Multiple Organ Failure Research Articles

The optimal timing for definitive operative stabilization of pelvic fractures in polytrauma patients: effects on clinical outcomes – a systematic review

PurposeThe optimal timing for definitive surgical treatment of pelvic fractures in polytrauma patients remains a topic of ongoing discussion due to the complexity of these injuries. This analysis therefore aims to systematically compare early versus late definitive operative stabilization of pelvic fractures on outcome in polytrauma patients.MethodsPubMed, CENTRAL and Web of Science were systematically searched to identify relevant completed and ongoing studies from the inception of each database to March 13, 2023. Systematic reviews, randomized control trials (RCTs) and observational studies comparing early (< 24 h) versus late (> 24 h) definitive operative stabilization in adult polytrauma patients admitted to the ICU were included.ResultsSince no systematic reviews and RCTs were available on this subject, one observational study was identified, including a total of 418 polytrauma patients (nearly = 165, nlate = 253), median age: 40.3 years (early 40.1 years, late 40.4 years). Early definitive stabilization was associated with a decreased risk of acute respiratory distress syndrome (ARDS) compared to late stabilization of unstable pelvis and acetabulum fractures (RR 0.38, 95% CI 0.18–0.81; RD 78 fewer per 1000, 95% CI 104 fewer to 24 fewer; 1 study, 418 participants; very low certainty of evidence). Furthermore, early definitive stabilization may decrease the risk of pneumonia compared to late stabilization of unstable pelvis and acetabulum fractures (RR 0.50, 95% CI 0.28–0.88; RD 85 fewer per 1000, 95% CI 122 fewer to 20 fewer); 1 study, 418 participants; very low certainty of evidence).ConclusionThere is limited evidence regarding early definitive fracture repair (≤ 24 h) compared to late repair of pelvic fractures in polytrauma patients. One observational study showed a reduced incidence of septic respiratory complications, ARDS, and multi-organ failure (MOF) in polytrauma patients who received early definitive fracture repair.

Predictors of moderate, severe, and critical COVID-19 infection in a largely vaccinated kidney transplant recipient cohort during the Omicron era: the importance of timely booster vaccinations and early presentation to care.

Kidney transplant recipients (KTRs) are at risk of coronavirus disease 2019 (COVID-19) complications and mortality. This study examined factors associated with moderate, severe, or critical COVID-19 infection among KTRs during the Omicron-predominant period. This single-center retrospective study included KTRs aged ≥18 years diagnosed with COVID-19 between January 1, 2022, and December 31, 2023. Mild infection was defined as symptomatic illness without lower respiratory tract infection (LRTI); moderate infection as LRTI without hypoxia; severe infection as oxygen saturation <94% on room air; and critical infection as respiratory failure, septic shock, or multiple organ dysfunction. We compared the characteristics of KTRs with asymptomatic or mild COVID-19 versus those with moderate to critical disease. Logistic regression analysis was performed to identify factors associated with moderate to critical illness. Most KTRs (94.4%) had received three or more vaccine doses. Of 603 episodes of COVID-19 infection during the study period, 554 (91.9%) were asymptomatic or mild, while 49 (8.1%) were moderate to critical. Multivariate analysis revealed that older age (adjusted odds ratio [aOR], 1.037; 95% confidence interval [CI], 1.006-1.069) and longer symptom duration before seeking care (aOR, 1.288; 95% CI, 1.155-1.436) were associated with higher odds of moderate to critical disease. Protective factors included receiving a vaccine booster within the past year (aOR, 0.414; 95% CI, 0.212-0.809) and higher glomerular filtration rate (aOR, 0.971; 95% CI, 0.956-0.986). KTRs should seek care early if infected with COVID-19 and keep their COVID-19 vaccine boosters updated within 1 year of the last dose.

Precise Monitoring of Transpulmonic Resistance in Bridge to Transplant Patients Supported by The Aeson Total Artificial Heart.

