Bariatric surgery (BS) is effective in treating morbid obesity, but the impact of prior BS on candidacy for liver transplantation (LT) is unclear. We examined 78 patients with cirrhosis with prior BS compared with a concurrent cohort of 156 patients matched by age, Model for End‐Stage Liver Disease score, and underlying liver disease. We compared rates of transplant denial after evaluation, delisting on the waiting list, and survival after LT. The median time from BS to LT evaluation was 7 years. Roux‐en‐Y gastric bypass was the most common BS procedure performed (63% of cohort). Nonalcoholic fatty liver disease was the leading etiology for liver cirrhosis (47%). Delisting/death on the waiting list was higher among patients with BS (33.3% versus 10.1%; P = 0.002), and the transplantation rate was lower (48.9% versus 65.2%; P = 0.03). Intention‐to‐treat (ITT) survival from listing to 1 year after LT was lower in the BS cohort versus concurrent cohort (1‐year survival, 84% versus 90%; P = 0.05). On adjusted analysis, a history of BS was associated with an increased risk of death on the waiting list (hazard ratio [HR], 5.7; 95% confidence interval [CI], 2.2‐15.1), but this impact was attenuated (HR, 4.9; 95% CI, 1.8‐13.4) by the presence of malnutrition. When limited to matched controls by sex, mortality attributed to BS was no longer significant for females (P = 0.37) but was significant for males (P = 0.046). Sarcopenia, as captured by skeletal muscle index, was calculated in a subset of patients (n = 49). The total skeletal surface area was lower in the BS group (127 [105‐141] cm2 versus 153 [131‐191] cm2; P = 0.005). Rates of sarcopenia were higher among patients delisted after listing (71.4% versus 16.7%; P = 0.04). In conclusion, a history of BS was associated with higher rates of delisting on the waiting list as well as lower survival from the time of listing on ITT analysis. Presence of malnutrition and sarcopenia among patients with BS may contribute to worse outcomes.
Venograms were used to determine the presence of venous obstruction. Interrelations between the incidence of venous obstruction and patient-or devicerelated parameters were identified using Fisher's exact test and univariate logistic regression. Multivariate logistic regression was used to identify independent predictors of venous obstruction. Results: 456 patients met the inclusion criteria (330 males, 126 females, 67.8 ± 12.9 years). 100 patients underwent first implantation, and 356 patients underwent device revision (mean time since implantation 82.5 ± 75.3 months). Venous obstruction was present in 11.0 % and 30.1 % before implantation and revision, respectively. Only presence of ventricular escape rhythm was significantly related to venous occlusion (p < 0.001) prior to first implantation. Prior to revision, significant predictors were male sex (p = 0.01), time since implantation (p < 0.0001), presence of escape rhythm (p = 0.02), compromised coagulation (p = 0.02), phenprocoumon (p = 0.005), and peripheral arterial disease (p = 0.01). Conclusion: Although several risk factors could be identified, reliable prediction of venous obstruction was not possible. Therefore, we advocate performing venography in all patients prior to device revision or upgrade to avoid complications. In cases of first device implantation, the risks associated with venography should be weighed against the surprisingly high rate of deep upper vein obstruction.This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Budd-Chiari syndrome (BCS) is a rare vascular disorder characterized by an obstruction of the hepatic venous outflow. Nodular regenerative hyperplasia (NRH) may develop as a result of an underlying autoimmune disease such as hepatic sarcoidosis. Only a few case reports have described cases with either NRH or hepatic sarcoidosis associated with BCS. We present a 42-year-old man presenting with BCS and signs of portal hypertension who was found to have an underlying pathological diagnosis of both hepatic sarcoidosis and NRH and who was successfully treated with a transjugular intrahepatic portosystemic shunt.
Introduction:The incidence of extra-nodal NHL is 25%. The Gastrointestinal (GI) tract is the most common extra-nodal site accounting for 30-40 % of extra-nodal NHL. GI lymphomas can be in the stomach (65%), small intestine (20%-30%), colon (10%-20%), and esophagus (, 1%). Here we are presenting a case of intestinal lymphoma presented with obstructive Jaundice. Case Description/Methods: A 79-year-old woman with a past medical history of HIV on treatment presented with abdominal pain, loss of appetite, and weight loss of 15 kg over a period of one year. Labs showed total bilirubin of 5.6 mg/dl and direct bilirubin of 3.12 mg/dl. Imaging showed dilated CBD measuring 1.8 cm, neoplastic mass in the cecum. MRI showed dilated common bile duct and abnormal ampullary area (Figure). The patient underwent upper Endoscopy which showed a mass at the major papilla. Biopsy of the mass is positive for CD45 with Ki-67 80% consistent with Diffuse large B cell Lymphoma (DLBCL). Colonoscopy revealed multiple malignant polypoid lesions in the cecum, ascending colon, hepatic flexure, transverse colon, and rectum with biopsy of all lesions consistent with DLBCL. Immunohistochemical analysis confirms the presence of a malignant B-cell lymphoma diffusely positive for CD20, CD79a, BCL-2, BCL6, MUM-1, and c-MYC with a high Ki and positive for cyclin D1. Bone marrow biopsy showed no evidence of lymphoma. Biliary decompression with a metallic stent was done under CT guidance. Dose adjusted mini-CHOP treatment was administered under close monitoring. Eventually, the patient deceased due to non-response and hemodynamic instability. Discussion: GI lymphomas can present with many manifestations but, obstructive jaundice is rare. We noticed the fungating mass around the ampulla our suspicion was a periampullary carcinoma. Colonoscopy revealed multiple masses and various locations, which lead us to consider a differential of carcinoid tumors. However, to our surprise biopsy revealed diffuse large B cell lymphoma as it accounts for only 1-2% of all GI malignancies. Obstructive jaundice occurs in 1-2 % of the cases of non-Hodgkin's lymphoma, which is mostly due to peri-hilar and peri-portal lymphadenopathy. This case is a rare finding due to intraluminal lymphoma causing distal biliary obstruction. Our patient is a rare finding as lymphoma has occurred even after risk mitigation for HIV. Standard treatment is a combination of chemoimmunotherapy (RCHOP)with excellent survival rates. Without therapy, the survival times are limited to a few months.
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