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Severe gastroparesis: case report A 68-year-old man developed severe gastroparesis while receiving immunosuppressive therapy with tacrolimus, mycophenolatemofetil and prednisolone following orthotopic heart transplantation. The man who had a history of non-insulin-dependent diabetes mellitus, chronic kidney disease, an inguinal hernia and ischaemic cardiomyopathy, presented with mild symptoms of abdominal pain, postprandial malaise and lack of appetite. Three months prior to the presentation, he had undergone orthotopic heart transplantation, and had been receiving immunosuppressive therapy with tacrolimus, mycophenolate mofetil and prednisolone. The dosage of tacrolimus at the time of discharge following the procedure was 14mg once daily for the maintenance of trough levels in the target range of 12–15 ng/mL. During cardiac rehabilitation, he developed gastrointestinal symptoms. His clinical examination showed abdominal distension, exsiccosis, cachexia and absent bowel sounds. However, no signs of inguinal incarceration were noted. His laboratory tests showed: tacrolimus trough level of 18.0 ng/mL, glucose of 134 mg/dL, haemoglobin of 10.5 g/dL, creatinine of 2.3 mg/dL, HbA1c of 5.7%, leucocytes of 8.6 G/L, glomerular filtration rate of 28.0 ml/min/1.73m2 and CRP of 0.1 mg/dL. ECG showed regular biventricular graft function. Rejection was not noted during prior endomyocardial biopsies. Abdominal-CT scan showed severe gastric enlargement with a calculated volume of 5088cm3. Aspiration of his gastric contents was attempted via a nasogastric tube, which failed. Therefore, he underwent gastroscopy under general anaesthesia with laryngotracheal intubation, and several liters of undigested chyme was removed from the gastric corpus. On the following day, gastroscopy was repeated for the extraction of reaming chyme. On the same day, he was extubated. His nasogastric tube was kept for two days, and he was started on light enteral nutrition. CT-scans performed prior to the orthotopic heart transplantation were reviewed, which showed a regularly sized stomach with no evidence of external pyloric compression. Review of his medications showed requirement of higher doses of tacrolimus (19 mg/day) for the maintenance of trough levels in the target range. Based on the examinations, gastroparesis possibly related to the immunosuppressive regimen (tacrolimus, mycophenolate mofetil and prednisolone) was considered. Consequently, the man’s tacrolimus therapy was changed to cyclosporine, and he also received unspecified prokinetic agents. Additionally, examinations showed impaired gastric emptying. Within five days, his symptoms recovered. Repeat examinations showed normal results. During follow-up examination after three months, not residual symptoms were noted. Angleitner P, et al. Severe gastroparesis after orthotopic heart transplantation. European Journal of Cardio-Thoracic Surgery : 15 Sep 2020. Available from: URL: http:// 803507672 doi.org/10.1093/ejcts/ezaa309

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