The Aeson Total Artificial Heart (TAH) features embedded pressure sensors for flow autoregulation, which can also be used to estimate pressure gradients. In this bridge-to-transplant study, right and left ventricular pressure data and pump output from the TAH were analyzed to estimate trans-pulmonic resistance (eTPR) every 30 days. Three patients (aged 60, 35, and 54) with pre-implant pulmonary vascular resistance of 7.0, 3.2, and 7.1 Wood Units, respectively, were supported by the TAH at pump outputs of 4.5-6.5 L/min. All showed significant eTPR reductions (1.4-1.5 Wood Units) and received donor hearts after 243, 155, and 109 days of support. Two patients underwent successful transplants without complications; one died post-transplant from pneumonia and multiorgan failure. The Aeson TAH's eTPR monitoring system offers a promising, non-invasive approach to managing pulmonary hypertension and assessing transplant eligibility in real time.

Primary large cell neuroendocrine carcinoma of the urethra: a case report

BackgroundPrimary neuroendocrine carcinoma of the urethra is a very uncommon malignant tumor, and no reports have been made about large cell neuroendocrine carcinoma (LCNEC) in the past.Case descriptionA 43-year-old non-smoking female patient presented with symptoms of dysuria and urination-related pain at TangDu Hospital in April 2022. A biopsy subsequently confirmed the diagnosis of primary urethral LCNEC. Following radical resection, the patient exhibited abnormal lymph node enlargement in the first month and pelvic metastases in the fourth month. Ultimately, the patient succumbed to the disease 486 days after the radical resection, attributed to widespread tumor metastases and concurrent multi-organ failure. The final pathological examination confirmed the presence of a high-grade LCNEC.ConclusionThe occurrence of primary LCNEC in the urethra is exceptionally uncommon. This particular instance was notable for its aggressive progression and unfavorable prognosis. Historically, there have been no prior documented instances of primary pure LCNEC in the urethra. It is imperative to emphasize that early identification and intervention for LCNEC could potentially offer patients a more favorable survival outcome.

Dengue with Sickle Cell Anaemia Associated with Acute Liver Failure: A Case Report

Aim: Dengue fever is a major health risk in endemic regions, and its complications can be severe in individuals with underlying haematological conditions like sickle cell anaemia (SCD). SCD increases the risk of Vaso-occlusive crises, haemolysis, and multi-organ dysfunction, which can be exacerbated by dengue’s endothelial damage. This case highlights the rare and complex interaction between SCD and dengue fever, particularly the severe hepatic complications due to co-existing illness, emphasizing the need for specialized treatment strategies. Case Presentation: A female patient from Chikkaballapur, Karnataka, India, with sickle cell anaemia (SCD), presented with dengue shock syndrome and severe hepatic complications. She experienced fever, shock, and liver dysfunction, worsened by both dengue and SCD. Diagnostic challenges arose due to overlapping symptoms. Management included careful hydration, pain control, and transfusion therapy, with close monitoring. Conclusions: This case demonstrates the complexities of managing patients with both SCD and dengue fever. The interaction between dengue-induced endothelial damage and SCD can lead to severe complications, including organ failure and death. Timely intervention, close monitoring, and a multidisciplinary approach are essential for improving outcomes. This case underscores the need for specific treatment guidelines for managing dengue in SCD patients to reduce morbidity and mortality.

PLACE: Multicenter Study for Right Ventricular Failure on Mechanical Cardiocirculatory Supports.

Isolated acute right ventricular failure (aRVF) is associated with poor prognosis in different scenarios. In severe conditions, temporary mechanical cardiocirculatory support (tMCS) is required. PLACE is an international, retrospective, multicenter registry including 17 centers that investigated patients affected by isolated aRVF and treated with various types of tMCS from January 2000 to December 2020. The registry included 644 (69.6% males, mean age: 55 years) patients. The most frequent etiologies were post-left ventricular assist device implantation (LVAD) and postcardiotomy shock. These patients received mostly mechanical circulatory support (MCS) and veno-arterial extracorporeal membrane oxygenation. Mean tMCS duration was 9 days, weaning was achieved in 70.5% of the patients, and the major cause of death on support was multiorgan failure (50.5%). The mortality rate was 45 and 48.4% in-hospital and at 3 month follow-up, respectively. Multivariable logistic regression analysis identified age, aRVF due to acute pulmonary hypertension, bilirubin level, and oliguria or anuria at tMCS implantation as risk factors for in-hospital mortality. Conversely, aRVF after LVAD was found to be associated with a lower risk of early mortality. In-hospital and 3 months mortality occurred in less than half of the aRVF-supported subjects. Furthermore, several preimplant aspects such as age, organ function, and type of tMCS are independently associated with in-hospital and 3 month mortality.

