COVID-19 Infection and Acute Pancreas Transplant Graft Thrombosis.

The coronavirus disease 2019 (COVID-19) pandemic created an unprecedented challenge for healthcare, and the world continues to struggle in recovering from its aftermath. COVID-19 has been clearly linked to hypercoagulable states and can lead to end-organ ischemia, morbidity, and mortality. Immunosuppressed solid organ transplant recipients represent a highly vulnerable population for the increased risk of complications and mortality. Early venous or arterial thrombosis with acute graft loss after whole pancreas transplantation is well-described, but late thrombosis is rare. We herein report a case of acute, late pancreas graft thrombosis at 13 years post pancreas-after-kidney (PAK) transplantation coinciding with an acute COVID-19 infection in a previously double-vaccinated recipient.

Successful Liver Transplantation After Neurologically Determined Death Donation Following Sodium Nitrite Poisoning.

Sodium nitrite poisoning has been reported with increasing frequency since 2017 and popularized on social media as an effective means to commit suicide. Though accidental, non-intentional consumption has been reported, it is uncommon. Sodium nitrite is a colorless, odorless, yellowish-white crystalline material that resembles table salt, is easily ingested for self-harm, and is readily accessible through purchase from online portals at low cost. The chemical is used industrially as a curing agent for meat, fish, and cheese, as it inhibits Clostridium botulinum and prevents botulism. We herein report a successful case of liver transplantation from an organ donor who suffered brain death after intentional sodium nitrite consumption. Despite conflicting evidence on sodium nitrite's toxic versus protective effects on the liver, our transplant recipient showed normal graft function in the four months following liver transplantation. It would have been helpful and reassuring to have had access to similar positive case reports when deciding to use such a donor.

Beware of Rattling Underfoot: Cystic Artery Pseudoaneurysm in Acute Cholecystitis With a Cholecystostomy.

Cystic artery pseudoaneurysm (CAP) is a very rare complication of acute cholecystitis. The pathogenesis of CAP in the context of cholecystitis is unknown but is possibly related to the inflammatory process in the vicinity of the cystic artery, leading to weakness in the wall of the artery. Though CAP has been reported in the literature, our patient had a unique presentation in the presence of a cholecystostomy catheter in situ. There were no risk factors for CAP in our patient including usage of anticoagulants, trauma, or surgical procedures. Fortunately, the blood-stained fluid in the cholecystostomy catheter effluent alerted the clinical team to a possible vascular complication in the background of ongoing cholecystitis. This finding should serve as a warning sign to alert clinicians to the possibility of CAP-beware of rattling underfoot.

Can Inflammatory Markers Foretell Aetiology and Prolonged Hospitalisation in Acute Pancreatitis?

Introduction Acute pancreatitis (AP) causes a cascade of complex inflammatory responses following an initial insult. Hence, the scoring systems include white blood cell count (WBC) as a marker of severity of acute pancreatitis. C-reactive protein (CRP) was also shown to be useful in predicting the course of pancreatitis. This study analyses role of inflammatory markers in predicting gallstone aetiology of AP and length of hospital stay (LOS). Materials and methods A total of 143 patients with acute pancreatitis between October 2016 and 2017 were included in this study and relevant parameters were collected from the electronic patient database. The parameters were WBC, CRP, and LOS. Results Among 143 patients with AP, 50 patients had gallstone pancreatitis (GP) and remaining of 93 patients suffered nongallstone pancreatitis (NGP). The WBC count at admission, 24 hours and 72 hours in GP versus NGP were 11.6± 5 versus 13.7±17; P = 0.24; 12.6±20 versus 10.1±17; P = 0.21; and 13.2±22 versus 9.2±4.7; P = 0.15, respectively. Similarly, the serum CRP levels at admission, 24 hours and 72 hours were 30.4± 73 versus 47.6±79; P = 0.25; 71.9±20 versus 92.2±97; P = 0.35; and 89±106 versus 122.7±107; P = 0.05, respectively. More number of patients with elevated WBC in GP arm compared to NGP (12/50±7/93; P = 0.0008) was noted. In GP arm, patients with elevated CRP at admission (10.5±8.67 versus 5.4±5.8 days; P = 0.02) and 24 hours (9.8±8.3 versus 4.2±4.7 days; P = 0.001) had long LOS. However, patients with elevated CRP at 72 hours (89±106 versus 122.7±107; P = 0.05) had longer LOS in NGP. Conclusion Significantly high CRP level at 72 hours was associated with NGP and longer length of hospital stay. In GP, patients with elevated CRP level at admission and 24 hours predicts long LOS.

Predictivity of Biochemical Markers on Aetiology and Length of Hospitalisation in Acute Pancreatitis.

