P. Ramirez Romero

Fracaso hepático fulminante y trasplante hepático. Experiencia del Hospital Virgen de la Arrixaca

Introduccion El tratamiento medico del fracaso hepatico fulminante busca la recuperacion espontanea de la funcion hepatica, pero sus resultados son muy desalentadores (mortalidad del 50-80%). El trasplante hepatico es una opcion en los pacientes con mala evolucion a pesar del tratamiento medico, con una supervivencia superior al 50%. El momento idoneo para efectuar el trasplante es discutido, pues no debe hacerse ni demasiado pronto, cuando la enfermedad hepatica aun es reversible, ni demasiado tarde, cuando el paciente se encuentra en una situacion clinica irreversible. Pacientes y Metodo Se revisaron de forma retrospectiva las historias clinicas de 34 pacientes ingresados en nuestro hospital con el diagnostico de fracaso hepatico fulminante, de los que 26 fueron sometidos a trasplante. La causa mas frecuente fue la viral con 10 casos (38%), sin que se pudiera establecer etiologia alguna en 11 casos (42%). Trece pacientes presentaron complicaciones preoperatorias, la mas frecuente de las cuales fue la insuficiencia renal. Segun el grado de compatibilidad ABO/DR, fueron identicos en 13 casos (40%), compatibles en 17 (51%) e incompatibles en los 3 casos restantes (9%). Resultados Se efectuaron 33 trasplantes en 26 pacientes: 4 fueron retrasplantados por rechazo cronico, dos por fallo primario del injerto y un caso por rechazo hiperagudo. La mortalidad global fue del 46% (12 pacientes), y la causa mas frecuente de fallecimiento fue la infecciosa (50%). La supervivencia actuarial global fue del 68% al ano, del 63% a los 3 anos y del 59% a los 5 anos. Los factores de mal pronostico fueron la insuficiencia renal y respiratoria, el electroencefalograma grado D y los grados de encefalopatia III y IV; este ultimo fue el unico factor pronostico segun el analisis multivariante. Los factores pronosticos de mortalidad fueron los hallazgos de un electroencefalograma grado D, los grados de encefalopatia III y IV y la insuficiencia respiratoria; este ultimo fue el unico factor pronostico segun el analisis multivariante. Conclusiones La obtencion de buenos resultados con el empleo del trasplante en el abordaje del fracaso hepatico fulminante depende de una optima seleccion de los candidatos a trasplante, lo que implica la identificacion temprana de los mismos, esto es, precocidad en la indicacion del trasplante, reduccion del tiempo medio de espera y exclusion de aquellos con factores de mal pronostico.

Laparoscopic Treatment of Biliary Peritonitis after Removal of T-Tube in Liver Transplant Patients

INTRODUCTION T-tube removal in liver transplant patients can occasionally cause a massive biliary leak and may require surgical treatment for its resolution. We present our experience with a laparoscopic approach to biliary peritonitis in liver transplant patients after the removal of a T-tube. PATIENTS AND METHODS From January 2003 until February 2010, we performed 351 liver transplantations in 313 recipients, including 135 with a T-tube. After its removal 31 biliary leaks developed (23%); 12 were massive and required surgery, which utilized a laparoscopic approach. RESULTS The mean length of the intervention was 72.9 ± 12.87 minutes (range = 55-95), without any complications during the procedure, and no need to convert to a laparotomy. Mean hospital stay after the intervention was 6.75 ± 3.88 days (range 4-18). There was no mortality from the procedure. CONCLUSION The laparoscopic approach for biliary leakage after T-tube removal is indicated when large diffuse acute peritonitis is established a few hours postremoval of the T-tube. This safe procedure treats the complication without the need for another laparotomy.

Tolerancia y quimerismo en el trasplante hepático

Advances in immunosuppressive therapy have greatly impacted on the successful outcome of organ –and most particularly liver– transplantation. With the introduction of new immunosuppressants the incidence of acute rejection has considerably decreased, and transplanted patient survival is now 83% and 70% after 1 and 5 years, respectively (1). However, toxicity associated with these drugs is significant, and induces the development of blood hypertension, hyperlipidemia, diabetes, renal failure, and de novo tumors in transplanted patients (2,3). As a result, and to improve immunosuppressive therapy efficacy and specificity, a greater insight into the mechanisms of primary allogeneic response to foreign antigens, and into the mechanisms of antigen-specific tolerance is crucial to help avoid or decrease immunosuppressant use as much as possible. It is a well known fact that liver transplants may be performed with no immunosuppression among animal species such as pigs, and selected rat and mouse combinations (4-6). This fact, and the possibility of completely avoiding immunosuppressants in selected patients with liver transplant (7-10), lead both to consider the liver an immunologically privileged organ (11) that may be tolerated with less immunosuppression after transplantation; immunosuppressants can be even completely withdrawn on occasion (operational tolerance) (12). Experimental data support the notion of induced tolerance in humans undergoing organ transplantation. While tolerance is an ideal goal, heterogeneity in potential donor-receiver combinations, the receiver’s immune status and underlying disease, and the unforeseeable consequences of infection render stable tolerance an extremely challenging objective for all patients (13). Tolerance in transplantation would be the lack of immune response to alloantigens (foreign antigens) in the transplanted organ in the absence of immunosuppression (14). Immune tolerance is the absence of response to an encountered antigen, and is therefore an active phenomenon (15). Tolerance to self antigens, as is the case with tolerance to alloantigens, is a function of the immune system. Mechanisms involved in tolerance to transplanted organs are complex and partly unknown. The goal of this review is to describe mechanisms involved in tolerance, particularly in the setting of liver transplantation, and to highlight the role of cell chimerism and immunoregulation phenomena in tolerance development.

Choledochoscopy Reduces Unnecessary Papillary Surgery

We present 200 patients, from the period January 1988 to July 1990, who received surgery for biliary lithiasis and required opening of the common bile duct. The patients were divided into two groups a

Correlation of Computed Tomography Findings in Gastric Carcinoma with Surgical and Pathological TNM Stage

The purpose of our study was to assess the value of CT in the preoperative staging of 40 patients with gastric cancer and correlate the CT findings with surgical and pathological findings. The average

Assessment of Gastroesophageal Reflux following Heller’s Myotomy Associated with a 270° Posterior Partial Fundoplication

By means of clinical, endoscopic, manometric and pH metric studies, the incidence of gastroesophageal reflux in 30 patients with achalasia of the cardia was evaluated at least 5 years after undergoing