MVT can be considered as an option for the treatment of patients with diffuse PMT. MVT is the only procedure that completely reverses portal hypertension and addresses the primary disease while achieving superior survival results in comparison to the alternative options.

Detrimental consequences of hypofibrinolysis, also known as fibrinolysis shutdown (FS), have recently arisen, and its significance in liver transplantation (LT) remains unknown. To fill this gap, this retrospective study included 166 adults who received transplants between 2016 and 2018 for whom baseline thromboelastography was available. On the basis of percent of clot lysis 30 minutes after maximal amplitude, patients were stratified into 3 fibrinolysis phenotypes: FS, physiologic fibrinolysis, and hyperfibrinolysis. FS occurred in 71.7% of recipients, followed by physiologic fibrinolysis in 19.9% and hyperfibrinolysis in 8.4%. Intraoperative and postoperative venous thrombosis events occurred exclusively in recipients with the FS phenotype. Intraoperative thrombosis occurred with an overall incidence of 4.8% and was associated with 25.0% in-hospital mortality. Incidence of postoperative venous thrombosis within the first month was deep venous thrombosis/pulmonary embolism (PE; 4.8%) and portal vein thrombosis/ hepatic vein thrombosis (1.8%). Massive transfusion of ≥20 units packed red blood cells was required in 11.8% of recipients with FS compared with none in the other 2 phenotype groups (P = 0.01). Multivariate analysis identified 2 pretransplant risk factors for FS: platelet count and nonalcoholic steatohepatitis/cryptogenic cirrhosis. Recursive partitioning identified a critical platelet cutoff value of 50 × 10 9 /L to be associated with FS phenotype. The hyperfibrinolysis phenotype was associated with the lowest 1-year survival (85.7%), followed by FS (95.0%) and physiologic fibrinolysis (97.0%). Infection/multisystem organ failure was the predominant cause of death; in the FS group, 1 patient died of exsanguination, and 1 patient died of massive intraoperative PE. In conclusion, there is a strong association between FS and thrombohemorrhagic complications and poorer outcomes after LT. Liver Transplantation 25 380-387 2019 AASLD.

Esophagectomy is the main option for treatment of esophageal cancer. Among the subjects of surgical interest is the use of anterior versus posterior mediastinum to permit reconstruction of the alimentary tract. We performed postmortem measurements in order to analyze the lengths of both routes. For each route (anterior and posterior) we performed two measurements. The first one was called anatomical route and the second was named as surgical route. Both routes begin at the cricoid cartilage. The anatomical route goes to the celiac axis and the surgical route goes to the gastroduodenal artery. Our results show that in both routes the posterior mediastinum is a shorter way to reach the cervical region.

New antibiotic options are urgently needed for the treatment of carbapenem-resistant Enterobacteriaceae infections. We report a 64-year-old female with prolonged hospitalization following an intestinal transplant who developed refractory bacteremia due to a serine carbapenemase-producing pandrug-resistant isolate of Klebsiella pneumoniae. After failing multiple antimicrobial regimens, the patient was successfully treated. CASE PRESENTATIONA 64-year-old female with a history of diabetes mellitus developed Clostridium difficile colitis with toxic megacolon requiring total colectomy. As a complication of the total colectomy, she had a volvulus requiring extensive resection of necrotic small bowel with resultant total parenteral nutrition-dependent short bowel syndrome (only 15 cm of small bowel left). The patient was referred to our institution for an intestinal transplant. Induction immunosuppression consisted of antithymocyte globulin at 2 mg/kg of body weight intravenously (i.v.) (5 doses), methylprednisolone at 500 mg i.v. every 24 h (q24h) (4 doses, followed by a slow taper over the first 2 weeks), and rituximab at 150 mg/m 2 i.v. (1 dose). Maintenance immunosuppression consisted of basiliximab at 40 mg i.v. every 4 weeks for the first 3 months, tacrolimus, and low-dose prednisone. The antimicrobial prophylaxis regimen consisted of ganciclovir (5 mg/kg i.v. q12h for 2 weeks, followed by valganciclovir at 900 mg per os [p.o.] daily) and trimethoprimsulfamethoxazole (80/400 mg p.o. three times a week) for cytomegalovirus and Pneumocystis jirovecii pneumonia prophylaxis, respectively. No multidrug-resistant organisms were identified by rectal and nasal surveillance cultures at the time of the transplant.The early posttransplant course was complicated by an intraabdominal hematoma on postoperative day 1, which required emergent surgical exploration and evacuation. Abdominal wound closure was performed on postoperative day 8. On postoperative day 12, the patient required another surgical exploration with intraoperative findings of pancreatitis with a small peripancreatic collection. Cultures from this collection obtained in the operating room yielded a heavy growth of Klebsiella pneumoniae. A Hodge test was positive, indicating carbapenemase production. The presence of the Klebsiella pneumoniae carbapenemase (KPC) gene was confirmed using the Verigene (Nanosphere, Inc., Northbrook, IL) Gram-negative blood culture nucleic acid test. The class B (IMP-type metallo-␤-lactamase, New Delhi metallo-␤-lactamase [NDM], and Verona integron-encoded metallo-␤-lactamase [VIM]) and class D (oxacillinase [OXA]-type) carbapenemase genes were not detected. The isolate was resistant to aminoglycosides but susceptible to tigecycline (MIC, 0.38 g/ml) and colistin (MIC, 0.19 g/ml). The patient was started on a combination of tigecycline (1 dose of 100 mg i.v., followed by 50 mg i.v. q12h) and colistin (2.5 mg i.v. q12h) and completed a 14-day course for complicated intra-abdominal infection (cIAI) due to carbapenem-resistant Klebsiella...

