Endometrial Cancer After Pancreas-After-Kidney Transplantation: A Case Report and Review of the Literature

BackgroundAs the number of long-term survivors after organ transplantation increases, malignancy has become a problem as a late complication. We herein report a case of endometrial cancer during the follow-up of pancreas transplantation after kidney transplantation.Case PresentationA 49-year-old woman was diagnosed with endometrial cancer. The patient had developed type 1 diabetes at 8 years old and started insulin treatment, and at 29 years old, she started hemodialysis for diabetic nephropathy. At 31 years old, she received living donor kidney transplantation and withdrew from dialysis. Hypoglycemia unawareness began to occur frequently from around 36 years old, and at 48 years old, the patient underwent deceased donor pancreas transplantation after kidney transplantation and achieved insulin independence. At 49 years old, she was diagnosed with endometrial cancer. Surgical treatment (total abdominal hysterectomy with left salpingo-oophorectomy) was performed. The pathologic diagnosis was confirmed as stage 1A uterine endometrioid carcinoma grade 1. The postoperative course was uneventful. She was discharged from our hospital on postoperative day 8. There has been no evidence of recurrence and/or metastasis of endometrial cancer for 16 months since the surgery.ConclusionsCarcinogenesis after pancreas transplantation may be a lethal late complication. It is important to carry out regular screening examinations with carcinogenesis in mind.     

彩色多普勒超声在诊断肝移植术后并发症中的价值

目的探讨彩色多普勒超声在肝移植术后并发症的诊断价值。方法回顾分析彩色多普勒超声对95例肝移植患者术后并发症的诊断结果。结果95例中发现肝动脉血栓形成3例（3.15%）,肝动脉狭窄2例（2.10%）,门静脉血栓形成1例（1.05%）,门静脉狭窄1例（1.05%）,下腔静脉狭窄2例（2.10%）,胆道并发症10例（10.52%）,排异反应7例（7.36%）,浆膜腔积液93例（97.89%）,肝周血肿7例（7.36%）,肿瘤复发5例（29.41%）。结论彩色多普勒超声在肝移植术后并发症诊断中具有重要的实用价值。     

儿童劈离式肝移植术后肝静脉流出道梗阻1例报道及文献复习

目的探讨儿童劈离式肝移植术后肝静脉流出道梗阻(hapatic venous outflow obstruction,HVOO)的病因、临床表现、诊断及治疗。方法回顾性分析1例儿童劈离式肝移植术后肝静脉流出道梗阻病例的临床资料并进行文献复习。结果患儿于术后8个月无明显诱因出现腹胀、纳差、双下肢水肿,经腹部B超、计算机断层摄影术(computed tomography,CT)增强扫描、下腔静脉及肝静脉造影确诊迟发型HVOO,遂行球囊扩张术,手术成功。球囊扩张术后10个月及15个月HVOO复发,均接受再次球囊扩张术,手术成功。随访至今患儿存活,未再发腹胀、纳差,肝功能正常。结论对于术后无明显诱因出现腹水、腹胀、纳差和双下肢水肿等表现的患儿,应重点排除HVOO,下腔静脉及肝静脉造影是诊断该病的金标准。对于迟发型的HVOO患儿,球囊扩张术和支架置入是理想的治疗方式,但支架置入的选择及时机仍存在争议。     

Hepatic hemangioendothelioma – A rare case report

Introduction and importanceHepatic hemangioendothelioma (HHE) is a very rare mild-moderate malignant tumor of the hepatic vascular endothelium. The etiology is yet not fully understood. Patients can be asymptomatic or may present with non-specific symptoms or hepatic insufficiency. CT and MRI scans show various radiographic features but a definitive diagnosis can be made with histological analysis and immunohistochemistry. Here we report a case of a patient who presented with a non-resectable disease for which living donor liver transplantation was done.Case presentationA 19-year-old female patient presented with intermittent moderate dull pain in the right hypochondrium for 9 months. Examination revealed mild tender hepatomegaly. On abdominal ultrasound, two hypoechoic lesions were noted in both lobes of the liver that were confirmed on CT scan. Histologic examination of the ultrasound-guided fine-needle aspiration cytology of the voluminous right lobe lesion clinched the diagnosis of HHE. The patient underwent successful living donor liver transplantation due to the multifocal bi-lobar nature of the lesions. At 8 months follow up, she is fine and doing well.ConclusionHHE is a very rare mild-moderate malignant tumor of hepatic vascular origin. Resection is the preferable treatment option in patients with resectable disease. However, liver transplantation has become the treatment of choice for patients with non-resectable multifocal and bi-lobar lesions. The long-term outcome of this malignancy is not fully known and there is a need for long-term follow-up studies to determine the actual recurrence rate of this disease.     

