Large bowel obstruction secondary to a cecal bascule with internal herniation through the foramen of Winslow: A case report.

INTRODUCTION: Internal hernias are a rare phenomenon, and even rarer is a herniation through the foramen of Winslow. The clinical presentation of patients with an internal hernia is often vague and difficult to diagnose clinically. If internal hernias go undiagnosed and untreated, patients can develop bowel compromise leading to a high morbidity and potential mortality. Radiologic imaging is helpful in bringing the diagnosis to the forefront of the clinicians mind, but the diagnosis is often made intra-operatively. PRESENTATION OF CASE: An eighty-one year old female presenting with a few months of vague abdominal symptoms who was found to have a cecal bascule internally herniating through the foramen of Winslow was treated successfully with surgical intervention. DISCUSSION: Internal hernias occur when there is a protrusion of a viscera through the peritoneum or mesentery and confined within the abdominal cavity. Internal hernias are classified according to location and vary from paraduodenal, transmesenteric, and pelvic to name a few. Hernias through the foramen of Winslow are a rare subset, and were the internal hernia found in our patient intra-operatively. Our patient's clinical presentation was vague with generic abdominal complaints and radiologic imaging was inconclusive for a definitive diagnosis. However, prompt surgical intervention resulted in a good outcome for our patient. CONCLUSION: Internal hernias, to be diagnosed and treated promptly, require a high index of suspicion from a clinician based on clinical presentation and radiologic imaging. These patients belong in the operating room, and interventions are directed based on the anatomical findings intra-operatively.

Richter's hernia at a Tenckhoff catheter exit site.

A 60-year-old male presented with a 2-day history of nausea, vomiting, and abdominal pain 3 months after kidney transplantation. No clinical and x-ray signs of small obstruction were present. A CT scan of the abdomen showed incarcerated small bowel loop at the site of the earlier peritoneal dialysis catheter (Tenckhoff) that was removed 2 months before. The hernia was repaired by laparoscopic approach using a biologic mesh. Only a few cases of small bowel obstruction at the Tenckhoff catheter exit site have been reported in the literature but none, to our knowledge, has described a case of partial small obstruction (Richter's hernia). The presentation of Richter's hernia can be very deceiving, especially in transplanted patients because of the masking effects of immunosuppression on symptoms and signs of inflammation and difficult differential diagnosis in these patients.

Overcoming diabetic gastroparesis en route to kidney transplant.

Gastroparesis is a debilitating condition that affects a significant number of diabetic patients. Some of these patients have end-stage renal disease and are in need of kidney transplant. Symptoms of gastroparesis include: early satiety, pyrosis, epigastric pain, nausea and vomiting, which may lead to caloric and electrolyte deficiencies as well as significant weight loss. A viable option for diabetic gastroparesis patients who fail first line treatments consisting of dietary changes and gastric prokinetic medications is gastric electrical stimulator (GES) implantation. We present a 41-yr-old man and 35-yr-old woman with diabetic gastroparesis, who were initially deemed unacceptable candidates for renal transplantation because of marked malnourishment and a concern that they would not be able to tolerate immunosuppressant medications. In less than two yr following GES implantation, each patient underwent a successful kidney transplant.

Outcome of renal transplants from pediatric donors <5 yr of age.

AIM: Outcomes of single renal transplants from donors <5 yr old have traditionally been inferior to those from older donors. We retrospectively studied our experience with patients who received renal transplants, either individually or en bloc, from young donors (<5 yr of age) to determine the utility of these organs. We also compared the outcomes of these transplant patients maintained on either cyclosporine- (CyA) or tacrolimus-based (TRL) immunosuppression regimens. PATIENTS: Ninety-eight patients received transplants at our center from donors <5 yr of age between August 1993 and August 2003. They were followed-up from 12 months to 11 yr. Patients were divided into four groups based on whether they received single or en bloc transplants, and whether CyA or TRL was the base immunosuppressive agent. Patients in group I (n = 13) received single pediatric kidneys and were treated with CyA regimens; group II patients (n = 26) also received single pediatric kidneys, but were treated with TRL regimens; group III patients (n = 31) were transplanted en bloc and were treated with CyA; and group IV patients (n = 28) received en bloc transplants and were treated with TRL. RESULTS: One-year patient and death-censored graft survival was not significantly different between recipients of en bloc vs. single grafts (i.e. 88 and 85% vs. 90 and 87%, respectively), or between the four treatment groups (group I: 85 and 85%, group II: 92 and 88%, group III: 87 and 84%, and group IV: 89 and 86%, respectively). The overall 1-yr rejection rate was 30% (29 of 98), which was significantly higher in the CyA-treated patients 19 of 44; i.e. 43%, than in TRL-treated patients 10 of 54, i.e. 19%, p = 0.03). In the en bloc recipients, seven grafts (12%) were lost as a result of vascular thrombosis. Notably, none of the single kidneys were lost because of vascular thrombosis. At the end of follow-up the creatinine levels of both groups were comparable. CONCLUSIONS: Pediatric donor kidneys transplanted individually provide for equal patient and graft survival when compared with en bloc transplants. TRL can be used reduce the detrimental effect of acute rejection on graft growth and function when compared with CyA. Single use of such kidneys can safely and efficaciously be transplanted into adult recipients, greatly expanding the donor pool.

