Bacteremia following liver biopsy in transplant recipients with Roux-en-Y choledochojejunostomy.

Between 1990 and 1995, 666 percutaneous liver biopsies were performed in 196 patients at Gregorio Marañón General Hospital (mean 3.4 biopsies/patient); 533 biopsies (80.03%) were carried out in patients with choledochostomy biliary anastomosis and 133 (19.97%) in patients with choledochojejunostomy. Infectious complications, in the form of sepsis, occurred in two patients, who recovered favorably with antibiotic therapy. These two patients had undergone Roux-en-Y choledochojejunostomy (1.5%, not significant). Our findings suggest that the incidence of infectious complications after liver biopsy in transplant recipients is very low. Antibiotic prophylaxis at the time of liver biopsy in patients with Roux-en-Y choledochojejunostomy may decrease the frequency of infectious complications.

[Severe complications of percutaneous hepatic biopsy in patients with orthotopic liver transplantation]. / Complicaciones graves de la biopsia hepática percutánea en los pacientes con trasplante hepático ortotópico.

The incidence and type of complications appearing following the performance of liver biopsies were analyzed in the first 166 liver transplants in our hospital. The presence of a severe complications was defined if a patient presented hemoperitoneum, pneumothorax, hemothorax, post biopsy infection or symptomatic puncture of abdominal organs other than the liver. Four hundred thirty-eight liver biopsies were carried out in 129 patients with a mean of 3.4 biopsies per patient. The severe complications were observed in 7 (1.6%), all of which were bleeding episodes. Four hemothorax requiring the placement of a thoracic drainage tube were observed. In two cases thoracotomy was required with death occurring in one patient. Three hemoperitoneum were also seen requiring laparotomy in one and transfusion in the remaining two patients. Out of the non transplanted patients, four presented severe complications (0.7%), 50% of which were hemoperitoneum. No patient presented hemothorax and no deaths were reported. The authors conclude that the incidence of severe post liver biopsy complications in transplanted is low, similar to that reported in non transplanted patients. Nonetheless, there does appear to be a higher incidence of bleeding complications in the transplanted patients.

Two-clamp method to avoid portal anastomotic stenosis in liver transplantation.

We developed a two-clamp technique to avoid stenoses in portal anastomoses during liver transplantation. A portal anastomosis is created with a continuous polypropylene suture. A second vascular clamp is placed on the donor portal vein before release of the recipient vein clamp. After release of the proximal clamp, the vein is allowed to distend to its maximal diameter, and the suture is gently tied. This technique was used in both portal and arterial anastomoses in 43 consecutive liver transplant recipients. No cases of postoperative stenosis or thrombosis were observed.

The anergic state as a predictor of pancreatic sepsis.

From 1984 to 1987, 187 patients with acute pancreatitis (AP) were studied. All patients were stratified according to Ranson's criteria upon admission and were followed up by performing a CT scan weekly. One hundred and thirty-eight patients had 3 or less Ranson's criteria (non-severe acute pancreatitis = NSAP) and 49 presented 4 or more (severe acute pancreatitis = SAP). Ninety-six percent of the patients with (p less than 0.0001). Of the 49 patients with SAP, 39 developed pancreatic or peripancreatic NSAP were reactive to skin tests on the third week, while 4% remained anergic necrosis and were operated. Twenty-two of these patients had positive cultures demonstrating the presence of bacteria in the tissue samples. One hundred percent of the infected patients remained anergic until surgery, while only 40% of those with negative cultures remained anergic (p less than 0.05). Mortality rate correlated well with skin test responses, being 31% in anergic patients while only 5% in reactive subjects. Sustained anergic state (AS), sequentially checked, is associated with a high incidence of pancreatic sepsis.

Treatment of severe intra-abdominal sepsis and/or necrotic foci by an 'open-abdomen' approach. Zipper and zipper-mesh techniques.

Undrained necrotic tissue or septic foci contribute to continued "activation" of host processes that in turn lead to multiple organ failure and death. We hypothesized that if wide-open drainage of the abdominal cavity is provided, thus not allowing intra-abdominal collections to form, mortality in these patients can be reduced. Since 1982 we have treated 49 patients with necrotic pancreatitis and related infections and 15 patients with severe intra-abdominal sepsis from intestinal perforations. The surgical treatment was based on the provision for daily laparotomies in the intensive care unit with the patient under epidural anesthesia by using an "open-abdomen" technique (zipper alone or a zipper-mesh combination). The APACHE II score and the functional classification were used to derive expected mortalities. The patients with intraabdominal sepsis had a mean APACHE II score of 25 and an expected mortality of 45%, vs the 26.5% mortality that we observed. The lowest mortality in the necrotic pancreatitis group was associated with noninfected pancreatic necrosis (6%) and single abscess (9%) vs 22% mortality rate in the patients with infected pancreatic necrosis. The mean expected mortality in this group was 47%, vs the observed 22%. We attributed this result to the daily abdominal explorations that achieved a complete excision of infected or necrotic tissue.