Long-Term Outcomes of Renal Function After Adult Intestinal Transplantation at a Single Small-Volume Center: 2 Cases of Renal Transplantation

PurposeRenal dysfunction more frequently occurs after intestinal transplantation (ITx) than after heart, lung, or liver transplantation. We provide a clinical analysis of renal function after adult ITx.MethodsWe retrospectively analyzed 8 adult ITx patients who survived for at least 6 months between 2004 and 2018. Glomerular filtration rate (GFR) measurements were performed at baseline, at 3 and 6 months post-transplantation, and yearly. The median follow-up duration was 53.5 months.ResultsAll cases were isolated ITx; 3 received living-donor ITx, and 5 received deceased-donor ITx. The mean baseline GFR was 97 mL/min/1.73 m². The GFR had decreased by more than 50% of baseline at 1 year post-transplant. Renal dysfunction was observed in 4 patients. Two patients developed acute kidney injury due to acute rejection and sepsis. One of these patients fully recovered renal function, but the second patient died. Another 2 patients developed chronic kidney disease and required hemodialysis (HD) within 6 and 3 years, respectively. The first living-donor ITx patient lost renal function progressively over 6 years after ITx. She received a renal graft from the same living donor as for the ITx after 3 years of HD. The other patient (deceased-donor ITx) received a kidney from his daughter at 5 months after HD.ConclusionsTo obtain an accurate assessment of renal function, frequent direct measurements of GFR should be performed to facilitate early diagnosis of renal impairment and to determine subsequent strategies to improve renal function after ITx.     

Single-Center Experience of Transplantation for Polycystic Liver Disease

BackgroundPolycystic liver disease (PLD) may lead to massive hepatomegaly, abdominal distension, pain, and various degrees of dyspnea. The surgical treatment of this entity remains controversial.MethodsWe report our experience from a retrospective analysis of 23 patients suffering from PLD who were treated with liver transplantation (LT) in our institution.ResultsLiver transplantation for PLD patients with extensive hepatic involvement offers excellent symptoms relief. The actuarial 1-, 3-, and 5-year survival rate after transplantation was 86%.ConclusionsOur experience demonstrates that PLD patients with extensive hepatic involvement and who are treated with LT have good long-term prognosis and excellent symptoms relief. LT might be considered in severe PLD cases where conventional surgery is not a curative option, and it must be balanced against the risks of LT and lifelong commitment to immunosuppression.     

Primary hepatic neuroendocrine tumour with multiple liver metastases: A case report with literature review

Introduction and importanceTo describe an unusual case with a primary hepatic neuroendocrine tumour (PHNET) with multiple liver metastases.Case presentationWe reported a 65-year-old woman with PHNET with multiple liver metastases. She was highly suspected of having primary liver cancer with multiple intrahepatic metastases before liver biopsy, but was diagnosed with PHNET with multiple liver metastases after histopathology and immunohistochemistry (IHC) examinations. The patient successfully underwent three times of transcatheter arterial chemoembolization (TACE), and is currently living in a good state without related complications.Clinical discussionNeuroendocrine tumors (NETs), also known as carcinoids or argyrophilic tumors, are very rare malignant tumors. The liver is the main metastasis site of NETs, but primary hepatic neuroendocrine tumors (PHNETs) are extremely rare. Histopathology and immunohistochemistry (IHC) examinations are still the main methods used for diagnosing NETs. There are no treatment guidelines for PHNETs, and surgical resection is generally the preferred treatment. For PHNET patients who are not suitable for surgery, TACE has been proven to be an effective alternative treatment that can effectively reduce the tumour burden and relieve symptoms, but the current evidence is still limited.ConclusionThe clinical diagnosis of PHNET still faces great challenges, imaging examinations often lead to misdiagnosis, and its diagnosis mainly depends on histopathology and immunohistochemical examinations. For PHNET patients who are not suitable for surgery, TACE may be an effective alternative therapy.     

