Juan José Vila

Long-gap esophageal atresia: reconstruction preserving all portions of the esophagus by Schärli's technique

Abstract For distances of over 4–5 cm, esophageal replacement is almost always necessary in esophageal atresias. We present the technical details and describe our experience with esophageal reconstruction by elongation of the lesser curvature (Schärlis technique) in four cases of very long atresias. A retrosternal transposition was made without a thoracotomy in two children, and an orthotopic mediastinal route through a right thoracotomy was done in two others. There were two main complications: anastomotic leaks in three patients that closed spontaneously, and too-rapid gastric emptying, resulting in dumping symptoms that improved with time and diet. One patient developed an anastomotic stricture that responded to bouginage, while another had temporary feeding problems. Esophageal reconstruction by elongation of the lesser curvature provides a relatively simple method of esophageal replacement in children in that all portions of the esophagus are preserved. We propose this technique for early establishment of esophageal continuity in neonates.

Predicting Early Transplant Failure: Neural Network Versus Logistic Regression Models

Coxs proportional hazard model or logistic regression model has been the classical mathematical approach to predict transplant results, but artificial neural networks may offer better results. In order to compare both methods, a logis- tic regression and a neural network model were generated to predict early transplant failure assessed at 90 days. Methods: Medical charts from 701 liver transplant patients were used as generation cohort, collecting variables from do- nor, recipient and operative data. The discrimination capacity of the models was measured through the area under their ROC curves. Models were validated by applying them to a second cohort of 170 patients (validation cohort), although af- terwards it was enlarged to 246 patients in order to increase statistical power. Results: For the generation sample, ROC curves were 75% for logistic regression and 96% for neural network (� 2 = 44,60. p<0,00001). Applied to the whole validation sample these values dropped to 68.7 % for logistic regression and 69.9 % for neural network (� 2 = 0.026. p: 0,87). However, when models where applied to the validation cohort in cumulative groups of 50 patients two aspects became evident: 1) predictions worsened for patients who were more distant in time from the generation cohort; 2) for the first hundred patients in validation cohort, neural network was clearly superior to logistic re- gression model (93 % vs 76 %; � 2 = 10.52. p:0,001). Conclusions: Our results suggest that, provided with the same information and for a limited period of time, neural net- works may offer better diagnostic performances than with logistic regression models.

Trasplante celular hepático: un nuevo tratamiento en las enfermedades hepáticas

Liver transplantation has been remarkably effective in the treatment in patients with end-stage liver disease. However, disparity between solid-organ supply and increased demand is the greatest limitation, resulting in longer waiting times and increase in mortality of transplant recipients. This situation creates the need to seek alternatives to orthotopic liver transplantation.Hepatocyte transplantation or liver cell transplantation has been proposed as the best method to support patients. The procedure consists of transplanting individual cells to a recipient organ in sufficient quantity to survive and restore the function. The capacity of hepatic regeneration is the biological basis of hepatocyte transplantation. This therapeutic option is an experimental procedure in some patients with inborn errors of metabolism, fulminant hepatic failure and acute and chronic liver failure, as a bridge to orthotopic liver transplantation. In the Hospital La Fe of Valencia, we performed the first hepatocyte transplantation in Spain creating a new research work on transplant program.

Surgical anterior cavoplasty for managing a case of early acute outflow obstruction after liver transplantation

HVOO following liver transplantation is rarely treated surgically because it tends to debut subacutely. However, acute HVOO is a surgical emergency that compromises the viability of the graft. We report a case of HVOO diagnosed intra‐operatively during surgical revision for a suspected arterial thrombosis in a 10‐month‐old male recipient of a second graft (segments II–III) for familial intrahepatic cholestasis. HVOO was related to a stenosis at the first transplant hepato‐caval anastomosis, left in place to obtain longer venous cuffs for retransplantation. An anterior cavoplasty was necessary to resolve the issue. The new anastomosis was created under total vascular exclusion after gaining control of the supradiaphragmatic vena cava, because the inferior vena cava was unsuitable for further surgery. This approach (normally used as a means to avoid sternotomy in patients with hepatic or renal tumours associated with venous thrombosis) allows adequate vascular control and, in selected cases, offers a surgical alternative for treating HVOO.

Surgical Findings in Transfusion-Associated Necrotizing Enterocolitis.

Introduction The extent of intestinal damage in transfusion-associated necrotizing enterocolitis (TNEC) has been scarcely studied. The aim of this investigation was to study surgical findings in TNEC and determine their severity considering the extent of the disease and risk of bowel perforation. Materials and Methods Neonates who required surgical treatment for necrotizing enterocolitis (NEC) were studied retrospectively. Patients who developed NEC within 48 hours after a red blood cell transfusion (RBCT) formed group TR48 and patients who did not receive a RBCT 48 hours before the diagnosis of NEC became group CN (conventional NEC). Both groups were compared: main outcomes were the extent of the disease (isolated, multifocal, or panintestinal), the existence of perforated NEC, and mortality. Categorical variables were analyzed with the chi-square test and continuous variables with the Mann-Whitney u-test. The relationship between RBCTs 48 hours before the diagnosis and the extent of intestinal disease was evaluated by ordinal logistic regression. Results Forty-seven patients were included in the study: 16 patients in TR48 and 31 in CN. The odds ratio of multifocal or panintestinal NEC for patients in TR48 was 0.5 (95% CI: 0.148-1.68). Neonates in TR48 had a relative risk (RR) of perforated NEC of 1.2 (95% CI: 0.76-1.85). The RR of death was 1.55 (95% CI: 0.76-3.14) in group TR48. Conclusion No differences in surgical findings between TR48 and CN could be demonstrated in this investigation; therefore, the hypothesis that intestinal damage might be more severe in TNEC was not confirmed.

