use this method as a last resort to treat postoperative chylous ascites. It can be concluded that when conservative management is not working for the treatment of postoperative chylous ascites in intractable cases, PRP-FG can be considered as a last resort treatment. A special home-made PRP-FG was prepared for the patient and of that, 90 mL was injected to the abdominal cavity via the drainage tube followed by a 25 mL of isotonic saline solution to prevent clot formation within the tube. Few days after treatment, chylous secretion decreased and then completely ceased. It can be concluded that when conservative management is not working for the treatment of postoperative chylous ascites in intractable cases, PRP-FG can be considered as a last resort treatment.

Tacrolimus-induced Ascites after Liver Transplant

Massive post-transplantation ascites is a rare but serious condition following liver transplantation. Although, many etiologies are suggested as the cause of this complication, in some cases the definitive etiology remains unknown. Drug-induced post-transplantation ascites is one of the possible etiologies. In this study we present a case of ascites caused by tacrolimus in the post-liver transplantation period. A 49-year-old man with hepatitis B virus cirrhosis underwent liver transplantation and received tacrolimus, mycophenolate and prednisolone, as the immunosuppressive regimen. Progressive ascites developed after 10 days, in spite of a normal liver function. Various studies, including liver biopsy, were performed but we could not find any etiology for this complication. The tacrolimus was switched to rapamune. Ascites was completely disappeared and up to the last follow-up visit, the patient remained asymptomatic for more than two years. We concluded that after ruling out other etiologies, tacrolimus as a rare cause of post-transplantation ascites should be taken into account. The treatment is discontinuation of the drug.

Left-Sided Inferior Vena Cava Encountered During Organ Retrieval Surgery: Report of Two Cases

Left-sided inferior vena cava (IVC) is the second most common anatomical anomaly of the IVC after duplication. Herein, we present two cases of left-sided IVC, diagnosed during organ retrieval procedure. In a young brain-dead man, a single left-sided IVC was observed; it originated from iliac confluence in the left side of the aorta and extended throughout the abdomen. There was no retrohepatic IVC in the patient; hepatic veins drained directly into the right atrium. The second case was a brain-dead young woman with a left-sided IVC originated from iliac confluence to the kidney level; then, the IVC crossed anterior to the abdominal aorta to join a normally positioned retrohepatic IVC. In cases of retroperitoneal surgeries, IVC anomalies should be considered during preoperative imaging studies, because they may be misdiagnosed as para-aortic lymphadenopathy, tumor or dilated gonadal vein that may result in iatrogenic damage during surgery.

Multivisceral and small bowel transplantation at shiraz organ transplant center

BACKGROUND

Multivisceral transplantations were initially done in animal models to understand the immunological effects. Later on, in human beings, it has been considered a salvage procedure for unresectable complex abdominal malignancies. With advancement in surgical techniques, availability of better immunosuppressive drugs, and development of better post-operative management protocols, outcomes have been improved after these complex surgical procedures.

OBJECTIVE

To analyze and report results of multivisceral, modified multivisceral, and small bowel transplantations done at Shiraz Organ Transplant Center, Shiraz, southern Iran.

METHODS

Medical records of all patients who underwent multivisceral, modified multivisceral, and small bowel transplants were retrospectively analyzed.

RESULTS

There were 18 patients. The most common indications for the procedure in our series were unresectable carcinoma of pancreas followed by short bowel syndrome. 10 patients were alive after a median follow-up of 8.7 (range: 3-32) months. The remaining 8 patients died post-operatively, mostly from septicemia.

CONCLUSION

Multivisceral and small bowel transplantations are promising treatments for complex abdominal pathologies.

Ex-vivo Resection and Small-Bowel Auto-transplantation for the Treatment of Tumors at the Root of the Mesentery

BACKGROUND

Tumors involving the root of the mesentery are generally regarded as "unresectable" with conventional surgical techniques. Resection with conventional surgery may end in life-threatening complications in these patients. Ex-vivo resection and auto-transplantation avoids excessive bleeding and prevents ischemic related damage to the small intestine and other organs.

OBJECTIVE

To share our experience of ex-vivo resection of the tumors with involvement of small bowel mesentery followed by small bowel auto-transplantation.

METHODS

In this study, medical records of all the patients who underwent ex-vivo resection and auto-transplantation at our center were retrospectively analyzed.

RESULTS

The most common indication for the procedure in our series was locally advanced pancreatic carcinoma. Our survival rate was 50% with a mean±SD follow-up of 10.1±9.8 (range: 0-26) months. Causes of early in-hospital mortality were multi-organ failure, sepsis, and cerebrovascular accident. Recurrence of disease was noted in one patient while one patient developed hepatic metastasis after 20 months of surgery.

CONCLUSION

Ex-vivo resection of the tumor and auto-transplantation is the surgical treatment of choice for the locally advanced abdominal tumors involving the root of the mesentery.

Reproducibility of lymphoscintigraphy before and after excisional biopsy of primary breast lesions: a study using superficial peri-areolar injection of the radiotracer

OBJECTIVE

A major controversial issue in the sentinel node biopsy of the breast is the applicability of sentinel node mapping in patients with the history of previous excisional biopsy of the breast lesions. In the current study, we evaluated the reproducibility of lymphoscintigraphy before and after excisional biopsy of the primary breast lesions using superficial peri-areolar injection of the radiotracer.