Jejunal transection following trivial trauma: Case report and review of literature

IntroductionSevere hollow organ injury following trivial blunt abdominal trauma is uncommon. If it occurs it can easily be missed during routine clinical evaluation. Though less than ten cases of jejunal transection following trivial trauma have been reported in literature, this is the first case of jejunal transection occurring in a patient who fell while walking.Case presentationWe report a 32 year old female Ugandan, who walked into the emergency room due to abdominal pain following a fall while walking. She was found to be hemodynamically stable and was initially hesitant to do further investigations but finally accepted to go for abdominal ultrasound scan and a chest x-ray. Abdominal ultrasound scan noted free peritoneal fluid and erect chest radiograph revealed a pneumoperitoneum. She was admitted for an exploratory laparotomy. At laparotomy we found a complete jejunal transection with mesenteric laceration. Primary anastomosis was done; the patient had an uneventful recovery and was discharged on the tenth postoperative day.DiscussionAny trauma to the abdomen can potentially cause devastating injury to hollow viscera and should therefore be evaluated thoroughly.ConclusionThis case demonstrates that even in a resource limited setting, basic investigations like an abdominal ultrasound scan and erect chest radiographs are important when managing a patient with blunt abdominal trauma even though the injury seems trivial.     

Donor-Derived Ovarian Cancer in a Male Recipient After Kidney Transplant: A Case Report

BackgroundPatients who receive kidney transplants and experience long-term immunosuppressive therapy are tied to higher risk of developing cancers. Reports concerning about donor-associated cancers are rarely reported, especially for male ovarian cancer.Case reportHere we report a case of donor-derived ovarian malignancy of a man after 3 years of renal transplantation. This case complied with the Helsinki Congress and the Istanbul Declaration. The donor is the recipient's mother who developed ovarian malignancy 6 months after the transplantation surgery and died 1.5 years later after diagnosis due to tumor progression. The patient devolved into abnormal renal function 3 years after the transplantation. The transplanted kidney lost its function and was subsequently surgically removed. The ovary cancer was confirmed as high-grade serous ovarian cancer by pathology and had potentially metastasized to donor kidney. Then the male patient received regular maintenance and dialysis. Four years after transplantation, he gradually developed the symptoms of coughing and sputum and computed tomography examination revealed a lung space-occupying lesion that was confirmed to be a metastatic tumor with the same pathology as before. Platinum-based combination chemotherapy can effectively control the condition; by the last follow-up evaluation, the progression-free survival of the patient was 23.5 months, and the overall survival was 36 months.ConclusionsThis case demonstrates that donor-derived ovarian tumor can be transferred into the recipient via the transplanted kidney even in the male recipient. This observation provides clinicians with effective treatment options for this rare type of patient population.     

Primary biliary cirrhosis in early childhood – A rare case report

Introduction and importancePrimary biliary cirrhosis (PBC) is a chronic and progressive autoimmune liver disease with no known etiology. This disease is mainly characterized by granulomatous destruction of intrahepatic biliary ducts, severe peri-portal inflammation, and ultimate progress to liver fibrosis and cirrhosis. Here, we report a five-year-old girl diagnosed with PBC, presented to us with end-stage liver disease for liver transplantation. Our patient successfully underwent liver transplantation with an uneventful recovery. This case highlights the need for awareness to report further PBC cases in the pediatric age group.Case presentationA five-year old female child presented with a 6 months history of progressive jaundice. She had multiple admissions for hepatic encephalopathy and this time she was admitted for hepatic transplantation. On examination, she was icteric and had hepatomegaly. After thorough workup, she underwent successful hepatic transplantation and was alright post-operatively. At 6 months follow up, she is doing well.ConclusionPBC is rare in childhood. The natural history and exact incidence of PBC in childhood are not known. Hence, there is a need for awareness to report further PBC cases in the pediatric age group.     