Septic Cardiomyopathy: Difficult Definition, Challenging Diagnosis, Unclear Treatment

Sepsis is a systemic inflammatory response syndrome of suspected or confirmed infectious origin, which frequently culminates in multiorgan failure, including cardiac involvement. Septic cardiomyopathy (SCM) remains a poorly defined clinical entity, lacking a formal or consensus definition and representing a significant knowledge gap in critical care medicine. It is an often-underdiagnosed complication of sepsis. The only widely accepted aspect of its definition is that SCM is a transient myocardial dysfunction occurring in patients with sepsis, which cannot be attributed to ischemia or pre-existing cardiac disease. The pathogenesis of SCM appears to be multifactorial, involving inflammatory cytokines, overproduction of nitric oxide, mitochondrial dysfunction, calcium homeostasis dysregulation, autonomic imbalance, and myocardial edema. Diagnosis primarily relies on echocardiography, with advanced tools such as tissue Doppler imaging (TDI) and global longitudinal strain (GLS) providing greater sensitivity for detecting subclinical dysfunction and guiding therapeutic decisions. Traditional echocardiographic findings, such as left ventricular ejection fraction measured by 2D echocardiography, often reflect systemic vasoplegia rather than intrinsic myocardial dysfunction, complicating accurate diagnosis. Right ventricular (RV) dysfunction, identified as a critical component of SCM in many studies, has multifactorial pathophysiology. Factors including septic cardiomyopathy itself, mechanical ventilation, hypoxemia, and hypercapnia—particularly in cases complicated by acute respiratory distress syndrome (ARDS)—increase RV afterload and exacerbate RV dysfunction. The prognostic value of cardiac biomarkers, such as troponins and natriuretic peptides, remains uncertain, as these markers primarily reflect illness severity rather than being specific to SCM. Treatment focuses on the early recognition of sepsis, hemodynamic optimization, and etiological interventions, as no targeted therapies currently exist. Emerging therapies, such as levosimendan and VA-ECMO, show potential in severe SCM cases, though further validation is needed. The lack of standardized diagnostic criteria, combined with the heterogeneity of sepsis presentations, poses significant challenges to the effective management of SCM. Future research should focus on developing cluster-based classification systems for septic shock patients by integrating biomarkers, echocardiographic findings, and clinical parameters. These advancements could clarify the underlying pathophysiology and enable tailored therapeutic strategies to improve outcomes for SCM patients.

Pathogenic and therapeutic roles of extracellular vesicles in sepsis

Sepsis is a systemic injury resulting in vascular dysfunction, which can lead to multiple organ dysfunction, even shock and death. Extracellular vesicles (EVs) released by mammalian cells and bacteria have been shown to play important roles in intercellular communication and progression of various diseases. In past decades, the functional role of EVs in sepsis and its complications has been well explored. EVs are one of the paracrine components of cells. By delivering bioactive materials, EVs can promote immune responses, particularly the development of inflammation. In addition, EVs can serve as beneficial tools for delivering therapeutic cargos. In this review, we discuss the dual role of EVs in the progression and treatment of sepsis, exploring their intricate involvement in both inflammation and tissue repair processes. Specifically, the remarkable role of engineered strategies based on EVs in the treatment of sepsis is highlighted. The engineering EVs-mediated drug delivery and release strategies offer broad prospects for the effective treatment of sepsis. EVs-based approaches provide a novel avenue for diagnosing sepsis and offer opportunities for more precise intervention.

Diagnosis and Management of Patients with Fulminant Myocarditis

Abstract Fulminant myocarditis (FM) is a progressive and severe form of acute myocarditis, complicated by cardiogenic shock. The clinical presentation and etiologies of FM is often heterogeneous, making it difficult to diagnose. Irrespective of how FM presents, it rapidly evolves to hemodynamic deterioration and requires prompt treatment to stabilize. As such, the use of mechanical circulatory support (MCS) devices has emerged as a critical intervention to achieve hemodynamic support, early unloading, systemic perfusion and to prevent multiorgan dysfunction in patients with FM. Although scientific societies have proposed recommendations and management pathways, due to the heterogeneity in FM there remains a lack of clarity in the diagnostic pathway and selection of MCS device for this young patient population. This review provides an updated and integrated overview of the diagnostic flow and important clinical considerations when managing patients with FM.

