Monia E. Werlang

Patent foramen ovale in liver transplant recipients does not negatively impact short-term outcomes

Patent foramen ovale (PFO) is a common atrial septal defect that is largely asymptomatic and often undiagnosed. The impact of a PFO in patients undergoing liver transplantation (LT) is unknown.

A hybrid endoscopic technique to close tracheoesophageal fistula

Tracheoesophageal fistula (TEF) is a congenital or with literature reporting up to 20% recurrence. Here we acquired pathologic entity characterized by an abnormal communication between the posterior aspect of the trachea and the anterior wall of the esophagus. Acquired TEF is a not uncommon adverse event secondary to mechanical ventilation, trauma, esophageal tumor, prior laryngectomy, or esophagectomy. Given the potential serious consequence of possible fatal pulmonary aspiration, prompt closure of TEFs is critical. Although an endoscopic approach to TEFs has been optimized over the past years, including endoscopic stent placement and over-the-scope clip system, recurrent TEFs remain a therapeutic challenge,

Endoscopic salvage of a large esophagojejunostomy dehiscence

Figure 2. Fully covered metal stent (18 mm 150 mm) was placed as a bridge for surgery. Esophagojejunostomy anastomosis (EJA) dehiscence is not uncommon (up to 3% to 15%). Management can be challenging depending on the size and location, and it frequently requires surgical repair, which is associated with significant morbidity and mortality. Although endoscopic clipping is commonly described in the literature for a dehiscence smaller than 2 cm, we describe the successful endoscopic salvage of a large 4-cm EJA dehiscence by use of a combined technique of flexible endoscopic suturing and covered metal stent placement. Our patient was a 34-year-old woman with invasive diffuse gastric adenocarcinoma who underwent total gastrectomy with en bloc splenectomy, distal esophagectomy, subtotal pancreatectomy, and intraoperative percutaneous jejunal tube placement. Seven days postoperatively she experienced septic shock, empyema, and tension pneumothorax, resulting in the placement of chest tubes. An EJA leak was suspected, and upper endoscopy showed a greater than 50% circumferential dehiscence of the EJA (Fig. 1). On endoscopy, lavage of the pleural cavity was done with a total of 500 mL of 1.5% hydrogen peroxide and normal saline solution with scant indigo carmine. The latter was used to observe the change in color of chest tube output and to determine whether this cavity was actively being drained. This was followed by placement of an 18 mm 150 mm fully covered metal stent as a bridge for surgery (Fig. 2). The stent was clipped to the esophageal wall to prevent stent migration. Clipping was possible, given that an adequate fold was obtained, with sufficient grasp of tissue and stent allowing for a fixation. Suturing can help to obviate migration, but migration can still occur with sutures as a result of metal scaffold cutting into the thread. Furthermore, the use of clips is less expensive than the endoscopic suturing kit. Four weeks later, she was still dependent on 1 chest tube, and an esophagogram showed a persistent leak at the EJA, even though the stent was in place. A multidisciplinary team, including the patient and her family, reached a consensus to attempt endoscopic closure of the EJA dehiscence instead of surgery. At subsequent endoscopy, the old stent was removed and thedehiscencewasevaluated (Fig. 3). Lavageof thepleural cavity was repeated. The surface of the EJA dehiscence was debrided, and the proximal loop of the jejunum was

Thoracentesis-Reverting Cardiac Tamponade Physiology in a Patient with Myxedema Coma and Large Pleural Effusion

A large pleural effusion causing cardiac tamponade physiology and severe hemodynamic compromise is an uncommon event. We report a case of a 53-year-old woman with severe hypothyroidism presenting with myxedema coma and refractory shock. Her hemodynamic status failed to respond to fluid resuscitation and vasopressors. A transthoracic echocardiogram and chest radiograph demonstrated a pericardial fluid accumulation associated with a large left-sided pleural effusion. Thoracostomy tube insertion resulted in prompt improvement of the patients hemodynamic status. Our finding demonstrates that a large pleural effusion may play an important role in cardiac tamponade physiology.

Tumor Necrosis Factor Alpha Inhibitor-Induced Acute Pancreatitis

Treatment of acute pancreatitis remains a challenge, with therapy focused on supportive care and treating the inciting etiology. Tumor necrosis factor-alpha (TNFα) inhibitors have shown promising results treating acute pancreatitis in animal models, but they have not been evaluated in human trials yet. A 25-year-old woman presented with ulcerative colitis. She was unresponsive to immunomodulators and developed acute pancreatitis shortly after initiation of a TNFα inhibitor. Her symptoms subsided after discontinuation of the medication, but reemerged when a different TNFα inhibitor was introduced to control her ulcerative colitis. Other potential etiologies were investigated and clinically excluded by laboratory and imaging studies.

79-Year-Old Woman With Dyspnea, Cough, and Renal Failure

Resident in Internal Medicine, Mayo School of Graduate Medical Education, Jacksonville, FL (N.J.P., M.E.W.); Advisor to residents and Consultant in Hospital Internal Medicine, Mayo Clinic, Jacksonville, FL (M.C.B.). A 79-year-old woman presented to the hospital from a rehabilitation facility with worsening dyspnea, nonproductive cough, and fever. Immediately before admission to the rehabilitation facility, she was hospitalized at an outside hospital for 1 month for evaluation of fever, chills, and malaise. During that hospitalization, she aspirated stomach contents, and pneumonia subsequently developed, which was treated with a 7-day course of intravenous vancomycin, piperacillintazobactam, and levofloxacin. Her hospitalization was further complicated by acute kidney injury after contrast computed tomography. Bilateral lower extremity deep venous thrombosis developed and was being treated with enoxaparin. A peripherally inserted central venous catheter and urinary catheter were placed during the hospitalization and removed before discharge. Three days after admission to the rehabilitation facility, the patient experienced dyspnea, a nonproductive cough, chest discomfort, and fever. The family reported that she was urinating several times daily. On admission to our hospital, the patient was afebrile and had a pulse rate of 89 beats/ min, respiratory rate of 24 breaths/min, blood pressure of 152/81 mm Hg, and oxygen saturation of 96% while receiving 15 L of oxygen via nonrebreather mask. She appeared frail and in moderate respiratory distress. Examination revealed 2-cm jugular venous distention above the sternal notch. She had decreased breath sounds in the right lower lobe, bibasilar crackles, and bronchial breath sounds in the upper airways. There was a 3/6 holosystolic murmur at the apex that radiated to the left axilla and 3þ left-sided and 2þ right-sided pretibial edema. She had normal bowel sounds and lower abdominal tenderness without guarding or rebound. There was no lymphadenopathy. Laboratory studies yielded the following results (reference ranges provided parenthetically): hemoglobin, 12.1 g/dL (12.0-15.5 g/dL); mean corpuscular volume, 84.1 fL