An Orthotopic Liver Transplantation Patient Survived Without Hepatic Artery Flow Due to Thrombosis: A Case Report

BackgroundHepatic artery thrombosis (HAT), a serious complication after orthotopic liver transplantation, almost always leads to morbidity and mortality without urgent revascularization or retransplantation, especially if HAT occurs within a few days after transplantation.Case PresentationHerein we describe a case report of an orthotopic liver transplantation patient surviving without hepatic artery flow due to HAT on postoperative day 1. Reanastomosis, thrombectomy, and intra-arterial thrombolysis were performed, but only retrograde arterial flow by Doppler ultrasound, not by angiography, could be demonstrated in the hepatic artery. This case report is in compliance with the Declaration of Helsinki and the Declaration of Istanbul.ConclusionBased on the evidence from this patient, we believe that patients with failed revascularization can experience a long-term survival with conservative treatment. Retransplantation should be evaluated based on laboratory findings because graft function in individual patients can recover.     

Culture-negative peritoneal dialysis peritonitis associated with pancreaticoduodenocystotomy leak of a pancreas transplant

Background:Peritoneal dialysis (PD) peritonitis is usually caused by infection and less commonly by a sterile inflammatory reaction.Methods:The authors report the case of a kidney-pancreas transplant recipient who was receiving PD after kidney transplant rejection 5 years after transplantation. The patient had a viable pancreas transplant. He had abdominal pain associated with cloudy PD effluent. The PD leukocyte count was elevated with a predominance of monocytic leukocytes.Results:Blood, urine, and PD effluent cultures were negative. An ultrasound scan of the transplanted kidney and a computerized tomography (CT) scan of the abdomen and pelvis did not identify the cause of the peritonitis. Foley catheter decompression of the bladder resulted in improvement of the abdominal pain and PD effluent leukocytosis. Twenty-five days later, the patient again experienced abdominal pain and cloudy PD effluent. Cultures of blood and PD effluent were again negative. CT scanning and cystoscopy of the transplanted pancreas identified a leak at the pancreaticoduodenocystotomy anastamosis. Urinary bladder decompression was followed by surgical exploration that identified an erosion of the distal transplanted duodenum, necessitating enteric diversion of the transplanted pancreas's exocrine secretions. The patient underwent conversion to hemodialysis, and the pancreas transplant continued to function well. He has subsequently received a living related kidney transplant.Conclusion:This is the first reported case of noninfectious PD peritonitis caused by pancreaticoduodenocystotomy leak in a patient with a functional pancreas transplant.     

Laparoscopic treatment for renal paratransplant hernia: A case report

IntroductionThere are limited reports regarding renal paratransplant hernia (RPH), which is a rare type of internal hernia. Herein, we report a case of successful laparoscopic treatment of RPH.Presentation of caseA kidney transplant recipient presented to our emergency department with a 6-h history of abdominal pain and vomiting. The patient had received a living-related donor kidney transplantation and native nephrectomy in our hospital last year. Computed tomography (CT) confirmed a diagnosis of RPH. We performed laparoscopic exploration, and the findings showed an incarcerated small bowel in the retroperitoneal space through a peritoneal defect. Short laparotomy was performed to resect the non-viable bowel. The peritoneal defect was opened adequately. The patient’s postoperative course was uneventful, with no complications.DiscussionRPH is an uncommon variant of internal hernia, which is a rare surgical complication after kidney transplantation. Early diagnosis and treatment are important once RPH develops. Due to immunosuppression in kidney transplant recipients, typical signs of peritonitis were not observed. This event can be critical to the patient. Laparoscopic surgery has recently become a treatment option for small bowel obstructions. We believe that this surgical procedure is useful for patients with RPH.ConclusionWe report a case of RPH treated laparoscopically. This approach can be a treatment of choice for RPH.     

Anesthesia for living-donor liver transplantation in a patient with adult polycystic liver disease

Anesthesia for living-donor liver transplantation (LDLT) was performed for two patients with adult polycystic liver disease (APLD). APLD is characterized by gradual cystic transformation of both lobes of the liver. Abdominal enlargement, poor appetite, abdominal pain, infection of liver cysts and portal hypertension are symptoms of this disease. Liver transplantation is indicated as the final therapy. Our two patients had very large livers (7400 g and 9500 g). The second patient had suffered renal failure due to a polycystic kidney so that continuous hemodiafiltration had to be performed after surgery. In both cases, sudden hypotension frequently occurred during manipulation of the enlarged liver. In the first case, sudden massive bleeding occurred as a result of laceration of the middle and left hepatic vein when the liver was dropped from the surgeon's hand. In both cases, the position of endotracheal tube became 2 cm shallower after surgery probably because of the shift in the position of the mediastinum after elimination of abdominal compression caused by the enlarged liver. One patient was discharged 39 days and the other 115 days after surgery. Anesthesiologists should pay special attention to the features reported here during LDLT for patients with APLD.     