Vascular catastrophes such as PA and AEF are potentially life-threatening complications of pancreas transplantation. Immediate treatment at the time of bleeding is essential and covered stenting of the involved artery may provide immediate vascular control in these situations.

Liver allocation was updated on February 4, 2020, replacing a Donor Service Area (DSA) with acuity circles (AC). The impact on waitlist outcomes for patients listed for combined liver‐intestine transplantation (multivisceral transplantation [MVT]) remains unknown. The Organ Procurement and Transplantation Network/United Network for Organ Sharing database was used to identify all candidates listed for both liver and intestine between January 1, 2018 and March 5, 2021. Two eras were defined: pre‐AC (2018–2020) and post‐AC (2020–2021). Outcomes included 90‐day waitlist mortality and transplant probability. A total of 127 adult and 104 pediatric MVT listings were identified. In adults, the 90‐day waitlist mortality was not statistically significantly different, but transplant probability was lower post‐AC. After risk‐adjustment, post‐AC was associated with a higher albeit not statistically significantly different mortality hazard (sub‐distribution hazard ratio[sHR]: 8.45, 95% CI: 0.96–74.05; p = .054), but a significantly lower transplant probability (sHR: 0.33, 95% CI: 0.15–0.75; p = .008). For pediatric patients, waitlist mortality and transplant probability were similar between eras. The proportion of patients who underwent transplant with exception points was lower post‐AC both in adult (44% to 9%; p = .04) and pediatric recipients (65% to 15%; p = .002). A lower transplant probability observed in adults listed for MVT may ultimately result in increased waitlist mortality. Efforts should be taken to ensure equitable organ allocation in this vulnerable patient population.

Background Vancomycin-resistant enterococci are an important cause of healthcare-associated infections and are inherently resistant to many commonly used antibiotics. Linezolid is the only drug currently approved by the US Food and Drug Administration to treat vancomycin-resistant enterococci; however, resistance to this antibiotic appears to be increasing. Although outbreaks of linezolid- and vancomycin-resistant Enterococcus faecium (LR-VRE) in solid organ transplant recipients remain uncommon, they represent a major challenge for infection control and hospital epidemiology. Methods We describe a cluster of 4 LR-VRE infections among a group of liver and multivisceral transplant recipients in a single intensive care unit. Failure of treatment with linezolid in 2 cases led to a review of standard clinical laboratory methods for susceptibility determination. Testing by alternative methods including whole genome sequencing (WGS) and a comprehensive outbreak investigation including sampling of staff members and surfaces was performed. Results Review of laboratory testing methods revealed a limitation in the VITEK 2 system with regard to reporting resistance to linezolid. Linezolid resistance in all cases was confirmed by E-test method. The use of WGS identified a resistant subpopulation with the G2376C mutation in the 23S ribosomal RNA. Sampling of staff members’ dominant hands as well as sampling of surfaces in the unit identified no contaminated sources for transmission. Conclusions This cluster of LR-VRE in transplant recipients highlights the possible shortcomings of standard microbiology laboratory methods and underscores the importance of WGS to identify resistance mechanisms that can inform patient care, as well as infection control and antibiotic stewardship measures.

This study describes the risk of thrombotic and hemorrhagic complications, both intraoperatively, and up to 1 month following visceral transplantation. Data from 48 adult visceral transplants performed between 2010 and 2017 were retrospectively studied [32 multivisceral (MVTx); 10 isolated intestine; six modified-MVTx]. Intraoperatively, intracardiac thrombosis (ICT)/pulmonary embolism (PE) occurred in 25%, 0% and 0% of MVTx, isolated intestine and modified MVTx, respectively, and was associated with 50% (4/8) mortality. Preoperative portal vein thrombosis (PVT) was a significant risk factor for ICT/PE (P = 0.0073). Thromboelastography resembling disseminated intravascular coagulation (DIC) (r time <4 mm combined with fibrinolysis or flat-line) was statistically associated with occurrence of ICT/PE (P < 0.0001). Compared to subgroup without ICT/PE, occurrence of ICT/PE was associated with an increased demand for all blood product components both overall, and each surgical stage. Hyperfibrinolysis (56%) was identified as cause of bleeding in MVTx. Incidence of postoperative thrombotic event at 1 month was 25%, 30% and 17% for MVTx, isolated intestine and modified MVTx, respectively. Incidence of postoperative bleeding complications at 1 month was 11%, 20% and 17% for MVTx, isolated intestine and modified MVTx. In conclusion, MVTx recipients with preoperative PVT are at an increased risk of developing intraoperative life-threatening ICT/PE events associated with DIC-like coagulopathy.