Antonio Capel

Comparative study of right portal vein ligation versus embolisation for induction of hypertrophy in two-stage hepatectomy for multiple bilateral colorectal liver metastases

AIM In patients with two-stage hepatectomy (TSH) for multiple bilobar liver metastases from colorectal cancer, few clinical series compare functional remnant hypertrophy of the liver volume between right portal vein ligation (PVL) and embolisation (PVE). Our objective is to analyse the effectiveness of portal vein ligation to achieve hypertrophy of the functional remnant volume (FRV) of the liver and to compare the results with portal vein embolisation in a series of patients with multiple bilobar liver metastases from colorectal carcinoma. PATIENTS AND METHODS Between September 2001 and September 2011 we performed a TSH in 41 patients with multiple bilobar colorectal liver metastases. A right PVL was performed in 23 patients with an insufficient FRV (three patients did not complete the second stage due to tumour progression and were excluded). We prospectively compare these results with the increased remnant volume obtained in 18 patients with right PVE. RESULTS The median FRV was higher in the patients with PVE, rising from 501 ml (range 309-703) to 636 ml (range 387-649), than those with PVL, rising from 510 ml (range 203-824) to 595 ml (range 313-1213) (p < 0.05). The median %FRVI was higher in the patients with PVE (median 40%; range 21-65%) than those with PVL (median 30%; range 21-60%) (p < 0.05). CONCLUSIONS PVL and PVE were effective in all cases for obtaining hypertrophy of the FRV before major liver resection. Right PVE obtains better results and should be used where necessary to achieve a further increase in volume.

Cálculo del volumen hepático mediante TC espiral: utilidad en la planificación de la resección hepática mayor en pacientes no cirróticos

Resumen Introduccion Mediante tomografia computarizada (TC) espiral es posible estimar la extension de la reseccion hepatica preoperatoriamente y seleccionar a los pacientes que presentan mayor riesgo de insuficiencia hepatica posquirurgica. El objetivo de este estudio es determinar de forma prospectiva la utilidad de la estimacion del volumen hepatico residual (VHR) mediante TC espiral en la planificacion de la reseccion hepatica mayor (RHM) en pacientes no cirroticos. Pacientes y metodo Entre septiembre de 2000 y marzo de 2003 se calculo el volumen hepatico total (VHT) y el VHR en 31 pacientes como parte de la planificacion preoperatoria de una RHM. En los pacientes con un porcentaje de VHR/VHT menor del 25% se realizo una oclusion portal derecha preoperatoria. Resultados En 7 pacientes, el porcentaje de VHR/VHT fue menor del 25%. En 2 posibles donantes vivos la reseccion estaba contraindicada. En los 5 restantes, tras la oclusion portal se consiguio suficiente hipertrofia del higado izquierdo para indicar la RHM. Conclusion La medida del VHR afecto a la decision quirurgica, al seleccionar los pacientes en los que es posible realizar una reseccion segura. En caso de quedar escaso higado residual, las tecnicas de embolizacion preoperatoria o ligadura intraoperatoria de vena porta han resultado ser un buen procedimiento para incrementarlo.

Tetralogía de Fallot en el adulto complicada con hemoptisis grave. Tratamiento mediante embolización de la arteria tirocervical izquierda

La tetralogia de Fallot con atresia pulmonar constituye una situacion especial en la que se permite la supervivencia hasta la edad adulta. En estos casos se desarrollan complicaciones, como la hemoptisis, que comprometen la vida del paciente y tienen dificil tratamiento. Cuando la causa del sangrado es la rotura de cortocircuitos arteriovenosos, frecuentes en las malformaciones vasculares multiples que se originan en esta cardiopatia, la embolizacion selectiva de estas malformaciones puede ser una opcion eficaz de tratamiento.

The evolution of therapeutic strategies for biliary tract complications after liver transplantation over a period of 20 years.

Despite the improved overall outcomes of liver transplantation as a result of advances in surgical techniques and improved immunosuppressive control, biliary complications (BCs) continue to be the most common cause of morbidity in liver transplant recipients. The objectives of this study were to analyze the incidence, type, and management of BCs over a 20-year period. We performed a comparative study of two groups of liver transplant patients in our unit operated on by the same surgical team: group I consists of the first 300 liver transplant patients (1989-1992), and group II is composed of the last 300 liver transplants (2007-2011). We found no significant differences in the number of cases of biliary leakage whether or not a Kehr T-tube was used. However, there was a significant relationship between a greater number of anastomotic strictures and less use of a Kehr T-tube. In our series, there has been a decrease over the years in the number of surgical interventions required to resolve these complications and an increase in radiologic and endoscopic treatment.

Quimioembolización previa a la resección hepática laparoscópica en el carcinoma hepatocelular precoz en pacientes cirróticos

OBJECTIVE To assess whether preoperative transarterial chemoembolisation (TACE) reduces haemorrhage during laparoscopic resection, thus making the Pringle manoeuvre unnecessary and avoiding any subsequent complications. PATIENTS AND METHODS We present 3 cirrhotic Child A patients with early hepatocellular carcinoma, all of whom had been given the same treatment involving resection by laparoscopy and preoperative TACE of the segments to remove. All the nodules were located in the right hepatic lobe. One case was treated using total laparoscopic surgery and the two remaining cases were converted to the hand-assisted technique. In the first case we carried out bisegmentectomy VI-VII; in the second, segmentectomy VI plus radiofrequency of a second nodule in segment VII, and in the third case, segmentectomy V. RESULTS There was no morbidity or mortality. Blood transfusion was not required by any of the patients; in fact blood losses were 100, 50 and 150 ml, respectively, and it was not necessary to carry out the Pringle manoeuvre. Surgical margin was greater than 1cm in the three cases and hospital stay was less than 3, 3 and 4 days, respectively. CONCLUSION TACE prior to early hepatocellular carcinoma resection in cirrhotic patients seems to improve surgical safety with low blood losses without the use of the Pringle manoeuvre. Prospective random studies should be carried out on a larger number of patients in order to assess this technique.

Successful embolization of a cytomegalovirus-related duodenal ulcer in a kidney-pancreas transplant recipient

One of the complications that can occur in pancreas transplant is a massive intestinal hemorrhage, although such a hemorrhage is very rarely caused by ulcers due to cytomegalovirus infection. Treatment is fundamentally based on relaparatomy, although in some cases interventional radiology can be an efficient alternative because it allows the exact bleeding point to be located and therapeutic embolization to be performed. In this case, a man with diabetes type 1 who was given a simultaneous kidney-pancreas transplant had an ulcer due to cytomegalovirus infection develop in the duodenal graft (in the early postoperative period), causing a severe hemorrhage in the lower part of the gastrointestinal tract that was controlled via selective embolization of a branch of the pancreaticoduodenal artery.