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.

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.

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.

Multivisceral transplantation for the treatment of intra-abdominal tumors.

BACKGROUND: Some intra-abdominal or retroperitoneal tumors such as low-grade slow-growing malignancies may seem unresectable due to major vessel encasement or presence of intra-abdominal dissemination, but the slow growth rate and to some extent long life expectancy of the patients urge us to find some strategies to cure the patients or at least achieve tumor remission or symptom palliation. En bloc resection, followed by multivisceral or liver-sparing "modified" multivisceral transplantation has recently been used for treatment of these patients. RESULTS: Between May 2010 and October 2012, 3 multivisceral and 3 modified multivisceral transplantations were performed in 6 patients (aged 14 to 55 years; mean, 32 years) with some slow growing intra-abdominal malignancies (2 neuroendocrine tumors, 2 gastrointestinal stromal tumors, 1 desmoid tumor, and 1 low-grade sarcoma). All patients survived the procedure. One patient died of pancytopenia 2 months after transplantation and another died with pulmonary emboli at 4 months. The remaining 4 patients are alive without any evidence of disease recurrence. CONCLUSIONS: Although large intra-abdominal desmoid tumors, well-differentiated neuroendocrine tumors, and gastrointestinal stromal tumors are slow growing, they tend to invade locally, especially to the mesenteric root and/or celiac axis and other abdominal viscera. Complete resection followed by multivisceral transplantation could be a therapeutic option for these advanced tumors.

Reproducibilidad de la linfogammagrafía antes y después de la biopsia excisional de las lesiones primarias de mama: estudio utilizando la inyección periareolar superficial del radiotrazador / Reproducibility of lymphoscintigraphy before and after excisional biopsy of primary breast lesions: A study using superficial peri-areolar injection of the radiotracer

Objetivo. Una cuestión de gran controversia en la biopsia del ganglio centinela de la mama es la aplicabilidad del estudio del ganglio centinela en pacientes con historia previa de biopsia excisional de las lesiones de la mama. En el presente estudio, evaluamos la reproducibilidad de la linfogammagrafía antes y después de la biopsia excisional de las lesiones primarias de mama utilizando la inyección periareolar superficial del radiotrazador. Material y métodos. Se incluyó en el estudio a 18 pacientes programadas para biopsia excisional de lesiones de mama. A las pacientes se les administró una inyección intradérmica del radiotrazador en el área periareolar del cuadrante con tumor, con 1 o 2h antes de la cirugía. La imagen se obtuvo el día posterior a la operación. Inmediatamente tras la primera imagen, a las pacientes se les administró otra inyección del radiotrazador con la misma técnica, dosis y localización. Se realizaron inmediatamente otras series de imágenes de linfogammagrafía, y a las 4h después de la segunda inyección. Se compararon las 2 series de imágenes de linfogammagrafía. Resultados. En 2 pacientes no se pudo identificar el ganglio centinela en ninguna de las series de imágenes. En las 16 pacientes restantes se detectó un ganglio centinela en ambas series de imágenes de linfogammagrafía. Los ganglios centinela de las segundas series de imágenes se detectaron en la misma localización que las primeras series de imágenes, con un contaje al menos 5 veces superior. Conclusiones. La biopsia excisional de las lesiones primarias de mama no parece modificar el patrón del drenaje linfático superficial desde la areola de la mama, pudiendo realizarse el estudio del ganglio centinela tras esta intervención, utilizando la técnica periareolar superficial(AU)

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(AU)

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.

The role of nasogastric intubation on postoperative gastrointestinal function in patients with obstructive jaundice.

It is the practice of many surgeons to use the routine nasogastric tube after biliary operations, but its usefulness has been questioned. This study was designed to determine the effect of postoperative nasogastric intubation on gastrointestinal function in patients with obstructive jaundice. In this randomized clinical trial, 40 patients who underwent choledochoduodenostomy or hepaticojejunostomy were randomly divided into two groups. Patients in the experimental group did not have the nasogastric tube, and in the control group the nasogastric tube was routinely applied after surgery. Gastrointestinal function was compared in these two groups. Patients with no nasogastric intubation did not show any postoperative complications or prolonged hospital stay. On the contrary, nasogastric tube insertion postponed return of bowel function and increased the incidence of nausea and vomiting, while it did not affect the incidence of postoperative ileus. Routine use of the nasogastric tube after choledochoduodenostomy or hepaticojejunostomy can delay normal gastrointestinal function and increase postoperative discomfort.

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.