Rosa Jorba

Management of portal vein thrombosis in liver transplantation: influence on morbidity and mortality

Abstract:  Background:  Splanchnic thrombosis is a surgical challenge in liver transplantation (LT). The aim of this study was to analyze our experience in the management of portal vein thrombosis, and its influence on evolution.

A Double-blind, Placebo-controlled Trial of Ciprofloxacin Prophylaxis in Patients with Acute Necrotizing Pancreatitis

BackgroundThe use of prophylactic antibiotics in acute severe necrotizing pancreatitis is controversial.MethodsProspective, randomized, placebo-controlled, double-blind study was carried out at Bellvitge Hospital, in Barcelona, Spain. Among 229 diagnosed with severe acute pancreatitis, 80 had evidence of necrotizing pancreatitis (34/80 patients were excluded of the protocol). Forty-six patients without previous antibiotic treatment with pancreatic necrosis in a contrast-enhanced CT scan were randomly assigned to receive either intravenous ciprofloxacin or placebo. Five patients were secondarily excluded, and the remaining 41 patients were finally included in the study (22 patients received intravenous ciprofloxacin and 19 patients placebo).ResultsComparing the 22 with intravenous ciprofloxacin and 19 with placebo, infected pancreatic necrosis was detected in 36% and 42% respectively (p = 0.7). The mortality rate was 18% and 11%, respectively (p = 0.6). No significant differences between both treatment groups were observed with respect to variables such as: non-pancreatic infections, surgical treatment, timing and the re-operation rate, organ failure, length of hospital and ICU stays.ConclusionThe prophylactic use of ciprofloxacin in patients with severe necrotizing pancreatitis did not significantly reduce the risk of developing pancreatic infection or decrease the mortality rate. The small number of patients included in this study should be considered.

Efficacy and safety of an early discharge protocol in low-risk patients with upper gastrointestinal bleeding

PURPOSE The outcome of patients with upper gastrointestinal hemorrhage is greatly influenced by recurrence of bleeding, but it may be possible to identify patients who have a low risk for rebleeding, and can be discharged after a short hospitalization. To examine the effect of an early discharge protocol (length of hospital stay < or =3 days), we conducted a 2-year prospective study in patients with upper gastrointestinal bleeding at low risk for rebleeding, as selected by clinical and endoscopic criteria. METHODS During the first year of the study, patients were managed according to the standard criteria by any of six surgical teams (control period). During the second year, patients were managed by only one surgical team under the early discharge protocol guidelines (study period). RESULTS Overall, 488 of 942 (52%) patients were considered as low risk. Early discharge was achieved in 26 of 230 (11%) patients in the control period and in 191 of 258 (74%) in the study period (P <0.001). Age and number of compensated comorbidities did not affect the rate of early discharge. Length of hospital stay was reduced from (mean +/- SD) 6 +/- 2.7 days (control period) to 3 +/- 2.3 days (study period, P <0.001). No differences were observed in rates of rebleeding, need for surgery, readmission or mortality. By contrast, no differences in lengths of stay were observed during that time period among patients admitted with coronary artery disease, colorectal cancer, or acute pancreatitis. CONCLUSION Most patients with upper gastrointestinal bleeding who are at low risk for rebleeding can be discharged early, leading to important cost savings.

Indicaciones y resultados de la cirugía conservadora en las lesiones localizadas en la cabeza pancreática

