Alejandro Mejia

Changing Pattern of Access Site Complications with the Use of Percutaneous Closure Devices

The authors report their experience with 15 cases of groin complications associated with the use of percutaneous closure devices following femoral arterial catheterization over a 2-year period. The complication rate was 1.7% for catheterizations in which a closure device was used. The 15 cases included 7 uncomplicated pseudoaneurysms (PSA), 3 infected pseudoaneurysms, 4 nonarterial groin infections (infected hematomas and/or abscesses), and 1 case of femoral artery occlusion. These complications presented at an average of 5 ±4 days postcatheterization. One patient with an infected PSA required a below-the-knee amputation. During the same time interval, there were no infectious complications in patients not receiving closure devices. We conclude that groin complications associated with such devices tend to present late and include a higher percentage of infections as opposed to complications occurring in patients not receiving closure devices. An aggressive surgical approach to these problems appears warranted.

Endovascular AAA repair in a patient with a horseshoe kidney and an isthmus mass.

PURPOSE To report the endovascular exclusion of an abdominal aortic aneurysm (AAA) in a patient with a horseshoe kidney and an isthmus mass with preservation of accessory renal vessels. CASE REPORT A 70-year-old man with a 5-cm AAA and renal cell carcinoma involving a horseshoe kidney was treated with an AneuRx bifurcated graft. Two accessory renal arteries believed to feed the isthmus mass were sacrificed, but 2 other accessory renal arteries from the left common iliac artery (CIA) were preserved by using an extension cuff to cover the aneurysmal left CIA distal to their origins. The right renal isthmus mass decreased in size on follow-up imaging. At 9 months, there was no endoleak evident on computed tomographic scans, and the aneurysm measured 4.8 cm. CONCLUSIONS The presence of accessory renal arteries in AAA patients with horseshoe kidneys should not automatically exclude them from consideration for endovascular repair. Creative stent-graft arrangements can be a treatment option.

Living and deceased donor liver transplantation for unresectable hepatoblastoma at a single center

Abstract:  Hepatoblastoma (HB) is the most common malignant liver tumor in children. The application of living donor liver transplantation (LDLT) in the management of unresectable HB may add new therapeutic opportunities. We evaluated the outcomes of patients who underwent liver transplantation for treatment of unresectable HB in the period between August 1985 and June 2003. Ten children had a diagnosis of unresectable HB. Mean age at transplantation was 5.8 yr. Eight patients were transplanted with deceased donor grafts. Two patients underwent LDLT. Pre‐transplant chemotherapy was used in 90% of cases. Post‐transplant survival ranges from 3.7 to 18.6 yr. Three patients died of recurrent disease at 4, 14 and 38 months. The two LDLT recipients were able to get pre‐transplant chemotherapy with a rapid decision towards transplantation; both are alive and well at 5.5 and 11 yr post‐transplant. Our experience supports the role of LDLT and deceased donor liver transplantation in the management of unresectable HB when waiting times can be detrimental to the patients survival.

Outcome of liver transplantation in Hispanics versus non-Hispanics: Is there a difference?

IN THE PAST DECADE 10% of orthotopic liver transplant (OLT) recipients in the United States have been of Hispanic origin. Little has been reported regarding OLT outcomes in reference to recipient ethnic origin. Differences in outcome have been shown in renal transplant graft survival of African-American recipients when compared to Caucasians. Differences in outcome of other organ transplants relative to ethnicity have never been clearly proven. At our center more than 50% of OLT recipients are from Hispanic origin, and it is of our particular interest to establish any ethnic difference in graft or patient survival if present. To determine the differences in outcome of the Hispanic (H) group versus the non-Hispanic group (NH), we analyzed our experience for the past 5 years.

Nonfatal intracardiac thromboembolism during liver transplantation.

I n NTRACARDIAC THROMBOEMBOLISM is a severe complication that can occur during orthotopic liver translantation (OLT). The risk for thromboembolic complicaions in this setting is related to several factors such as xcessive activation of the coagulation system, venous stais, activators released form the grafted liver, and massive lood transfusions.1 The authors report a case of a nonfatal ight atrial thrombus during the native hepatectomy of a irrhotic patient undergoing OLT in which no antifibrinoytics, anticoagulants, thrombolytics, or embolectomy were ecessary.

