Salvage after Retroperitoneal Kidney Allograft TorsionRead the full article
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Hepatic Artery Pseudoaneurysm in the Liver Transplant Recipient: A Case Series
Introduction. Hepatic artery pseudoaneurysm is a rare and potentially fatal complication of liver transplantation with a reported incidence of 0.3–2.6% and associated mortality approaching 75%. Clinical presentation typically includes sudden hypotension, gastrointestinal bleed or abnormal liver function tests within two months of transplantation. We report a series of four cases of hepatic artery pseudoaneurysm in adult liver transplant recipients with the goal of identifying factors that may aid in early diagnosis, prior to the development of life threatening complications. Methods. A retrospective chart review at a high volume transplant center revealed 4 cases of hepatic artery pseudoaneurysm among 553 liver transplants (Incidence 0.72%) between March 2013 and March 2017. Results. Two of the four patients died immediately after intervention, one patient survived an additional 151 days prior to death from an unrelated condition and one patient survived at two years follow up. All cases utilized multiple imaging modalities that failed to identify the pseudoaneurysm prior to diagnosis with computed tomography angiography (CTA). Two cases had culture proven preoperative intrabdominal infections, while the remaining two cases manifested a perioperative course highly suspicious for infection (retransplant for hepatic necrosis after hepatic artery thrombosis and infected appearing vessel at reoperation, respectively). Three of the four cases either had a delayed biliary anastomosis or development of a bile leak, leading to contamination of the abdomen with bile. Additionally, three of the four cases demonstrated at least one episode of hypotension with acute anemia at least 5 days prior to diagnosis of the hepatic artery pseudoaneurysm. Conclusions. Recognition of several clinical features may increase the early identification of hepatic artery pseudoaneurysm in liver transplant recipients. These include culture proven intrabdominal infection or high clinical suspicion for infection, complicated surgical course resulting either in delayed performance of biliary anastomosis or a biliary leak, and an episode of hypotension with acute anemia. In combination, the presence of these characteristics can lead the clinician to investigate with appropriate imaging prior to the onset of life threatening complications requiring emergent intervention. This may lead to increased survival in patients with this life threatening complication.
Severely Disseminated Kaposi Sarcoma after ABO-Incompatible Kidney Transplantation Treated Successfully with Paclitaxel and Gemcitabine Combined with Hemodialysis
Kaposi Sarcoma (KS) is driven by human herpes virus 8 causing vascular proliferation which is induced by loss of immune function most often due to HIV or immunosuppressants. KS occurs with increased incidence in kidney transplant recipients, but rarely is disseminated. We report a 64-year-old male who developed severely disseminated KS 5 months after ABO-incompatible kidney-transplantation. No guidelines for chemotherapy exist in this case and reduced kidney function and impaired immune system complicates the use of systemic chemotherapy in kidney transplant recipients. A combination of paclitaxel and gemcitabine followed by two days of hemodialysis treatment was chosen since paclitaxel can be given in full dose independently of kidney function and gemcitabine is metabolised to 2′,2′-difluorodeoxyuridine which is found to be highly dialysable. The present treatment was well tolerated by the patient with one episode of leukopenia and elevated alanine transaminase during treatment which resolved. There were no serious adverse events and the patient obtained a complete remission verified by Positron Emission Tomography CT after ending chemotherapy and at one-year follow up.
Wide Excision of a Retroperitoneal Liposarcoma with En Bloc Ureterectomy and Renal Salvage by Autotransplantation
Liposarcoma is a malignant mesenchymal neoplasm composed of adipose tissue with varying degrees of atypia. These tumors grow slowly and may reach an enormous size particularly if located in the retroperitoneum. We report a 40-year-old male with a 6-month history of gradual abdominal enlargement. Computed tomography (CT) of the abdomen showed a huge retroperitoneal mass with characteristic features consistent with liposarcoma. On laparotomy, the mass was noted to be encasing the right ureter for which a wide excision with en bloc ureterectomy and subsequent renal autotransplantation for organ preservation was done. Post-operative course was uneventful with excellent outcome after 6 months of follow-up. Final histopathologic diagnosis was low-grade, well differentiated liposarcoma, which has favorable prognosis following radical surgery. This was the first report of such a case in the Philippines.