Background Acute pancreatitis (AP) is a common cause of emergency hospital admission. Predictive value of biochemical markers including alanine aminotransferase (ALT), alkaline phosphatase (ALP), bilirubin and lipase on pancreatitis has not been fully established. This study aimed to assess the role of ALT, ALP, bilirubin and lipase levels at admission on predicting the aetiology and length of hospital stay in AP. This study also assesses quantitative high lipase as a predictor of gallstone pancreatitis (GP). Methods All patients above the age of 18 with a diagnosis of AP between October 2016 - 2017 were included in our study. The exclusion criteria were patients with a known history of pancreatitis or biliary disease/bile duct stones and pregnancy. This is a retrospective study performed from a prospectively collected electronic patient database at our hospital. Results Among the 143 patients with AP, 50 patients were diagnosed with gallstone pancreatitis (GP) and the remaining of 93 patients suffered non-gallstone pancreatitis (NGP). Mean ALT level was significantly higher in gallstone pancreatitis (237 ± 351 IU) compared to non-gallstone pancreatitis (107 ± 162 IU; P = 0.005). ALP level was numerically high in GP (151.5 ± 186) compared to NGP (138 ± 105 IU; P = 0.64). Similar results in bilirubin level also noted in GP (35.5 ± 24.5) comparing to NGP (20.7 ± 79.6 µmol/L; P = 0.09). Raised ALT (9.3 ± 8.2 versus 3 ± 2.19 days), bilirubin (8.5 ± 2.5 versus 6.9 ± 1.19 days) and ALP levels (6.26 ± 6.1 versus 3.5 ± 10 days respectively; P = 0.05) were associated with longer hospitalisation in GP comparing to NGP. The lipase level more than 10 times the upper reference level (10-URL) was found to be associated with GP (39/50) than NGP (54/93; P = 0.027). Conclusion Raised ALT, high lipase of 10 URL levels were associated with gallstone pancreatitis. In gallstone pancreatitis, patients with high ALT, bilirubin and ALP levels had longer hospital stay.

An enigmatic triad of acute pancreatitis, diabetic ketoacidosis and hypertriglyceridaemia: who is the culprit?

Acute pancreatitis(AP) is one of the common causes of acute abdomen and known to be associated with high morbidity and mortality in severe cases. Though most common causes of AP are cholelithiasis and alcoholism, it has also been reported in association with diabetic ketoacidosis (DKA). Triad of AP, hypertriglyceridaemia (HTG) and DKA is rare co-association and here the causal factor of AP is still not fully established. We report a case of AP in a DKA patient with recent diagnosis of hyperlipidaemia and diabetes. Usually AP has been associated with severe HTG; interestingly, our patient showed only moderate raise in triglycerides but still suffered AP during DKA. Hence, it raises question about the real culprit in this enigmatic triad.

An Unusual Case of Resistant Hypokalaemia in a Patient with Large Bowel Obstruction Secondary to Neuroendocrine Carcinoma of the Prostate.

Neuroendocrine Carcinoma of the Prostate (NECP) is rare and only few cases have been reported, constituting less than 0.5% of prostatic malignancies. We report a rare case of large bowel obstruction from NECP posing a further challenge in management due to resistant hypokalaemia. A 70-year-old man presented with clinical signs of large bowel obstruction who was known to have prostatic carcinoma three years ago, treated initially with hormone therapy then chemoradiation. The blood profile showed a severe hypokalaemia and CT scan revealed liver and lung metastases apart from confirming large bowel obstruction from local invasion of NECP. Severe hypokalaemia was believed to be caused by paraneoplastic syndrome from tumor burden or by recent administration of Etoposide. Intensive potassium correction through a central venous access in maximal doses of 150 mmol/24 hours under cardiac monitoring finally raised serum potassium to 3.8 mmol/L. This safe period allowed us to perform a trephine colostomy at the left iliac fossa. The postoperative period was relatively uneventful. This first case report is presenting a rare cause of large bowel obstruction from a neuroendocrine carcinoma of prostate and highlights the importance of an early, intensive correction of electrolytes in patients with large tumor burden from NECP.

Lower limb gigantism, lymphedema, and painful varicosities following a thigh vascular access graft.

Prosthetic arteriovenous grafts (AVGs) are associated with greater morbidity than autogenous arteriovenous fistulas (AVFs), but their use is indicated when AVF formation is not possible. This report adds to the literature a case of lower limb gigantism, painful varicosities, and lymphedema following long-term use of AVG in the upper thigh. The patient's past medical history included renal transplantation on the same side well before the AVG was inserted and right leg deep vein thrombosis. Suspicion of AVG thrombosis was excluded by Doppler ultrasound, which demonstrated an access flow of 1700 mL/min. A computed tomography (CT) scan of the abdomen and pelvis did not identify the cause of her symptoms. Whereas functional incompetence of the iliac vein valve might be responsible for the varicosities, the extent of hypertrophy in this case raises the suspicion of lymphatic blockage possibly secondary to groin dissection undertaken at the time of graft insertion, in addition to the previous dissection at the time of transplantation. This case highlights the need for minimal groin dissection during AVG insertion, particularly in patients with a history of previous abdominopelvic surgery.

Renal transplantation from elderly living donors.