Liver Transplantation for Hepatocellular Carcinoma (Hcc)

Hepatocellular carcinoma (HCC) is the third most common cause of cancer mortality worldwide and accounts for 20% of all liver transplants (Wigg, 2010). Its incidence has increased two fold in the last decade and it is the fifth leading cause of cancer in males. The availability of liver transplantation as a cure for chronic liver disease and the demonstration of outcomes exceeding 70% at 5 years after transplantation for HCC have pushed the field to refine this therapy in order to utilize this precious resource in the most effective, fair and safe manner. The combination of a rising incidence of HCC and a flat donor procurement rates has resulted in longer waiting times in many areas. The complex decision making and management issues of patients with HCC, cirrhosis and possibly undergoing oncological therapies while waiting for an organ transplant poses challenges to the management team, not encountered in any other clinical or surgical field.

Bile duct obstruction after cholecystectomy caused by clips: undo what has been undone, then do what you normally do

The overall frequency of operative bile duct injury (OBDI) has not substantially decreased, and the incidence of major bile duct injury during laparoscopic cholecystectomy remains about 0.5%. The consequences of OBDI can be devastating, with risks for major morbidity, costly medical care, liability risk, and even fatal outcomes. The most serious OBDI is a complete duct transection for which surgical treatment is obligatory. Complete obstruction caused by clips placed on the common duct has been considered a similar injury with regard to severity and its need for surgical therapy. We report a case that was treated by removing the clips at laparotomy followed by endoscopic stenting.

Use of split-liver allografts does not impair pediatric recipient growth

The use of split‐liver (SL) allografts continues to be an excellent option for many pediatric recipients. Patient and graft survival with this graft type are comparable to patient and graft survival with whole organ grafts. Quality‐of‐life issues, specifically growth, for SL recipients have not been compared to those of recipients of more conventional whole‐organ recipients. Pediatric recipients of SL and whole allografts at 2 institutions were identified. Height, z score, and delta z score were calculated for all recipients for each year after transplant. Between 1995 and 2004, 201 pediatric liver transplants were analyzed. Data were collected on 39 split‐graft recipients and 36 whole‐size recipients. Only subjects 3 years or younger were included in the study. Growth retardation was present in all recipients at transplant. Height z score post split and whole‐size transplant were not statistically different at 1‐ (P = 0.65), 2‐ (P = 0.13), and 3‐year (P = 0.32) anniversaries, respectively. Catch‐up growth was present only in recipients of split grafts. In conclusion, the use of split grafts as opposed to whole‐size grafts revealed no significant differences in terms of linear growth. Our report indicates that split‐liver transplantation does not impair recipient growth. Liver Transpl, 2006.

Recurrent cholangitis due to intraductal papillary mucinous neoplasm of a cystic duct remnant

re 1. A, EUS image of a thickened common bile duct (CBD) with hypoechoic wall thickening. B, Endoscopic view of cholangioscope and guidewire ulation of bile duct. C, Fluoroscopic view of cholangioscope in cystic duct. D, Cholangioscopic view of cystic duct remnant showing a villous tumor numerous frondlike projections. E, Intraoperative view of laparoscopic robotic excision of the cystic duct with primary closure of the common bile F, Histologic view of cystic duct remnant showing intraductal papillary mucinous neoplasm with low-grade to intermediate-grade intraepithelial lasia (H&E, orig. mag. 40).

Selective internal radiation therapy using yttrium-90 resin microspheres in patients with unresectable hepatocellular carcinoma: a retrospective study

Background Selective internal radiation therapy (SIRT) with yttrium-90 resin (Y-90 resin) microspheres has been used as a locoregional therapy for patients with unresectable hepatocellular carcinoma (HCC). We examined patient and disease characteristics that might affect survival after Y-90 resin, as well as treatment tolerability. Methods Data from patients with unresectable HCC treated with Y-90 resin at a single institution were reviewed retrospectively. Survival was assessed with Kaplan-Meier curves and log-rank tests. Response was evaluated with the response evaluation criteria in solid tumors (RECIST) criteria. Adverse events (AEs) were noted, and laboratory values were graded with CTCAE v3.0. Results Data from 111 patients were analyzed. AEs occurred in 23 patients at 1 week after treatment and in 46 at 3 months. At 6 months, 13 patients had a complete response and 13 had a partial response. Factors associated with longer overall survival (OS) included early-stage disease [27.8 months for patients with Barcelona-Clinic Liver Cancer (BCLC) A vs. 9.2 months for BCLC C]; treatment with other locoregional therapies (69.0 vs. 11.4 months); and lack of bilobar disease (23.5 vs. 9.4 months), portal vein thrombosis (16.2 vs. 8.6 months), ascites (16.6 vs. 10.3 months), and treatment with sorafenib (17.2 vs. 10.3 months). In six patients, Y-90 resin was used as a bridge to liver transplantation, which greatly improved survival (69.0 vs. 12.1 months). Conclusions Several characteristics may prove useful for selecting patients likely to respond well to Y-90 resin. These results should be confirmed in prospective studies.