Management of ectopic intestinal variceal bleeding following pancreatic transplant: Two cases.

Ectopic variceal bleeding is a potentially under recognized source of gastrointestinal (GI) hemorrhage. While vascular complications following pancreatic transplant are relatively common, the development of symptomatic ectopic venous varices has rarely been reported. We report two patients with a remote history of simultaneous kidney pancreas transplant (SPK) presenting two decades after transplant with an occult GI bleed. In both cases, a lengthy diagnostic course was required. The varices were treated with coil embolization via transhepatic approach. Our findings add to the limited literature on this topic and aid in the recognition, diagnosis, and management of this unusual presentation.

Liver Transplantation for Unresectable Colorectal Liver Metastasis: Perspective and Review of Current Literature.

The treatment of unresectable colorectal liver metastasis (CRLM) has previously been limited to palliative chemotherapy. Traditionally, the role of liver transplant has not been associated with sufficient survival to justify a patient undergoing a major operation with the associated requirement for postoperative immunosuppression. With improvements in chemotherapy options, a certain subset of patients can experience stable disease for years, which has prompted investigation into the role of liver transplant in these patients. Several recent studies have shown promising results in well-selected patients, with posttransplant survival approaching that of liver transplant recipients for other diseases. Here, we present a review of the data and current protocols for liver transplant for unresectable CRLM.

Acute liver failure secondary to acute antibody mediated rejection after compatible liver transplant: A case report.

BACKGROUND: The liver has traditionally been regarded as resistant to antibody-mediated rejection (AMR). AMR in liver transplants is a field in its infancy compared to kidney and lung transplants. In our case we present a patient with alpha-1-antitrypsin disease who underwent ABO compatible liver transplant complicated by acute liver failure (ALF) with evidence of antibody mediated rejection on allograft biopsy and elevated serum donor-specific antibodies (DSA). This case highlights the need for further investigations and heightened awareness for timely diagnosis. CASE SUMMARY: A 56 year-old woman with alpha-1-antitrypsin disease underwent ABO compatible liver transplant from a deceased donor. The recipient MELD at the time of transplant was 28. The flow cytometric crossmatches were noted to be positive for T and B lymphocytes. The patient had an uneventful recovery postoperatively. Starting on postoperative day 5 the patient developed fevers, elevated liver function tests, distributive shock, renal failure, and hepatic encephalopathy. She went into ALF with evidence of antibody mediated rejection with portal inflammation, bile duct injury, endothelitis, and extensive centrizonal necrosis, and C4d staining on allograft biopsy and elevated DSA. Despite various interventions including plasmapheresis and immunomodulating therapy, she continued to deteriorate. She was relisted and successfully underwent liver retransplantation. CONCLUSION: This very rare case highlights AMR as the cause of ALF following liver transplant requiring retransplantation.

Endoscopic removal of eroded laparoscopic adjustable gastric bands: a preferred approach.

BACKGROUND: Complications related to laparoscopic adjustable gastric banding (LAGB) have led to an increased number of removals. An uncommon but potentially devastating complication is gastric band erosion into the gastric lumen, which can be managed by open surgical, laparoscopic, and endoscopic approaches. OBJECTIVE: A wide array of management techniques has been reported for removal of LAGB that have eroded into the stomach. We describe the preferred method for successful endoscopic band removal at our institution. SETTING: Community tertiary-care referral hospital accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. METHODS: A single-center, retrospective review of a prospectively maintained database was used to identify patients who underwent LAGB removal from 2009 to 2019. We identified the subset of patients with band erosion. We analyzed patient characteristics, presenting symptoms, diagnostic modalities, and method of band extraction. RESULTS: A total of 132 patients underwent LAGB removal, among whom 22 (16.7%) patients were diagnosed with erosion. Seven (32%) patients underwent laparoscopic removal, 14 (64%) patients underwent endoscopic removal, and 1 patient (4%) underwent combined laparoscopic and endoscopic approach. These latter patients had variable amounts of erosion and buckle visibility, but all underwent endoscopic retrieval. We found that using an endoscopic retrograde cholangiopancreatography guidewire with an endoscopic retrograde cholangiopancreatography mechanical lithotriptor for band transection and snare for retrieval have been effective. CONCLUSIONS: A standardized, multidisciplinary, and minimally invasive endoscopic approach for LAGB erosion has been found to be successful without the need for further surgical intervention and may be offered to patients upon discovery of erosion.

Stable isotopes in elephant hair document migration patterns and diet changes.

We use chronologies of stable isotopes measured from elephant (Loxodonta africana) hair to determine migration patterns and seasonal diet changes in elephants in and near Samburu National Reserve in northern Kenya. Stable carbon isotopes record diet changes, principally enabling differentiation between browse and tropical grasses, which use the C3 and C4 photosynthetic pathways, respectively; stable nitrogen isotopes record regional patterns related to aridity, offering insight into localized ranging behavior. Isotopically identified range shifts were corroborated by global positioning system radio tracking data of the studied individuals. Comparison of the stable isotope record in the hair of one migrant individual with that of a resident population shows important differences in feeding and ranging behavior over time. Our analysis indicates that differences are the result of excursions into mesic environments coupled with intermittent crop raiding by the migrant individual. Variation in diet, quantified by using stable isotopes, can offer insight into diet-related wildlife behavior.