Nineteen years retrospective analysis of epidemiology, antifungal resistance and a nomogram model for 30-day mortality in nosocomial candidemia patients

BackgroundThe incidence of nosocomial candidemia has increased in recently years, however, the epidemiological data remain insufficient in China.MethodsA total of 234 candidemia patients were included from Xiamen University Zhong Shan hospital between January 2006 and October 2024. Incidence, species proportion, distribution, antifungal drug resistance of candidemia was analyzed. A nomogram model for 30-day morbidity of candidemia was determined using the least absolute shrinkage and logistic regression analysis.ResultsThe incidence of candidemia increased in recent years (2020: 0.025%, 2021: 0.029%, 2023:0.022%). The dominant species of candidemia were Candida albicans (n=99,42.31%), Candida parapsilosis (n=47,20.09%), Candida tropicalis (n=43,18.38%), Candida glabrata (n=31,13.25%). Departments with a higher detection of candidemia included intensive care unit (n=55), emergency department (n=24) and hepatobiliary surgery (n=22). Candida tropicalis performed the highest resistance to azole (fluconazole: 55.81%, voriconazole:55.00% and itraconazole:58.14%). The resistance of Candida albicans to fluconazole, voriconazole and itraconazole were 32.32%, 23.53% and 31.31%. The mortality rate of 30-day discharge for candidemia reached 52.99%. 205 cases of candidemia patients from January 2006 to December 2023 were included as the training set, while 29 cases of candidiasis patients from January to October 2004 were included as the validation set. Five independent factors included Candida albicans, decreased albumin, multiple organ dysfunction syndrome, solid tumor and septic shock were adopted in a nomogram for 30-days mortality of candidemia. In the training set, the area under curve was 0.866 (95%CI: 0.817-0.916), the optimal cutoff value was 0.617, the sensitivity was 80% and the specificity was 80.4%. In the validation set, the area under curve was 0.808 (95%CI:0.737-0.970), the optimal cutoff value was 0.543. The sensitivity was 72.7% and the specificity was 83.3%.ConclusionThe incidence of nosocomial candidemia has risen in recent years. Candida albicans remains the primary species, with the highest incidence is intensive care unit. Candida tropicalis exhibits the highest resistance rate to azole drugs. A nomogram predicting 30-day mortality discharge for candidemia patients has been constructed, and the independent risk factors including Candida albicans, multiple organ dysfunction syndrome, septic shock, solid tumors, and decreased albumin.

Utility of sepsis-induced coagulopathy among disseminated intravascular coagulation diagnostic criteria: A multicenter retrospective validation study.

The criteria for diagnosing sepsis-induced coagulopathy (SIC) may overlap with those of Japanese Association for Acute Medicine (JAAM) disseminated intravascular coagulation (DIC). We aimed to determine if the diagnostic criteria for SIC overlap with those for the JAAM DIC diagnosis of International Society on Thrombosis and Haemostasis (ISTH) DIC and whether patients have the same prognosis when diagnosed using these criteria. This multicenter retrospective study included patients with sepsis diagnosed using the JAAM and ISTH DIC and SIC criteria on days 1 and 4. The established ISTH DIC criteria was reference standard for primary outcome that compared the characteristics of SIC and JAAM DIC. Secondary outcomes were multiple organ dysfunction syndrome (MODS), ventilator- and intensive care unit-free days, and in-hospital mortality. A total of 1,438 patients were included in this study. On day 1, the JAAM DIC and SIC criteria diagnosed almost all patients with ISTH DIC (98% and 94%, respectively), predicting ISTH DIC (area under the receiver operating curve [AUC]: 0.740 vs. 0.752, P = 0.523) and MODS (AUC: 0.686 vs. 0.697, P = 0.546) on day 4 and progressing to ISTH DIC in the same proportion (28.6 vs. 30.1%, P = 0.622). There were no differences in survival probabilities (P = 0.196) or secondary outcomes between patients diagnosed using JAAM DIC and SIC criteria on day 1. SIC and JAAM DIC diagnoses were equal among patients with sepsis, suggesting that SIC criteria add little to current DIC scoring systems.