Resumen Introduccion La cirugia conservadora de la region duodenopancreatica ha quedado bien establecida en pancreatitis cronica (PC) e incluso algunos grupos han comenzado a utilizar estas tecnicas para tratar tumores benignos y de potencial de malignidad incierto. Ahora bien, la complejidad tecnica de este tipo de intervenciones puede ser superior a la de la duodenopancreatectomia cefalica y las complicaciones, incluso mas frecuentes; por lo tanto, las indicaciones estan en debate. El objetivo de este estudio es evaluar la experiencia acumulada en nuestro centro durante los ultimos anos en el empleo de la cirugia conservadora (CC) de la region duodenopancreatica. Material y metodos Desde 1996 a 2006, hemos realizado CC por afeccion localizada en la region cefalica del pancreas en 24 pacientes. Hemos definido CC como cualquiera de las siguientes tecnicas: pancreatectomia cefalica con preservacion duodenal (PCPD), uncinectomia (UC) y enucleacion de tumores quisticos (EN). Resultados . Realizamos PCPD en 20 (83%) pacientes, UC en 1 (4%) y EN en 3 (13%). Los pacientes fueron intervenidos por PC en 11 casos, cistoadenoma seroso en 4, TPMI en 5 y lesiones de estirpe diversa en los 4 casos restantes. En cuanto a la evolucion postoperatoria, la serie presenta una morbilidad del 54%, sin mortalidad postoperatoria. La estancia hospitalaria postoperatoria mediana fue de 11 (7-43) dias. Conclusiones En definitiva, tras analizar la experiencia obtenida en estos anos, y evidenciar una nula mortalidad con morbilidad aceptable, creemos que la utilizacion de tres tecnicas de preservacion de parenquima pancreatico es util mientras estas sean indicadas con rigor. Estudios posteriores deberian ahondar en la mejoria de la calidad de vida y la repercusion fisiologica segun la tecnica empleada.

[Surgical treatment of pancreatic adenocarcinoma by cephalic duodenopancreatectomy (Part 1). Post-surgical complications in 204 cases in a reference hospital].

Abstract Introduction Cephalic duodenopancreatectomy (CDP) is the treatment of choice in cancer of the head of the pancreas. However, it continues to have a high post-surgical morbidity and mortality. The aim of this article is to define variables that influence post-surgical morbidity and mortality after cephalic duodenopancreatectomy due to pancreatic adenocarcinoma (PA) cancer of the head of the pancreas (CHP). Material and methods The variables were prospectively collected form patients operated on between 1991 and 2007, in order to investigate the factors of higher morbidity. Results A total of 204 patients had been intervened due to PA, of whom 57 were older than 70 years. Of these patients, 119 had a CDP, 11 extended lymphadectomy, 66 with pyloric conservation, and 8 with extension to total pancreatectomy due to involvement of the section margin. Portal or mesenteric vein resection was included in 35 cases. Post-surgical complications were detected in 45% of cases, the most frequent being: slow gastric emptying (20%), surgical wound infection (17%), pancreatic fistula (10%), and serious medical complications (8%). Further surgery was required in 13%, and the over post-surgical mortality was 7%. A patient age greater than 70 years, post-surgical haemoperitoneum, gastroenteric dehiscence, and the presence of medical complications were post-surgical mortality risk factors in the multivariate analysis. Pancreatic fistula was not a factor associated with post-surgical mortality. Conclusions Cephalic duodenopancreatectomy is a safe technique but with a considerable morbidity. Patients over 70 years of age must be carefully selected before considering surgery. Serious medical complications must be treated aggressively to avoid an unfavourable progression.

Papel de la cirugia en el manejo de las complicaciones biliares tras el trasplante hepatico

UNLABELLED Management of biliary tract complications (BTC) after liver transplantation (LT) has progressed in recent years. The aims of this study were, to analyse the incidence and management in our institution of BTC after 1000 LT; and to study the management of patients with anastomotic strictures (AS). RESULTS The incidence of BTC was 23%. There were 76 cases of bile leak, 106 cases of anastomotic strictures, 46 non-anastomotic strictures, 42 choledocolithiasis and 19 other complications. Among 106 cases of anastomotic strictures, radiological treatment, either PTC or ERCP, was initially indicated in 62. The AS of 38 patients (33%) were resolved with surgical treatment, 18 of them after a previous attempt at radiological treatment. Patients who were treated initially by radiologically required more procedures. Morbidity and mortality related to BTC were slightly higher in the group of patients treated by radiology (morbidity: surgical: 4 (18%) vs. radiological: 20 (32%); p=0.2 and mortality: surgical: 0% vs. radiological: 8 (11%); p=0.23). Among 46 patients with non-anastomotic strictures, 29 were resolved with retransplantation (63%). CONCLUSIONS Surgery has a significant role in the management of BTC, and is the treatment of choice in some cases of anastomotic strictures. Retransplantation may be the preferred option in patients with non-anastomotic strictures.