[Hepatic cell transplantation: a new therapy in liver diseases].

Abstract Liver transplantation has been remarkably effective in the treatment in patients with endstage liver disease. However, disparity between solid-organ supply and increased demand is the greatest limitation, resulting in longer waiting times and increase in mortality of transplant recipients. This situation creates the need to seek alternatives to orthotopic liver transplantation. Hepatocyte transplantation or liver cell transplantation has been proposed as the best method to support patients. The procedure consists of transplanting individual cells to a recipient organ in sufficient quantity to survive and restore the function. The capacity of hepatic regeneration is the biological basis of hepatocyte transplantation. This therapeutic option is an experimental procedure in some patients with inborn errors of metabolism, fulminant hepatic failure and acute and chronic liver failure, as a bridge to orthotopic liver transplantation. In the Hospital La Fe of Valencia, we performed the first hepatocyte trasplantation in Spain creating a new research work on transplant program.

Endoscopic Cauterization with Pneumatic Distension for Piriform Fossa Sinus Tracts

INTRODUCTION Piriform fossa sinus tracts (PFSTs) are a cause of recurrent neck infections in the pediatric population. Conventional management required open resection, but over the last years minimally invasive approaches have been reported in an attempt to endoscopically obliterate the PFST, using different methods such as electrocautery, laser, trichloroacetic acid, or silver nitrate. MATERIALS AND METHODS We undertook a retrospective review of the medical records of 12 children (aged 4 months to 14 years) with PFSTs treated with endoscopic sclerosis with diathermy (ESD) between 2010 and 2016 at a tertiary care childrens hospital. We also present a technical modification of ESD, using continuous infusion of airflow through the gastroscopy, to distend the piriform sinus and facilitate its recognition. PFST obliteration was performed using diathermy through a guide wire. RESULTS Clinical presentation of the 12 affected children included neck tumor (7 [58%]), neck abscesses (4 [33%]), and thyroiditis (5 [41%]). All lesions occurred on the left side. All patients underwent both ultrasonography and barium esophagography (the latter being positive only in 50%). Two patients were treated with ESD after the open approach had failed. There was no procedure-related morbidity. One patient had a recurrence (positive barium swallow without symptoms). The success rate of this procedure in our series was 91% with one attempt and 100% with two attempts. CONCLUSION In our experience, treatment of PFST with ESD is a reproducible, noninvasive, and an effective option. ESD could be considered a primary approach and also for revision after open surgery has failed in these patients.

Role of Intraluminal Esophageal Impedance Baseline in the Diagnosis of Esophagitis in Children

Introduction Low values of esophageal impedance baseline (EIB) have been related to esophagitis. The aim of this study was to evaluate the diagnostic performance of EIB for erosive esophagitis (ErE) and histological esophagitis (HiE) in children studied for gastroesophageal reflux. Material and Methods Children who underwent esophageal multichannel intraluminal impedance‐pH monitoring (MII‐pH) and upper‐endoscopy with esophageal biopsies were studied retrospectively. EIB values were obtained by MII‐pH. ErE was assessed by endoscopy following the Hetzel‐Dent classification; HiE was defined by basal zone hyperplasia, papillary lengthening, or inflammatory infiltration. EIB was compared between groups. Receiver operating characteristic (ROC) curves were obtained to calculate the global diagnostic performance of EIB and to find cut‐off values for sensitivity and specificity. Logistic regression was used for age adjustment. Results Fifty‐one patients were studied: 11 had ErE and 23 had HiE. EIB median values were 1,159 in ErE versus 2,583 in non‐ErE (U = 80, p < 0.01). The adjusted ROC curve analysis for ErE was 0.85 (95% CI = 0.74‐0.96); the EIB cut‐off value = 2,379 determined sensitivity = 100% and specificity = 52.6% in children < 4 years old. and sensitivity = 100% and specificity = 63.2% in children > 4 years old. EIB median values were 1,666 in HiE versus 2,669 in non‐HiE (U = 80, p < 0.01). The adjusted ROC curve analysis for HiE was 0.75 (95% CI = 0.59‐0.90); the EIB cut‐off value = 2,296 determined sensitivity = 71.2% and specificity = 83.1% in children < 4 years old, and sensitivity = 75.1% and specificity = 80.1% in children > 4 years old. Conclusion EIB provides statistically significant diagnostic performances for ErE and HiE. It could become a useful tool, especially to discriminate between ErE and non‐ErE, avoiding other invasive tests.