Risk factors associated with mortality and pathogen characteristics of bloodstream infection-induced severe sepsis in the pediatric intensive care unit: a retrospective cohort study

BackgroundBloodstream infection (BSI)-induced severe sepsis is a common cause of mortality, frequently resulting in septic shock and multiple organ dysfunction syndrome (MODS). This study aimed to analyze mortality risk factors and summarize pathogen characteristics associated with BSI-induced severe sepsis in the pediatric intensive care unit (PICU).MethodsThis retrospective study was conducted at a tertiary pediatric hospital between January 2015 and December 2023, encompassing children with BSI-induced severe sepsis in the PICU. Clinical characteristics, laboratory parameters, pathogen characteristics, and drug resistance profiles of the patients were collected. Clinical and laboratory indicators along with pathogen characteristics were summarized. Logistic regression analysis was employed to identify independent risk factors associated with 28-day mortality.ResultsA total of 192 patients with bloodstream infection (BSI)-induced severe sepsis were identified, with a 28-day in-hospital mortality rate of 36.98% (71/192). The incidence of septic shock (42.1% vs. 69%, P &amp;lt; 0.001) and AKI (14% vs. 31%, P = 0.005) was significantly lower in the survival group compared to the non-survival group. In multivariate analysis, independent risk factors for 28-day mortality were the pediatric sequential organ failure assessment (pSOFA) score (OR 1.176; 95% CI: 1.046-1.321, p = 0.007) and the P/F value (OR 0.994; 95% CI: 0.991-0.997, P &amp;lt; 0.001). Double organism growth was detected in 8 cultures, and a total of 200 pathogenic bacteria were isolated from all blood cultures. Of these, 110 strains (55.0%) were Gram-negative bacteria, 88 strains (44.0%) were gram-positive bacteria, and 2 strains (1.0%) were Candida albicans. The most commonly isolated pathogens were Staphylococcus aureus, Coagulase-negative Staphylococcus, and Escherichia coli. The detection rate of carbapenem resistance (CR) in Acinetobacter baumannii (66.7%) was higher than that in Pseudomonas aeruginosa (15.4%). The detection rates of extended-spectrum cephalosporin resistance (ECR) and fluoroquinolone resistance (FQR) in Escherichia coli (E. coli) were higher than those in Klebsiella pneumoniae.ConclusionIn the PICU, higher mortality was observed in children with BSI-induced severe sepsis who presented with elevated pSOFA scores and low P/F values. Acinetobacter baumannii exhibited the highest levels of CR and FQR, while Escherichia coli demonstrated the highest level of ECR.

Guidelines for the management of drug-induced hypersensitivity syndrome 2023.

Drug-induced hypersensitivity syndrome (DIHS) is one of the severe drug eruptions accompanied by fever and multiple organ dysfunction, and it is induced by a relatively limited range of drugs, including anticonvulsants. A distinctive feature of this condition is its association with the reactivation of herpes viruses, particularly human herpesvirus 6. The pathogenesis involves two key factors: drug allergy and herpesvirus reactivation. DIHS is often challenging to diagnose in its early stages, and its clinical course varies widely, ranging from relatively mild to life-threatening cases. Additionally, unexpected complications, such as autoimmune diseases, may occur during the convalescent phase. As a result, diagnosing, treating, and predicting the prognosis of DIHS remain complex issues. In response to these challenges, the Ministry of Health, Labour and Welfare Study Group on Severe Erythema Multiforme has taken the lead in developing new guidelines for the management of DIHS. These guidelines aim to support clinical practice by providing up-to-date, evidence-based information on the diagnosis, treatment, and prognosis of DIHS.