Influencia de la aplicación de un protocolo de actuación en el tratamiento de los traumatismos abdominales cerrados

Resumen Introduccion El manejo del traumatismo abdominal cerrado ha variado mucho en los ultimos anos Material y metodos Estudiamos la aplicacion de un protocolo prospectivo a los pacientes con traumatismo abdominal cerrado durante un ano, con el objetivo de evaluar la utilidad del tratamiento no operatorio y su influencia en la morbimortalidad. Todos los pacientes atendidos siguiendo dicho protocolo fueron comparados con un grupo de pacientes previo Resultados Durante el periodo de estudio prospectivo, 65 pacientes fueron ingresados con traumatismo abdominal cerrado (grupo prospectivo [P]). Durante el periodo previo fueron atendidos 77 pacientes (grupo retrospectivo [R]). No hubo diferencias significativas entre ambos grupos en cuanto al sexo, la edad, la escala HIS (Haemodynamic Injury Scale) o el mecanismo de lesion. El 55% de los pacientes del grupo R fue intervenido, mientras que en el grupo P se intervino al 25% (p = 0,0005). Entre los pacientes con lesion esplenica, en el grupo R fue intervenido el 85%, mientras que en el grupo P solo el 50% (p = 0,03). Entre los pacientes con lesiones hepaticas fue intervenido el 70% en el periodo R y solo el 16% en el periodo P (p = 0,05). No hubo diferencias significativas entre los grupos R y P en la estancia hospitalaria, la estancia en UCI, la transfusion y la mortalidad hospitalaria Conclusiones La aplicacion de un protocolo de manejo de los pacientes con traumatismo abdominal cerrado permite el tratamiento no operatorio en la mayoria de los casos sin aumentar la morbimortalidad, la estancia hospitalaria o los requerimientos transfusionales, evitando la morbilidad ocasionada por la propia cirugia

Utilidad de la PET-TC en la estadificación previa a la cirugía por metástasis hepáticas de carcinoma colorrectal

Resumen Introduccion El descubrimiento de enfermedad tumoral no sospechada es frecuente durante la cirugia de pacientes con metastasis hepaticas de carcinoma colorrectal (CCR). El 60% de los pacientes sometidos a una reseccion hepatica “curativa” presenta una recidiva tumoral en los 3 anos siguientes. Estos datos avalan la necesidad de una estadificacion preoperatoria mas precisa. La tecnica de imagen que combina la tomografia por emision de positrones (PET) y la tomografia computarizada (TC) (PET-TC) podria contribuir de manera significativa a una mejor seleccion de los pacientes para la cirugia curativa de las metastasis hepaticas de CCR. Objetivo Establecer la utilidad de la informacion adicional proporcionada por la PET-TC con respecto al estudio radiologico convencional (TC y resonancia magnetica [RM]) en pacientes con metastasis hepaticas resecables de CCR. Pacientes y metodo Entre junio de 2006 y agosto de 2007, se recogieron, de manera prospectiva, los datos de 63 pacientes evaluados para una primera reseccion de metastasis hepaticas de CCR. Se realizo TC, RM y PET-TC a cada paciente: Se intervino a 43 pacientes y a 42 se les realizo hepatectomia. Resultados Los datos aportados por la PET-TC implicaron cambios en la estrategia terapeutica en 9 (14%) pacientes. La nueva informacion fue correcta en 4 (6,4%) casos, falsamente positiva en otros 4 y falsamente negativa en uno. En un analisis lesion por lesion de las metastasis hepaticas resecadas, la sensibilidad y el valor predictivo positivo fueron, respectivamente, del 78,4 y el 96% para la TC-RM y del 55 y el 100% para la PET-TC. Esta ultima tecnica fue superior a la TC-RM para la deteccion de la recidiva local. Conclusiones La PET-TC proporciona informacion adicional util en el 6,4% de los pacientes estudiados para la cirugia de las metastasis hepaticas de CCR. Sin embargo, este porcentaje podria incrementarse con un seguimiento mas prolongado. Por nuestros datos actuales, la PET-TC solo estaria claramente indicada en la estadificacion de pacientes con elevado riesgo de recidiva local.

