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Weise LB, Crisostomo PR, Bechara CF, Soult MC. Iliac artery-enteric fistulas following failed pancreatic transplant. J Vasc Surg Cases Innov Tech 2024; 10:101427. [PMID: 38375348 PMCID: PMC10875587 DOI: 10.1016/j.jvscit.2024.101427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 12/26/2023] [Indexed: 02/21/2024] Open
Abstract
Arterial-enteric fistulas occur from a multitude of causes, especially following surgical manipulation of vasculature. The development of an iliac artery-enteric fistula (IEF) occurs rarely in patients with failed pancreatic transplants. IEFs warrant urgent intervention due to the high mortality from hemorrhagic and septic shock. The diagnosis can be delayed by a lack of suspicion, the low sensitivity of diagnostic tests, and the nonspecific signs of fistulas on computed tomography. The management of IEFs is adapted from guidelines for arterial-enteric fistulas of other causes, with little consensus on ideal vascular reconstruction and postoperative antimicrobial management. The outcomes are limited to the short-term results from case reports and case series. We report two cases of IEFs in patients with a history of simultaneous pancreatic kidney transplant. Our patients underwent successful resolution of gastrointestinal bleeding and sepsis, with definitive management of fistula resection and interposition iliac artery bypass. The index of suspicion for IEFs should be high, and they should be considered as a source of anemia or gastrointestinal bleeding of an unknown source in patients with failed pancreatic transplant. Definitive management should be pursued in patients who can tolerate fistula resection, allograft explant, and arterial reconstruction.
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Affiliation(s)
- Lorela B. Weise
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University of Chicago, Maywood, IL
| | - Paul R. Crisostomo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University of Chicago, Maywood, IL
| | - Carlos F. Bechara
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University of Chicago, Maywood, IL
| | - Michael C. Soult
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Loyola University of Chicago, Maywood, IL
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Pfister M, Kobe A, Pfammatter T, Bonani M, Rössler F. Peritransplant Varicosis After Simultaneous Pancreas and Kidney Transplantation Is an Uncommon Cause of Late-Onset and Recurrent Gastrointestinal Bleeding. Cureus 2023; 15:e40522. [PMID: 37461789 PMCID: PMC10350313 DOI: 10.7759/cureus.40522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 07/20/2023] Open
Abstract
Ectopic peritransplant varicosis represents an uncommon cause of late-onset gastrointestinal (GI) bleeding after simultaneous pancreas and kidney transplantation (SPK). We report on a 53-year-old female patient who suffered from recurrent upper GI bleeding seven years after SPK with persistent graft function. Upper endoscopy revealed perianastomotic angiodysplasias, treated by clipping and Argon-Plasma-Coagulation. Repeated endoscopy showed no signs of anastomotic ulcer. With persistent symptoms, computed tomography and angiography revealed extensive ectopic varicosis around the pancreas and duodenal graft. With no signs of portal hypertension, pancreas graft venous outflow impairment or arterio-venous fistula, the origin of variceal formation remained unknown. The extended finding did not allow for endovascular treatment by embolization. Surgery with extensive variceal ligation led to persistent cessation of hemorrhage and maintained stable graft function. In patients with unclear recurrent upper GI bleeding after SPK, one should consider ectopic peritransplant varicosis as an exceptional bleeding cause. If endoscopic treatments fail, angiography should be performed to rule out unusual causes of vascular complications. In case of extensive peritransplant varicosis, surgery may remain the only successful therapy, whenever possible including graft preservation in well-functioning grafts.
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Affiliation(s)
- Matthias Pfister
- Surgery and Transplantation, Universitatsspital Zürich, Zürich, CHE
| | - Adrian Kobe
- Diagnostic and Interventional Radiology, Universitätsspital Zürich, Zürich, CHE
| | - Thomas Pfammatter
- Diagnostic and Interventional Radiology, Universitätsspital Zürich, Zürich, CHE
| | - Marco Bonani
- Nephrology, Universitätsspital Zürich, Zürich, CHE
| | - Fabian Rössler
- Surgery and Transplantation, Universitätsspital Zürich, Zürich, CHE
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Afzal S, Mathew Vennikandam M, Ahmad I, Coleski R, Jones D. A Rare Cause and Alternative Algorithm for the Treatment of Gastrointestinal (GI) Bleed: Complications of a Failed Pancreatic Transplant. Cureus 2023; 15:e39741. [PMID: 37398825 PMCID: PMC10310495 DOI: 10.7759/cureus.39741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
A 39-year-old woman with no known risk factors presented for a recurrent upper gastrointestinal (GI) bleed. She had a prior history of failed kidney and pancreatic transplants secondary to childhood diabetes mellitus type I. After an extensive workup, she was found to have active hemorrhage into an area of the small bowel from an artery supplying her failed pancreatic transplant. Here, we discuss the importance of a systematic approach to evaluation, a high index of suspicion, and a known but not entirely common method of treatment for this condition.
