Severe alloimmune hemolytic anemia after renal transplantation

Alloimmune hemolytic anemia is a rare complication following allogeneic organ transplantation. Despite that some other drugs have also been reported, in the majority of cases this complication has been associated with cyclosporine therapy. We here present a case of severe alloimmune hemolytic anemia due to ABO minor incompatibility after renal transplantation in a patient treated with tacrolimus.     

Esophageal carcinoma following bariatric procedures.

BACKGROUND: The long-term success of bariatric operations for weight reduction has been well documented, but their potential effects on the risk of esophageal cancer have not been evaluated. METHODS: We performed operations on 3 patients for esophageal cancer following bariatric operations: 2 had Roux-en-Y gastric bypass, and 1 underwent vertical banded gastroplasty. All of these patients had adenocarcinoma at the gastroesophageal junction; 1 involved the entire intrathoracic esophagus. RESULTS: The intervals between the weight-loss operations and cancer diagnoses were 21, 16, and 14 years. All 3 patients had symptoms of reflux for many years before dysphagia developed and cancer was diagnosed. We performed a limited esophagogastrectomy, a classic Ivor-Lewis procedure, and a total esophagectomy with jejunal free-tissue transfer from stomach to cervical esophagus. Two patients had positive lymph nodes. One patient is alive at 6 years; 2 died at 13 and 15 months after undergoing operation for recurrent cancer. CONCLUSION: The effect of bariatric operations on gastroesophageal reflux is not known, although gastric bypass has been advocated as the "ultimate antireflux procedure." The presence of esophageal cancer in these 3 patients years after the weight loss operation is worrisome. We believe that patients who develop new symptoms should have endoscopic evaluation and that epidemiologic studies on the incidence of esophageal cancer occurring years after bariatric operation should be performed.     

A surgical case for severe hemolytic anemia after mitral valve repair.

We report a rare case of severe hemolytic anemia accompanied by moderate renal insufficiency after mitral valve repair. Although the degree of the residual mitral regurgitation was less than 1+ during the first three weeks after the operation, the maximum lactate dehydrogenase (LDH) was up to 7,430 U/l and the minimum hemoglobin was 4.9 g/dl. The mitral valve replacement successfully resolved the hemolysis, but the renal function did not completely recover.     

Phenazopyridine-induced hemolytic anemia

An elderly inan was seen with hemolytic anemia due to the urinary tract analgesic, phenazopyridine hydrochloride. The inechanisins underlying this toxic reaction are presented. Cautious use of this drug in elderly patients and in those with renal insufficiency is emphasized.     

肝移植术后并发急性溶血性贫血一例

目的报道1例ABO血型不同肝移植术后并发急性溶血性贫血的治疗经验。方法 2010年9月对1例肝癌复发患者行肝癌射频消融联合同种异体背驮式肝移植术,供、受者ABO血型分别为O型及A型。术后第10天发生急性溶血性贫血,血常规示血红蛋白下降至56 g/L,骨髓穿刺检查提示各系增生活跃,粒红比0.52∶1,给予免疫抑制剂及输注O型洗涤红细胞治疗。结果患者一般情况好转,血红蛋白上升,术后第34天上升至111 g/L。随访12个月,患者血红蛋白维持在正常范围。结论对于ABO血型不同但血型相合的肝移植术后并发急性溶血性贫血,免疫抑制剂及输注供体血型的洗涤红细胞可有效缓解溶血,提高肝移植成功率。     

Open vs. laparoscopic procedures in bariatric surgery

Conclusions Laparoscopic GBP is a complex advanced laparoscopic operation that accomplishes the same objectives as open GBP but avoids a large upper midline abdominal incision. The differences between laparoscopic and open bariatric surgery are the method of access and exposure. By reducing the size of the surgical incision and the operative trauma associated with the operative exposure, the surgical insult should be less after laparoscopic compared to open bariatric surgery. We reported a reduction in the surgical insult after laparoscopic GBP and believe that this is the physiologic basis for the observed clinical advantages of laparoscopic GBP. The important clinical advantages of laparoscopic GBP are not the reduced length of hospitalization but the reduction in postoperative pain, lower rate of wound-related complications, and faster recovery. Given the currently available evidence-based data, laparoscopic bariatric surgery should be considered the new standard for the treatment of morbid obesity as long as the surgeon has passed the learning curve of the laparoscopic approach.     

A surgical case for hemolytic anemia after ascending and total arch replacement.

A 61-year-old man presented with consistent hemolytic anemia 15 months after ascending and total arch replacement for DeBakey I type acute aortic dissection. The cause of hemolysis turned out to be mechanical damage of red blood cells at the inverted felt of the proximal anastomosis. Reoperation of resection of the felt and repair of the proximal anastomosis successfully resolved this problem. We report a rare case of hemolytic anemia at the site of inverted felt strip after total arch replacement.     

Mechanical hemolytic anemia after surgical correction of a congenital cardiopathy

Mechanical hemolytic anemia is a well known complication after prosthetic valve replacement; however it is very rare after operations for congenital heart diseases, except ostium primum. We present a case of severe hemolysis in the postoperative period after the correction of an aneurysm of the sinus of Valsalva which had ruptured into the right ventricle of a 12 years old girl. The mechanical cause of the hemolysis was confirmed with the study of the mean life of transfused red blood cells marked with Cr 51. The etiology of the hemolytic anemia, the response to the iron treatment, as well as the need for further surgery are discussed.     