Outcomes of Living Kidney Transplantation for Mitochondrial Disease Patients: A Case Series

PurposeMitochondrial disease can affect many organs, including the brain, nerves, heart, liver, eyes, ears, pancreas, and kidneys. Kidney transplantation is a treatment option for renal failure due to mitochondrial disease; however, the prognosis of patients who undergo kidney transplantation for mitochondrial disease is unknown. Here we evaluated the outcomes of kidney transplant recipients with mitochondrial disease.MethodsClinical data were obtained from 4 kidney transplantation recipients who were followed at our department. Of the 4 transplantations, 3 were performed in our department: 2 patients received kidneys from their fathers, and a third from his wife. The fourth recipient received a kidney from her mother—who had a mitochondrial genetic abnormality—at another hospital. Of the 4 recipients, 3 were diagnosed with mitochondrial disease before the transplantation, and the fourth was diagnosed after. All recipients had sensorineural deafness and diabetes mellitus, and only 1 had a history of encephalopathy and stroke-like episodes before the transplantation.ResultsOne patient died 2 years after transplantation due to encephalopathy progression with stable kidney function. The grafted kidney of the patient who received it from her mother lost function at 5 years post-transplantation. A graft biopsy revealed focal segmental glomerular sclerosis due to mitochondrial disease. The other patients’ kidney functions remained stable. None of the recipients experienced rejection.ConclusionsIn kidney transplantation for mitochondrial disease, attention should be paid to the exacerbation of comorbidities, while careful consideration should be given to donors with a mitochondrial genetic abnormality.     

A case report of bloody pancreatitis

IntroductionHaemobilia is an uncommon entity even though its frequency has increased with hepato-biliary instrumentation and procedures. It can be associated with obstructive jaundice and pancreatitis (Green et al., 2001) [1]. Haemobilia following cholecystectomy has frequently been reported in association with hepatic artery pseudo-aneurysm (Curet et al., 1981; Ribeiro et al., 1998) [2,3]. The authors wish to report a case of haemobilia due to a porto-biliary fistula presenting as acute pancreatitis.Presentation of caseA 34-year-old female admitted as an urgency with upper abdominal pain for 3 weeks. She had, in the preceding days, been admitted to another hospital with acute pancreatitis. She reported an episode of rectal bleeding during that admission and possessed an abdominal ultrasound scan (USS) and magnetic resonance cholangiopancreatography (MRCP) which suggested the presence of a biliary tract neoplasm. The patient was also found to be jaundiced and the diagnosis of a porto-biliary fistula was made at operation.ConclusionThe diagnosis in this case was found to be a portal vein-biliary tract fistula occurring post cholecystectomy. An awareness of the spectrum of complications related to modern surgical techniques may aid timely diagnosis and the achievement of favourable outcomes.     

Abdominal Pain and Diffuse Colitis Following COVID-19 Infection: Report of a Case

IntroductionAlthough this is often overlooked, the gastrointestinal (GI) involvement of COVID-19 has been introduced. Diarrhea, nausea, vomiting, and abdominal discomfort are among the most common GI symptoms reported. Diffuse Colitis following COVID-19 infection is a rare presentation.Case presentationA 52-year-old female presented with intensified abdominal pain following COVID-19 infection to the emergency department. She was diagnosed with peritonitis due to diffuse colitis and perforation of sigmoid colon. The patient was treated with total colectomy with an end ileostomy.ConclusionThe purpose of this study was to increase awareness among clinicians about the existence of this rare cause of abdominal pain after COVID-19 infection, diffuse colitis. Although uncommon, these presentations can potentially lead to delay in diagnosis among unfamiliar clinicians with GI presentation of COVID-19.Level of evidenceV.     