MATERIAL AND METHODS

Eighteen patients scheduled for excisional biopsy of breast lesions were included into the study. The patients received intra-dermal injection of the radiotracer in the peri-areolar area of the index quadrant 1 to 2h before surgery. Imaging was performed the day after surgery. Immediately after completion of the first imaging, the patients received another injection of the radiotracer with the same technique, dose, and location. Other sets of lymphoscintigraphy imaging were taken immediately and 4h post second injection. The two sets of lymphoscintigraphy images were compared.

RESULTS

In 2 patients, sentinel node could not be identified in either set of images. In the remaining 16 patients, one sentinel node was detected in both lymphoscintigraphy image sets. The sentinel nodes of the second image sets were all in the same location of the first sets with at least 5 times higher count.

CONCLUSIONS

Excisional biopsy of the primary breast lesions does not seem to change the superficial lymphatic drainage pattern from the areola of the breast and sentinel node mapping can be performed after this procedure using superficial periareolar technique.

Transient and permanent hypoparathyroidism following thyroidectomy

AIM

This study was designed to identify the risk factors of transient and permanent hypoparathyroidism in patients undergoing thyroidectomy. We also studied the duration of transient hypoparathyroidism following thyroid surgery.

METHODS

A prospective study was conducted on 163 consecutive patients undergoing thyroidectomy. Serum Levels of calcium and parathyroid hormone (PTH) were determined the day before surgery and then on the 1st and 10th postoperative day to determine the postoperative course of serum PTH and calcium. Patients were followed for six months after surgery.

RESULTS

The incidence of transient and permanent hypoparathyroidism was 8.6% and 0%, respectively. Among all of variables, only the extent of surgery had a significant relationship with postoperative hypoparathyroidism (P=0.010). PTH measurement at 10th day postoperatively became normal, except in one patient in whom it continued to be low until two months.

CONCLUSION

The extent of surgery is the leading cause of postoperative hypoparathyroidism, though, in most of the patients this is a transient complication and PTH level revert to normal within 10 days after surgery.

Is C-reactive protein helpful for early diagnosis of acute appendicitis?

PURPOSE

Appendectomy is one of the most common surgical procedures all over the world. Although various laboratory tests and imaging studies are available to improve the accuracy of diagnosis, the rate of negative appendectomy is still about 15-30%. This study was designed to assess the diagnostic value of quantitative C-reactive protein (CRP) in patients suspected to acute appendicitis.

MATERIALS AND METHODS

In a prospective study, blood samples of 102 patients were collected before appendectomy. CRP was measured by immunoturbidimetry and the data were compared with the final histopathologic reports. Diagnostic accuracy of the CRP test was analyzed by ROC curve.

RESULTS

In histopathology, 83 patients (81/4%) had acute appendicitis and 19 (18/6%) had normal appendices. Considering 14 mg/lit as the cut-off point, this test shows 59% (95% CI, 48-69%) sensitivity and 68% (95% CI, 47-88%) specificity. The positive and negative predictive values were 89% (95% CI, 80-97%) and 27% (95% CI, 14-39%), respectively.

CONCLUSIONS

The measurement of CRP levels is not an ideal diagnostic tool for ruling out or determination of acute appendicitis.

Spontaneous aortocaval fistula: a case report and literature review

Spontaneous aortocaval fistula is a rare complication of abdominal aortic aneurysms. We describe two cases of spontaneous aortocaval fistula. The first patient is a woman who was admitted with abdominal pain and pulsatile abdominal mass. Another patient was a man admitted with progressive abdominal pain and hypotension. Computed tomography (CT) scan in both patients showed an infrarenal aortic aneurysm and simultaneous contrast enhancement in the inferior vena cava. Both patients underwent an urgent laparotomy in which the diagnosis of an aortocaval fistula was confirmed. We review the literature on spontaneous aortocaval fistula as a consequenceof complicated aortic aneurysms.

Uncut Roux-en-y esophagojejunostomy: A new reconstruction technique after total gastrectomy

PURPOSE

Uncut Roux-en-y is a reconstruction method with a main purpose of diminishing Roux stasis syndrome. In this study we performed this procedure to evaluate utility and complications of this technique, as well as its effect on Roux stasis syndrome.

METHODS

Total gastrectomy with Uncut Roux-en-y esophagojejunostomy was performed on 94 patients. This technique consists of an artificial jejunal occlusion 5 cm proximal to anastomosis and a jejunojejunostomy between afferent and efferent loops. Diagnosis of "Roux stasis syndrome" was made by clinical criteria.

RESULTS

According to the mentioned criteria, the "Roux stasis syndrome" occurred in 21.2% of the patients. Whereas occurrence rate of other complications was: dysphasia (13.8%), benign stricture in anastomosis (9.6%), and fistula (5.3%).

CONCLUSIONS

Comparing the results of our study to other related studies indicates that this type of operation has lower rate of "Roux stasis syndrome", and also decreases the postoperative stricture rate of the anastomosis.