Endoluminal procedures for bariatric patients: expectations among bariatric surgeons

BackgroundPrimary and revisional bariatric endoluminal procedures are currently being developed. Acceptable levels of risk and weight loss for these procedures have not yet been established. The aim of this study was to evaluate the expectations and concerns among bariatric surgeons regarding these procedures.MethodsThe American Society for Metabolic and Bariatric Surgery Emerging Technologies Committee developed a questionnaire that was distributed to the membership. Risk tolerance was assessed with comparison to commonly performed endoscopic and bariatric procedures. The percentage of excess weight loss (EWL) ranges were provided to assess the expectations for results 1 year after the procedure.ResultsA total of 214 responses were returned. The acceptable level of risk to achieve 10–20% EWL after primary and revisional procedures was equivalent to, or less than, that of a therapeutic endoscopic procedure for 81% and 76% of respondents, respectively. The acceptable level of risk to achieve 30–40% EWL after primary and revisional procedures was equivalent to that after laparoscopic adjustable gastric banding for 45% and 35% of respondents, respectively and equivalent to that after laparoscopic Roux-en-Y gastric bypass for 8% and 22%, respectively. In addition, 62% of respondents responded that 10–30% EWL would be acceptable for revisional procedures, and 35% responded that 10–30% EWL would be acceptable after a primary procedure. The primary concern was unproven efficacy, followed by durability, poor weight loss, availability of equipment, and procedural risk. Finally, 58% would not be willing to recommend an endoluminal procedure until the efficacy has been established, regardless of the risk.ConclusionRisk tolerance and weight loss expectations among bariatric surgeons are different for primary and revisional endoscopic procedures. Most surgeons were unwilling to consider endoluminal procedures for their patients until the efficacy has been proven.     

Severe hemolytic anemia due to passenger lymphocytes after living-related bowel transplant

BACKGROUND: Hemolytic anemia following solid organ transplant may be caused by 'passenger' lymphocytes producing antibodies against erythrocytes. This phenomenon has never been described after intestinal transplant. MATERIALS AND METHODS: We report a case of severe, immune-mediated hemolysis due to symptomatic passenger lymphocyte syndrome (PLS) in a 4-yr-old recipient of living donor small bowel transplant. The Coombs'-positive hemolysis was caused by anti-A,B antibodies derived from donor lymphocytes in an ABO-compatible donor-recipient pair (O into A). RESULTS: This complication was successfully and efficiently treated by the novel combined use of group O RBC transfusion, plasmapheresis and rituximab (anti-CD20). CONCLUSIONS: A severe hemolytic anemia due to PLS can occur in bowel transplantation. This complication should be considered when performing ABO-incompatible bowel transplant with a blood group O donor and an A or B recipient. Treatment with plasmapheresis, blood group O transfusion and rituximab has proved successful in our case.     

Acute complications after laparoscopic bariatric procedures: update for the general surgeon

Background

Development and widespread use of laparoscopic bariatric surgery exposes emergency room physicians and general surgeons to face acute or chronic surgical complications of bariatric surgery.

Methods

The most common surgical emergencies after bariatric surgery are examined based on an extensive review of bariatric surgery literature and on the personal experience of the authors' practice in four high-volume bariatric surgery centers.

Results

An orderly stepwise approach to the bariatric patient with an emergency condition is advisable. Resuscitation should follow the same protocol adopted for the non-bariatric patients. Consultation with the bariatric surgeon should be obtained early, and referral to the bariatric center should be considered whenever possible. The identification of the surgical procedure to which the patient was submitted will orient in the diagnosis of the acute condition. Procedure-specific complication should always be taken into consideration in the differential diagnosis. Acute slippage is the most frequent complication that needs emergency treatment in a laparoscopic gastric banding. Sleeve gastrectomy and gastric bypasses may present with life-threatening suture leaks or suture line bleeding. Gastric greater curvature plication (investigational restrictive procedure) can present early complications related to prolonged postoperative vomiting. Both gastric bypass and bilio-pancreatic diversion may cause anastomotic marginal ulcer, bleeding, or rarely perforation and severe stenosis, while small bowel obstruction due to internal hernia represents a surgical emergency, also caused by trocar site hernia, intussusceptions, adhesions, strictures, kinking, or blood clots. Rapid weight loss after bariatric surgery can cause cholecystitis or choledocholithiasis, which are difficult to treat after bypass procedures.

Conclusions

The general surgeon should be informed about modern bariatric procedures, their potential acute complications, and emergency management.     

Laparoscopic revisional surgery after malabsorptive procedures in bariatric surgery, more specifically after duodenal switch

Laparoscopic revisional surgery for both biliopancreatic diversion and duodenal switch is not a frequent event, and literature is sparse. Nevertheless, like any other weight loss surgical procedures, weight gain is possible or aggressive weight loss combined with micronutrients malnutrition may oblige surgeons to revise these original procedures. Reintervention strategies may include surgical improvements, conversion to other surgical procedures, or reversal. Revisions after duodenal switch are usually around 5% and may involve performing a re-sleeve or an elongation of the common channel at the expense of the biliopancreatic limb.