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Affiliation(s)
- Soha Afzal
- Department of Internal Medicine, McLaren Greater Lansing, Lansing, USA
- Department of Internal Medicine, Michigan State University, Lansing, USA
| | | | - Iftiker Ahmad
- Department of Gastroenterology and Hepatology, Sparrow Hospital, Lansing, USA
- Department of Gastroenterology and Hepatology, McLaren Greater Lansing Hospital, Lansing, USA
| | - Radoslav Coleski
- Department of Gastroenterology and Hepatology, McLaren Greater Lansing Hospital, Lansing, USA
- Department of Gastroenterology and Hepatology, Sparrow Hospital, Lansing, USA
| | - Dorian Jones
- Department of Gastroenterology and Hepatology, McLaren Greater Lansing Hospital, Lansing, USA
- Department of Gastroenterology and Hepatology, Sparrow Hospital, Lansing, USA
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GI Hemorrhage From an Arterio-Enteric Fistula From a Failed Pancreas Allograft. ACG Case Rep J 2022; 9:e00822. [PMID: 35822156 PMCID: PMC9270599 DOI: 10.14309/crj.0000000000000822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/17/2022] [Indexed: 11/17/2022] Open
Abstract
Arterio-enteric fistulas involving pancreas allograft are rare complications of transplantation that manifest as gastrointestinal bleeding. We discuss the case of a 34-year-old patient with failed pancreas transplant who presented with recurrent sentinel bleeding before catastrophic hemorrhage. Multiple endoscopies did not identify the source of bleeding, and subsequent angiography demonstrated a fistulous connection between the transplanted pancreatic artery and the small bowel. A stent graft was placed with immediate stabilization. We provide a review of the literature and discuss the clinical manifestations, diagnosis, and management of arterio-enteric fistulas to highlight the importance of early recognition and intervention in preventing life-threatening bleeding.
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St Jules R, Blech D, Smith NK, Sakai T. Abdominal Organ Transplantation: Noteworthy Literature in 2021. Semin Cardiothorac Vasc Anesth 2022; 26:140-153. [PMID: 35608409 DOI: 10.1177/10892532221093955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This review highlights noteworthy literature pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. In 2021, we identified noteworthy papers from over 1,200 peer-reviewed publications on pancreatic transplantation, over 1,400 on intestinal transplantation, and over 9,000 on kidney transplantation. The liver transplantation section focuses on clinical trials and systematic reviews and meta-analyses published in 2021 and features 20 selected papers. COVID-19 and abdominal organ transplantation are featured in an independent section.
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Affiliation(s)
- Robert St Jules
- Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Daniel Blech
- Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Natalie K Smith
- Department of Anesthesiology, Perioperative and Pain Medicine, The Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA, USA
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Matejak-Górska M, Witkowski G, Durlik M. Vascular Complications After Simultaneous Pancreas and Kidney Transplantation: A Case Report. Transplant Proc 2022; 54:1183-1188. [PMID: 35450723 DOI: 10.1016/j.transproceed.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/21/2022] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
Abstract
A 51-year-old patient with type I diabetes and end-stage renal disease was qualified for a simultaneous kidney and pancreas transplant. The procedure was performed in a typical manner: arterial anastomosis to the right common iliac artery, the graft's portal vein with inferior vena cava, and side-to-side duodenal intestinal anastomosis. The kidney was implanted retroperitoneally. Six months after the transplant, the patient reported pain in the right lower abdomen, and imaging examinations revealed arterial anastomosis. Reconstruction of the right common iliac artery was performed with a Gore-Tex prosthesis and the pancreatic artery reanastomosed to the right external iliac artery. After the surgery, the function of the transplanted pancreas deteriorated, the level of C-peptide was decreased, and the patient required low doses of insulin. After another 8 months, the imaging studies revealed an aneurysm located in the bifurcation of the aorta up to the anastomosis of the pancreatic graft artery with the iliac artery. The patient was qualified for the implantation of an endovascular of 2 prosthesis, which improved the graft's function. After another 2 months, the presence of an aneurysm at the endovascular prosthesis was found again. The patient was requalified for endovascular prosthesis implantation. Currently, there is no aneurysm but the function of the pancreas graft is impaired, though the kidney graft function is good. Patients after simultaneous kidney and pancreas transplant are a group of patients with an increased risk of vascular complications. Treatment should take place in a multidisciplinary center.
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Affiliation(s)
- Marta Matejak-Górska
- Department of General Surgery and Transplantology, Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw, Warsaw, Poland; Centre of Postgraduate Medical Education, Warsaw, Poland.
| | - Grzegorz Witkowski
- Department of General Surgery and Transplantology, Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw, Warsaw, Poland; Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Marek Durlik
- Department of General Surgery and Transplantology, Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw, Warsaw, Poland; Centre of Postgraduate Medical Education, Warsaw, Poland
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