Surgical Site Infections Complicating the Use of Negative Pressure Wound Therapy in Renal Transplant Recipients
Surgical site infections (SSI) of the abdominal wall in renal transplant recipients can on occasion require management with negative pressure wound therapy (NPWT). This is often successful, with a low risk of further complications. However, we describe three cases in which persistent or recurrent surgical site sepsis occurred, whilst NPWT was being deployed in adults with either wound dehiscence or initial SSI. This type of complication in the setting of NPWT has not been previously described in renal transplant recipients. Our case series demonstrates that in immunosuppressed transplant recipients, there may be ineffective microbial or bacterial bioburden clearance associated with the NPWT, which can lead to further infections. Hence recognition for infections in renal transplant patients undergoing treatment with NPWT is vital; furthermore, aggressive management of sepsis control with early debridement, antimicrobial use, and reassessment of the use of wound dressing is necessary to reduce the morbidity associated with surgical site infections and NPWT.
Combined Chylothorax and Chylous Ascites Complicating Liver Transplantation: A Report of a Case and Review of the Literature
Chyle leaks may occur as a result of surgical intervention. Chyloperitoneum, or chylous ascites after liver transplantation, is rare and the development of chylothorax after abdominal surgery is even more rare. With increasingly aggressive surgical resections, particularly in the retroperitoneum, the incidence of chyle leaks is expected to increase in the future. Here we present a unique case of a combined chylothorax and chyloperitoneum following liver transplantation successfully managed conservatively. Risk factors for chylous ascites include para-aortic manipulation, extensive retroperitoneal dissection, use of a Ligasure device, and early enteral feeding as well as early enteral feeding. The clinical presentation is typically insidious and may include painless abdominal distension. Diagnosis can be made by noting characteristic milky white drainage which on laboratory examination has a total fluid triglyceride level >110 mg/dl, an ascites/serum triglyceride ratio of >1 and a leukocyte count in fluid >1000/uL with a lymphocyte predominance. Chyle leaks may lead to significant morbidity and mortality. Numerous management options exist, with conservative nonoperative measurements leading to the most consistent and successful outcomes. This includes a step-up approach beginning with dietary modifications to a low-fat or medium chain triglyceride diet followed by nil per os with addition of total parenteral nutrition and somatostatin analogues such as octreotide. Rarely do patients require more invasive treatment. Early recognition and appropriate management are imperative to mitigate this complication.
Nontraditional Use of TEE to Evaluate Hepatic Vasculature and Guide Surgical Management in Orthotopic Liver Transplantation
Intraoperative Transesophageal Echocardiography (TEE) during orthotopic liver transplant (OLT) is used to gather real-time information on cardiovascular function and intravascular volume status. We report a case where nonstandard TEE views were used to inspect the hepatic vasculature after allograft implantation. A 29-year-old male with secondary biliary cirrhosis with a MELD score of 20 underwent OLT using a liver from a 21-year-old brain-dead donor. Postreperfusion TEE, using the modified hepatic vein views, confirmed the presence of an inferior vena cava (IVC) suprahepatic anastomotic stenosis and hepatic vein and IVC thrombus resulting in hepatic venous outflow obstruction, allograft congestion, and hemodynamic instability. These nonstandard TEE images established the extent of suprahepatic caval outflow obstruction, in which intraoperative ultrasound was unable to definitively demonstrate. This guided real-time surgical decision-making in the postimplantation phase of the operation—ultimately leading to hepatic vein and IVC thrombectomy and revision of suprahepatic caval anastomosis.