T2 breast cancer presenting with diffuse liver metastases and hepatic failure following fertility treatment. Cautionary report

BackgroundDiffuse hepatic metastases with hepatic failure as a presentation of a T2 breast cancer is rare. This is also remarkable seeing our case had been on fertility treatments before presentation. There are no documented reports of breast cancer patient on fertility treatment presenting with diffuse hepatic metastases and liver failure.Case summaryA 41 year old Para 1 Nigerian woman being managed for secondary infertility with an extended use of clomiphene presented with a 3 months history of a left breast lump, nipple bleeding and later, yellowness of eyes, right hypochondrial pain malaise and drowsiness. Abdominal USS showed an enlarged liver with diffuse metastatic nodules. Liver function tests showed persistently elevating liver enzymes and serum bilirubin. Serology showed Hepatitis B negative. She was diagnosed with a T2 left invasive ductal carcinoma, Er−, Pr+ Her2+ with deteriorating liver function from diffuse hepatic metastases She had chemotherapy but succumbed barely a week of presentation.ConclusionBreast cancer screening for patients before fertility treatments and continual surveillance while on such treatment is highly recommended.     

Pancreatic resection for renal cell carcinoma metastasis: An exceptionally rare coexistence

IntroductionPancreatic metastases are uncommon and only found in a minority of patients with widespread metastatic disease at autopsy. The most common primary cancer site resulting in pancreatic metastases is the kidney, followed by colorectal cancer, melanoma, breast cancer, lung carcinoma and sarcoma.Presentation of caseHerein, we report a 63-year-old male patient who presented −3.5 years after radical nephrectomy performed for renal cell carcinoma (RCC)-with a well-defined lobular, round mass at the body of the pancreas demonstrated by abdominal Magnetic Resonance Imaging (MRI). The patient underwent distal pancreatectomy combined with splenectomy and cholecystectomy. Histopathological examination revealed clusters of epithelial clear cells, immunohistochemically positive for RCC marker, and negative for CD10 and CA19-9. A final diagnosis of clear RCC metastasizing to pancreas was obtained in view of the past history of RCC, microscopy and the immunoprofile. This was the second metachronous disease recurrence after a previous metastatic involvement of the liver, developed 19 months from the initial diagnosis. The patient has remained well at a 6 month follow up post-resection.DiscussionSolitary pancreatic metastases may be misdiagnosed as primary pancreatic cancer. However, imaging including computed tomography (CT) and MRI, may discriminate between them. Surgical procedures could differentiate solitary metastasis from neuroendocrine neoplasms. The optimal resection strategy involves adequate resection margins and maximal tissue preservation of the pancreas.ConclusionRecently, an increasing number of surgical resections have been performed in selected patients with limited metastatic disease to the pancreas. In addition, a rigid follow-up scheme, including endoscopic ultrasound (EUS) and CT is essential give patients a chance for a prolonged life.     

Percutaneous Embolization of Periduodenal Varix Due to Portal Hypertension in a Patient With Kidney-Pancreas Transplantation: A Case Report

Kidney-pancreas transplantation is a valid therapeutic option for patients with insulin-dependent diabetes mellitus. However, vascular complications associated with pancreas transplantation are not uncommon. Herein we have reported a 32-year-old woman with a history of insulin-dependent diabetes mellitus and celiac disease. She underwent liver transplantation for acute hepatitis. After 7 years, the patient developed end-stage kidney disease beginning hemodialysis and being listed for a kidney-pancreas transplantation, which was successfully performed when she was 29 years old with enteric diversion (Roux intestinal loop reconstruction). Five years after kidney-pancreas transplantation, she was admitted to our hospital with serious intestinal bleeding and poor liver function. The ultrasound showed a pattern like a arteriovenous fistula near the head of the pancreas. Computed Tomography was not diagnostic; an arteriogram showed the presence of a mesenteric varix and a mesenteric-caval shunt through the duodenum of the pancreatic graft. The liver biopsy and portal pressure gradient showed portal hypertension and liver cirrhosis. To obtain time a waiting a new liver, the patient underwent percutaneous embolization of the mesenteric varix through jugular access. The procedure was uneventful. The patient was successfully transplanted 2 months later. Pancreas function was always satisfactory.