Outcomes of Sepsis–Associated Acute Kidney Injury

Background Acute kidney injury (AKI) is common in tropical countries. Most common cause of AKI in India is sepsis. AKI is known to progress to acute kidney disease (AKD). Long-term follow-up of sepsis associated AKI is pivotal for identifying factors influencing progression. Materials and Methods We conducted a case record review of patients admitted between January 2022 and January 2023 to assess the outcomes of sepsis-AKI and the factors associated with the transition to chronic kidney disease (CKD). Results Of a total of 2600 renal intensive care admissions, 451 were diagnosed with sepsis-AKI. About 8.8% (40 cases) completely recovered within the first week (AKI recovered), and the remaining 91.1% cases (AKD) were followed up for 1 week to 1 year. The mortality rate between this period was about 45.7% (188 patients). On the assessment of survivors (223 patients), complete renal recovery was noted in 160 patients, and 28.3% (63 patients) transitioned to CKD. Elderly age, high SOFA score, and multiorgan failure were associated with higher progression to CKD (P &lt; 0.05). Conclusion AKI patients need a follow-up period of at least 1 year, as delayed recovery is common. Sepsis-associated AKI progresses to CKD in about 28% of patients with risk factors being old age, presence of comorbidities, severe sepsis with multiorgan involvement, and high SOFA score.

Shock with Severe Rhabdomyolysis and Multiorgan Failure Following Detergent Ingestion

Shock with Severe Rhabdomyolysis and Multiorgan Failure Following Detergent Ingestion

Acute diquat poisoning induces paralytic ileus and hepatic portal venous gas: a case report

Diquat is a non-selective, broad-spectrum herbicide. Although its toxicity is significantly lower than paraquat, it still has a high mortality rate when ingested in large quantities. This report presents the case of a 21-year-old female who developed severe paralytic ileus and the rare radiological finding of hepatic portal venous gas (HPVG) after ingesting 150 mL of diquat. Despite aggressive treatment, including gastric lavage, drainage, and blood purification, the patient ultimately succumbed to multiple organ failure. This report explores the potential causes of HPVG, including infection and elevated intestinal pressure, and highlights the possibility that montmorillonite may have exacerbated this process.

Acute Kidney Injury During Sepsis and Prognostic Role of Coexistent Chronic Heart Failure

Background: The recently updated definition of sepsis considers pathophysiologic mechanisms to guide initial therapy. Clearly, generalized recommendations for sepsis therapy may be limited by pre-existing multimorbidity in addition to sepsis-related multi-organ failure. In particular, a recommendation regarding fluid rescue therapy may require adequate cardiac function and/or the absence of sepsis-induced cardiomyopathy. In all sepsis patients with compromised cardiac function or sepsis-induced cardiomyopathy, a patient-specific therapy regimen is required to prevent pulmonary edema and early death. Similarly, in sepsis, acute kidney injury with or without pre-existing chronic kidney disease requires attention to be paid to excretory renal function to avoid hypervolemia-mediated acute heart failure. In addition, hyponatremia related to intravascular hypovolemia may be explained by vasopressin stimulation. However, hypothetically, vasopressin hyporesponsiveness may contribute to sepsis-related acute kidney injury. In this review, relevant cardiorenal pathomechanisms will be assessed in the context of sepsis therapy. Conclusions: In conclusion, therapy for sepsis with acute kidney injury has to take cardiac comorbidity, if present, into account. The extent to which vasopressin hyporesponsiveness aggravates sepsis-mediated hypovolemia and renal insufficiency should remain a subject of further study.

A challenging case of recurrent cholangitis caused by isolated bile duct metastasis of colorectal adenocarcinoma – rescue therapy through EUS-guided hepaticoesophagostomy.

