Search

The use of extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) has rapidly grown since the 1960s. Improvements in materials, device mechanics, the treatment of the underlying conditions, and provider proficiency, have resulted in better outcomes. The most common indication for ECLS in the pediatric population is viral pneumonia [ 1 ]. Complications secondary to ECLS are common with thromboembolic events (8%) and hemorrhage (27%) being amongst the most frequent [ 2 ]. We report a case of a 13-year-old female who presented to the Emergency Department with altered mental status and respiratory distress following a treatment course for influenza. She was diagnosed with multifocal pneumonia and developed fulminant respiratory failure requiring ECLS. The causative organism was later found to be Methicillin-Resistant Staphylococcus Aureus (MRSA). She was maintained on ECLS for 49 days and developed secondary complications of lung necrosis, an intrathoracic hematoma, and multiple bronchopleural fistulae. She was managed non-operatively for these complications until she stabilized enough to be weaned off ECMO. In this particular case, we resisted the urge to surgically intervene until she was decannulated. On day 86, she underwent a thoracotomy for evacuation of an intrathoracic hematoma and repair of a bronchopleural fistula. The patient survived and was discharged on hospital day 146. Currently, she is thriving and recovering well. We present this case due to its unusual duration of ECLS and to highlight the decision-making behind the initial non-operative management of the life-threatening complications that ensued.

Background Acute cellular rejection (ACR) is a common complication of small bowel transplantation (SBTx) and the major cause of graft loss. However, little is known regarding the genetic graft response to ACR in clinical transplants. In this study, we have determined a genetic expression profile of intestinal graft response to ACR after living related (LR) SBTx. Results By identifying the expression profiles of reported markers of rejection we were able to identify 57 genes that had significantly increased (more than twofold) expression in response to ACR. Known markers of rejection identified: MMP-9, MMP-2, VIP, IFNγ, IL-2R, MADCAM-1, HSP-60 , and HSP-70 all had greater than twofold increased expression after ACR diagnosed (week 3 to week 6). The newly identified genes were: IFI27, EPST11, APAF1, LAP3, STK6 , and MDK. Conclusion Newly identified up-regulated genes in response to ACR in small bowel graft are involved in the immune response, cell adhesion, neurogenesis, cell division and proliferation, DNA replication/repair, protein ubiqutin/proteolysis, and apoptosis. TNF α up-regulated early at week 2 biopsy may be an early genetic marker of ACR in SBTx.

The purpose was to determine whether magnification endoscopy (ME) accurately diagnosed rejection in living related small bowel transplants (LRSBTx) during initial morphological adaptation of segmental intestinal grafts. The small bowel recipient was a 44-year-old woman with short gut syndrome following multiple bowel surgeries for familial adenomatous polyposis. ME was enhanced by chromoendoscopy staining. Bowel mucosa was washed with acetic acid and stained with methylene blue for optimal visualization of mucosal villi and to improve the diagnostic yield of biopsies. The recipient underwent surveillance ME with biopsy 16 times through the ileostomy in the first 9 months following transplantation. The recipient developed diarrhea in the postoperative course, which led to the suspicion of rejection. ME findings of patchy villus blunting were consistent with biopsy samples that showed mild acute cellular rejection. Episodes of rejection were treated with high-dose immunosuppressants and steroids. Reversal of rejection was monitored by follow-up ME, which showed increased length of villi and normalization of morphology. Biopsy confirmed these findings. The first endoscopy, at 5 days posttransplant, showed no evidence of intestinal ischemia. LRSBTx involves early morphological adaptation of the recipient small bowel mucosa, characterized by an increased length of villi. ME is a reliable technique to follow adaptation and detect early rejection. The superior imaging of small bowel mucosa created by ME chromoendoscopy enables early diagnosis and delivery of more prompt antirejection therapy to prevent progression of rejection. ME also confirmed that segmental LRSBTx caused minimal ischemic injury to the recipient.