Role of surgery in the management of biliary complications after liver transplantation

UNLABELLED: Management of biliary tract complications (BTC) after liver transplantation (LT) has progressed in recent years. The aims of this study were, to analyse the incidence and management in our institution of BTC after 1000 LT; and to study the management of patients with anastomotic strictures (AS). RESULTS: The incidence of BTC was 23%. There were 76 cases of bile leak, 106 cases of anastomotic strictures, 46 non-anastomotic strictures, 42 choledocolithiasis and 19 other complications. Among 106 cases of anastomotic strictures, radiological treatment, either PTC or ERCP, was initially indicated in 62. The AS of 38 patients (33%) were resolved with surgical treatment, 18 of them after a previous attempt at radiological treatment. Patients who were treated initially by radiologically required more procedures. Morbidity and mortality related to BTC were slightly higher in the group of patients treated by radiology (morbidity: surgical: 4 (18%) vs. radiological: 20 (32%); p=0.2 and mortality: surgical: 0% vs. radiological: 8 (11%); p=0.23). Among 46 patients with non-anastomotic strictures, 29 were resolved with retransplantation (63%). CONCLUSIONS: Surgery has a significant role in the management of BTC, and is the treatment of choice in some cases of anastomotic strictures. Retransplantation may be the preferred option in patients with non-anastomotic strictures.

Quistes de los conductos biliares del adulto: estrategia quirúrgica

Resumen Introduccion Los quistes de los conductos biliares son una enfermedad muy poco prevalente. Sin embargo, su presentacion clinica es comun a la de otros procesos biliopancreaticos. Presentamos nuestra serie de pacientes intervenidos en los ultimos 15 anos. Material y metodo Se han revisado retrospectivamente las historias clinicas de los pacientes intervenidos por esta enfermedad, en nuestro hospital, entre 1990 y 2002. A partir de 2002, se toman los datos de forma prospectiva hasta 2005. Se han analizado variables de metodos de diagnostico, tecnica quirurgica, morbilidad y mortalidad postoperatoria y seguimiento posterior. Resultados En los ultimos 15 anos se ha intervenido a 18 pacientes (6 varones, 12 mujeres). La presentacion clinica mas comun ha sido el dolor abdominal, seguido del cuadro clinico de colangitis aguda. La tecnica quirurgica ha sido reseccion total del quiste + derivacion biliodigestiva en el 100% de los casos. El diagnostico anatomopatologico ha sido de quiste coledocal en 12 casos, enfermedad de Caroli en 5 casos, quiste coledocal malignizado (adenocarcinoma) en 1 caso. La complicacion postoperatoria mas frecuente ha sido la fistula biliar (3 casos, 16,6%). La mortalidad postoperatoria ha sido del 0%. En el seguimiento tardio, no se ha evidenciado recidiva del quiste en ningun caso (0%). Conclusiones El tratamiento quirurgico de eleccion es la reseccion total del quiste con derivacion biliodigestiva. Nuestros resultados son equiparables a los de los equipos que practican una tecnica de reseccion radical y, a su vez, son mejores que los de las series que practican resecciones parciales.