A 64-year-old male was admitted with fever, abdominal pain and jaundice. Medical history was relevant for colorectal adenocarcinoma eleven years before and right hepatectomy due to liver metastasis. MRCP revealed left hepatic duct stenosis without liver nodules. ERCP was performed for biliary drainage with plastic stents. After inconclusive brush cytology, cholangioscopy (Spyglass™DS2) was performed showing villous mucosa surrounded by irregular vessels suggestive of tumor neovascularization. Spybite™ biopsies confirmed biliary metastasis of colorectal origin. The patient started palliative chemotherapy being readmitted six months later with acute cholangitis. Diffuse infiltrating intrabiliary lesion with 120mm was detected in control MRCP. Given its intraductal extension and gastric compression by the hypertrophied liver leading to duodenoscope mispositioning, transpapilar stents could not be deployed. Multiorgan dysfunction developed despite broad-spectrum antibiotics and EUS-guided biliary drainage was proposed. Although EUS access was limited by gastric bulging, puncture of a dilated intrahepatic duct was accomplished with a 19G needle. PCSEMS (GIOBOR™8x100mm) placement was only possible above the gastroesophageal junction with the proximal flare being incidentally deployed in a 3cm intraparietal esophageal tract. The misplaced stent was immediately recanalized and a stent-in-stent FCSEMS (Wallflex™80x10mm) allowed the hepaticoesophagostomy creation. Since the stent opening was orally oriented in esophageal lumen, parenteral nutrition was started to avoid contamination. Sepsis recovering and liver tests normalization were observed. Before hospital discharge stent reposition was planned to resume oral feeding. After placement of a third stent-in-stent NCSEMS (Wallflex™120x10mm) in the hepaticoesophagostomy to prevent migration, the proximal flare was oriented to the stomach gently pushing with the endoscope aiding by an inflated biliary balloon. The patient resumed chemotherapy but died 8 months after due to disease progression. Isolated bile duct metastasis is an uncommon complication of colorectal cancer. EUS-guided hepaticoesophagostomy is feasible when puncture through the esophagus was inevitable, especially in patients with liver hypertrophy.

Giant Uterine Leiomyoma Causing Severe Hemodynamic Instability

BACKGROUND: Uterine leiomyomas occasionally manifest as giant leiomyomas, displaying exceptional sizes within the uterus and abdominal cavity. These massive growths, although rare because of increased patient awareness, can severely distort pelvic structures and pose life-threatening complications by compressing adjacent organs. We report a case of a patient who presented with severe hemodynamic instability, cardiac arrest, and multiorgan failure caused by a giant 54.8-kg uterine leiomyoma, representing the heaviest weight ever reported in the literature in surviving patients so far. CASE: This article documents a case of a 56-year-old woman with a giant uterine leiomyoma in critical condition characterized by multiorgan failure and acute kidney injury necessitating urgent surgical intervention. A laparotomy and subsequent total abdominal hysterectomy were performed. Histopathologic examination revealed a giant uterine leiomyoma. Postoperatively, the patient underwent intensive care management followed by rehabilitation, exhibiting significant clinical recovery. CONCLUSION: Managing giant uterine leiomyomas demands a multidisciplinary approach, emphasizing tailored treatment strategies and specialized surgical expertise. The case report describes one of the largest leiomyomas in the literature, underscoring its rarity, and highlights the significance of timely diagnosis and appropriate interventions.

Multiorgan Dysfunction and its Association With Congestion and Outcome in Aortic Stenosis Treated WithTAVI.

Degenerative severe aortic stenosis (AS) is treated by valve replacement to improve outcome. Despite diagnostic advancements, many AS patients are still diagnosed late with advanced heart failure. The aim of the study was to assess multiorgan dysfunction in severe AS using blood biomarkers and their association with quantitative fluid levels and clinical outcomes after transcatheter aortic valve implantation (TAVI). Consecutive AS patients undergoing TAVI received comprehensive preinterventional assessment with serum biomarker profiles reflecting organ dysfunction and quantitative fluid overload (FO) using bioelectrical impedance spectroscopy. FO by bioelectrical impedance spectroscopy was defined according to a previously established cut-off (≥1.0 L). Time to first heart failure hospitalization or death served as composite primary endpoint. Among 880 patients (age 81 ± 7years, 47% female), 41% had FO and 89% had biomarker abnormalities of at least one domain. Ascending fluid levels were independently associated with distorted biomarkers across domains of myocyte stress, hepatic dysfunction, renal dysfunction, inflammation, and anemia. After 2.4±1.0years of follow-up, 27% had reached the primary endpoint (29 heart failure hospitalization, 194 deaths, 13 both). Biomarkers across all domains were individually and independently associated with outcomes. In a multidomain approach, every affected extra-cardiac domain was associated with a 71% increase in event hazard (adjusted HR: 1.71; 95%CI: 1.39-2.11). Also, for each domain, the combination of distorted biomarkers and FO had the highest event risk. Biomarker abnormalities are highly prevalent in severe AS, influenced by congestion, and associated with impaired prognosis post-TAVI. Multiorgan dysfunction faces a particularly dismal outcome.