Acute esophageal necrosis following kidney transplantation.

We are reporting a case of spontaneous acute esophageal necrosis "black esophagus" of unclear etiology in a kidney transplant recipient. A patient with end-stage renal disease due to IgA nephropathy received a deceased-donor kidney transplant. The surgical procedure was uneventful, without hemodynamic instability. He was started on alemtuzumab for immunosuppression induction followed by maintenance immunosuppression with intravenous methylprednisolone for 3 days, then oral prednisone, mycophenolate mofetil and tacrolimus (a target level between 8 and 10ng/ml) daily. On postoperative day (POD) 3, the patient started to develop significant gastro-intestinal symptoms: epigastric pain, dysphagia, odynophagia, eructation, pyrosis, nausea, and regurgitation of food contents. He was diagnosed with esophageal necrosis by upper endoscopy on postoperative day 4. We describe a successful treatment with supportive therapy and complete recovery despite receiving immunosuppressive therapy. To our knowledge, this case is one of the few reported cases of esophageal necrosis in kidney transplant recipients and the first case that was not associated with clinical risk factors.

Acute Pancreatitis in Patients with a History of Bariatric Surgery: Is It Less Severe?

INTRODUCTION: Bariatric surgery (BSx) leads to weight loss and causes alterations in gastrointestinal and pancreatic peptides. This raises questions on acute pancreatitis (AP) occurrence and outcomes in this cohort of patients. We aim to assess mortality, morbidity, and resource utilization of AP in patients with BSx. METHODS: Observational retrospective cohort study (2012-2016) with propensity score match. Patients with a principal diagnostic ICD9-10CM code for AP were included. Stratification for the coexistence of history of BSx was performed. The primary outcome was mortality. Secondary outcomes were morbidity, resource utilization, length of hospital stay (LOS), total hospital charges, and costs. RESULTS: Out of 920,615 AP patients, 15,345 had undergone BSx. After propensity matching, 8220 patients with BSx had AP. The mortality for AP was 0.42 (p < 0.01) and for biliary AP 0.29 (< 0.04) in the history of BSx group compared to patients without BSx history. Acute kidney insufficiency (AKI), shock, ICU, multiorgan failure, ERCP, costs, charges, and LOS were all lower for patients with AP who had history of BSx. Patients with biliary AP showed even lower odds of AKI, ICU, multiorgan failure, costs, charges, and LOS, but higher odds of cholecystectomy. CONCLUSION: Patients with AP with history of BSx have lower mortality, morbidity, and resource utilization. This may be due to post-surgical alterations in pancreatic and gastrointestinal functions including hormonal and anatomical changes. Interestingly, patients with biliary AP and BSx had even lower odds of mortality and morbidity than patients with non-biliary AP, suggesting an added benefit with milder disease course.

Endoscopic Mucosal Resection of Jejunal Polyps using Double-Balloon Enteroscopy.

BACKGROUND: There are only two single case reports describing double-balloon enteroscopy (DBE)-assisted endoscopic mucosal resection (EMR) of the jejunum. The aim of this case series was to evaluate the feasibility and utility of DBE-assisted EMR in patients with familial and non-familial jejunal polyps. PATIENTS AND METHODS: Observational, open-label, retrospective, single-arm case series in two hospitals. RESULTS: Eight patients underwent DBE assisted jejunal EMR. Median age of patients was 42 years (range 24-62 years), male: female ratio 1.5:1. DBE was done through the antegrade (i.e. oral) route in all patients. Four patients had FAP; two had Peutz-Jeghers syndrome, one had a sporadic adenoma and one had a bleeding jejunal polyp, which on histological examination turned out to be lipoma. 3/8 underwent piece-meal EMR. No immediate adverse events occurred. CONCLUSIONS: This is the first case series presenting the technical details, feasibility and outcomes of EMR of the small bowel. EMR of the jejunum is feasible and safe during DBE.

INTRODUÇÃO: Existem apenas duas séries clínicas na literatura a descrever os resultados da mucosectomia no jejuno por enteroscopia de duplo balão (DBE). O objetivo desta série de casos foi avaliar a exequibilidade e utilidade da mucosectomia por DBE em doentes com pólipos jejunais familiares e não familiares. MÉTODOS: Estudo observacional, retrospectivo, open-label, descrevendo uma série de casos em dois hospitais. RESULTADOS: Oito doentes realizaram mucosectomia por DBE. A idade mediana foi 42 anos (âmbito 24­62 anos), razão homem:mulher 1,5:1. Foi realizada DBE por via anterógrada (oral) em todos os doentes. Quatro doentes tinham polipose adenomatosa familiar (PAF); dois tinham síndroma de Peutz-Jeghers, um tinha um adenoma esporádico e um tinha um pólipo jejunal sangrante, cuja avaliação anatomopatológica revelou tratar-se de um lipoma. A mucosectomia foi fragmentada em 3 dos 8 doentes. Não se verificou nenhum efeito adverso imediato. CONCLUSÕES: Este é o primeiro estudo que descreve os detalhes técnicos, exequibilidade e resultados da mucosectomia no intestino delgado. A mucosectomia no jejuno por DBE é exequível e segura.