Improved freedom from rejection after a loading dose of sirolimus.

BACKGROUND: Sirolimus (SIR) in combination with cyclosporine reduces the incidence of acute rejection in renal transplant recipients. Limited data are available regarding SIR in combination with tacrolimus (TAC). METHODS: A single-center, retrospective review of renal transplant recipients receiving SIR, TAC, and corticosteroids postoperatively was conducted. A total of 118 consecutive renal transplant recipients were included on the basis of availability of day 1 SIR dose information. Seventy-seven patients received an SIR loading dose (SIR-LD) immediately posttransplantation, and 41 patients did not (SIR no loading dose [SIR-NLD]). RESULTS: The two groups showed similar demographic and transplant characteristics. SIR doses and trough levels were significantly higher in the SIR-LD patients at 1 and 7 days posttransplantation; however, no differences occurred beyond day 7. Patients receiving an SIR-LD experienced significantly better freedom from rejection at 1, 3, and 6 months posttransplantation (P<0.05). This rejection benefit in the SIR-LD group was independent of donor source and use of antibody induction. SIR-LD patients experienced fewer serious infections (12% SIR-LD vs. 27% SIR-NLD, P=0.04) and a lower incidence of delayed graft function (21% SIR-LD vs. 39% SIR-NLD, P<0.05). No significant differences in serum creatinine, hemoglobin, and platelet counts occurred in the first 180 days posttransplantation, but the patients in the SIR-NLD group experienced lower hemoglobin levels at day 30 than those in the SIR-LD group (10.8 g/dL SIR-LD vs. 9.7 g/dL SIR-NLD, P=0.03). CONCLUSION: SIR-LD significantly improves early posttransplantation freedom from rejection in renal transplant recipients without increasing other complications.

Outcome after simultaneous abdominal aortic aneurysm repair and aortocoronary bypass.

Myocardial infarction remains the leading cause of early and late death after abdominal aortic aneurysm (AAA) repair. Myocardial revascularization is staged either before or concomitant with AAA resection, but results are far from uniform. We retrospectively analyzed our experience with patients who underwent concomitant AAA resection and aortocoronary bypass (ACB) to examine the factors affecting early morbidity/mortality and early results. Forty-two patients (all men; mean age, 67.2 years) underwent simultaneous ACB grafting and AAA repair between 1975 and 1998. All were managed postoperatively in the cardiothoracic intensive care unit (mean stay, 6.1 days). The mean total hospital stay was 17.2 days. Two died in the early postoperative period (4.8%): 1 of sustained myocardial failure following a third ACB, and 1 of coagulopathy after concomitant ACB, aortic valve replacement, and AAA. One patient developed a nonfatal MI on postoperative day 3. The incidence of wound and bleeding complications was higher for patients undergoing both ACB and AAA repair than for patients undergoing AAA resection alone. On follow-up (mean, 10 years; range, 7 months to 15 years), only 2 of 10 late deaths were due to cardiovascular causes. We believe that concomitant myocardial revascularization is warranted in select patients requiring elective or urgent AAA resection in order to decrease perioperative risk and improve late survival. Cardiac failure or ischemia during aortic surgery can be prevented by proper perfusion with or without cardiopulmonary bypass. In patients undergoing simultaneous procedures, the increased risk is related to the severity of the vascular and coronary artery disease and not to the combined operations.