Acceptance of elderly living kidney donors remains controversial due to the higher incidence of comorbidity and greater risk of postoperative complications. This is a review of publications in the English language between 2000 and 2013 about renal transplantation from elderly living donors to determine trends and effects of donation, and the outcomes of such transplantation. The last decade witnessed a 50% increase in living kidney donor transplants, with a disproportionate increase in donors >60 years. There is no accelerated loss of kidney function following donation, and the incidence of established renal failure (ERF) and hypertension among donors is similar to that of the general population. The overall incidence of ERF in living donors is about 0.134 per 1000 years. Elderly donors require rigorous assessment and should have a predicted glomerular filtration rate of at least 37.5 mL/min/1.73 m(2) at the age of 80. Though elderly donors had lower glomerular filtration rate before donation, proportionate decline after donation was similar in both young and elderly groups. The risks of delayed graft function, acute rejection, and graft failure in transplants from living donors >65 years are significantly higher than transplants from younger donors. A multicentred, long-term, and prospective database addressing the outcomes of kidneys from elderly living donors is recommended.

Perforated Meckel's Diverticulum Lithiasis: An Unusual Cause of Peritonitis.

Meckel's diverticulum is the commonest congenital malformation of gastrointestinal tract and represents a persistent remnant of the omphalomesenteric duct. Although it mostly remains silent, it can present as bleeding, perforation, intestinal obstruction, intussusception, and tumours. These complications, especially bleeding, tend to be more common in the paediatric group and intestinal obstruction in adults. Stone formation (lithiasis) in Meckel's diverticulum is rare. We report a case of Meckel's diverticulum lithiasis which presented as an acute abdomen in an otherwise healthy individual. The patient underwent an exploratory laparotomy which revealed a perforated Meckel's diverticulum with lithiasis; a segmental resection with end-to-end anastomosis of small bowel was performed. Patient recovery was delayed due to pneumonia, discharged on day 20 with no further complications at 6 months following surgery.

Extending anatomic barriers to right laparoscopic live donor nephrectomy.

OBJECTIVE: To analyze the effects of a right-sided-complex laparoscopic live donor nephrectomy, defined as bifurcation of the right renal artery behind the inferior vena cava. Right-sided laparoscopic live donor nephrectomy is now a widely accepted procedure when complex anatomy is encountered on the left. TECHNICAL CONSIDERATIONS: The present retrospective case note review involved 59 of 303 laparoscopic live donor nephrectomy procedures performed in a single center from January 2001 to April 2010 (group 1, simple, n=48; and group 2, complex, n=11). The effect of a donor right procedure on warm ischemia, graft function, and donor/recipient complications was analyzed. RESULTS: No difference in donor or recipient age or first and second warm ischemic times was found between the 2 groups. No difference was found in the estimated glomerular filtration rate or serum creatinine at 1 week and 3 and 6 months [estimated glomerular filtration rate (6/12), 49±15 vs 60±9 mL/min, P=.087; and serum creatinine (6 months), 159±116 vs 120±25 µmol/L; P=.356]. No cases of delayed graft function were reported, and none of the grafts developed vascular thrombosis. The cumulative estimated glomerular filtration rate at 6/12 was 51±15 mL/min and the serum creatinine was 153±108 µmol/L. Two patients (4%) required conversion to open surgery in group 1, and the cumulative conversion rate was 3.3%. In the complex group with retrocaval dissection, 8 kidneys were retrieved with a single artery and 3 had multiple vessels (2 with 2 vessels and 1 with 3 vessels; anastomotic time 26±6 minutes). CONCLUSION: Complex vasculature in a right-sided donation should not be considered a contraindication, because the kidneys procured had excellent function compared with those with single vasculature with no increase in the conversion or vascular thrombosis rate. In addition, the described techniques permit improved arterial length and, importantly, organs procured with a single artery.

A nodulo-cystic eumycetoma caused by Pyrenochaeta romeroi in a renal transplant recipient: A case report.

INTRODUCTION: Pyrenochaeta romeroi (P. romeroi) is a saprophytic fungus found in soil and plants. The fungal spores can be introduced into deeper tissues by trauma. It causes eumycetoma, which affects skin and subcutaneous tissues. CASE PRESENTATION: A 57-year-old South Asian man presented with a painless, nodular lesion (1 cm × 0.5 cm) on the left knee. He had had a renal transplant eight months earlier for end-stage renal failure. The patient was on tacrolimus, mycophenolate mofetil and prednisolone for immunosuppression. The lesion had progressed dramatically (to 5 cm × 5 cm) despite antibiotic treatment. The size and location of the lesion was severely affecting his quality of life, so an excision biopsy was performed. Nuclear ribosomal repeat-region sequencing confirmed the causative organism as P. romeroi. An in vitro antifungal susceptibility test demonstrated that P. romeroi was sensitive to voriconazole. Following a successful surgical removal, voriconazole was continued orally for two months. CONCLUSION: To the best of our knowledge, we are reporting the first case of Eumycetoma caused by P. romeroi in a renal transplant recipient. Physicians should be aware of this rare fungal disease in transplant recipients. We recommend a combination of medical and surgical management in these immunosuppressed patients.