Gastrointestinal complications in critically ill patients during the COVID-19 pandemic pose a diagnostic and treatment dilemma. We present a case of a 74-year-old male who was brought to our emergency department with worsening shortness of breath, fever, and dry cough and was found to have COVID-19 pneumonia. Early in his hospital course, he was admitted to the intensive care unit, and was found to have significant abdominal distension with large amounts of simple fluid on bedside ultrasound. Bedside paracentesis returned succus and enteric feeds, and a methylene blue test confirmed a likely gastrointestinal perforation. The patients’ family refused surgical intervention and the patient underwent bedside drainage. This case represents several critical dilemmas clinicians faced during the recent surge of the COVID-19 pandemic.
The best type of biliary anastomosis to use in lower weight pediatric liver transplant recipients is debatable. In this study, we share a single center's experience comparing the rate of anastomotic biliary complications based on the type of biliary anastomosis performed in this population of patients. A retrospective review of pediatric liver transplants for recipients weighing <15 kg from 11/2003 till 12/2011 was performed. Patients were grouped based on the type of biliary anastomosis into two groups: duct-to-duct (d-d) and Roux-en-Y hepaticojejunostomy (h-j) anastomoses. A total of 24 patients (12 males, 12 females) with a mean age of 26 ± 20 months and a mean weight of 9.27 ± 2.63 kg (range = 5.3-13.9 kg) were studied. All anastomotic complications occurred in patients who received left lateral segments. No statistical differences were found in the post-operative biliary (p = 0.86) or vascular (p = 0.99) complications between the two groups. Acknowledging the limited sample size, our data suggest that duct-to-duct anastomosis can be performed safely in pediatric liver transplantation recipients weighing below 15 kg.
INTRODUCTIONSpontaneous renal allograft rupture (RAR) is a serious and potentially life-threatening complication of kidney transplantation. Debate on the management of RAR has focused on graft nephrectomy versus salvaging in cases where: the allograft rupture site is surgically manageable; the bleeding can be controlled; and/or leaving the renal allograft in situ does not compromise patient survival.PRESENTATION OF CASEA 45-year-old, living-related, female, kidney allograft recipient experienced RAR on the fourth day post transplantation. Surgical exploration showed 12 cm laceration along the convex border of the graft. Histologically the graft demonstrated mild acute kidney injury and linear deposition of C4d along the cortical peritubular capillaries; morphological features for violent humoral or cellular rejection were not identified. The graft was surgically salvaged with excellent clinical and biochemical improvement.DISCUSSIONObservations arising from this case are: (1) RAR caused by rejection is still encountered in clinical practice despite effective immunosuppressive management; (2) the severity of the histopathological features of rejection does not necessarily correlate with the extent of graft rupture; and (3) salvaging the graft should be attempted whenever possible as current immunosuppression and advances in surgical techniques may have an impact on long-term graft function and survival, differing from those previously published.CONCLUSIONWith modern immunosuppression therapy and proven surgical procedures, the efficacy of salvaged renal grafts and graft survival rates may improve substantially.
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