RESUMEN
BACKGROUND & AIMS: There is controversy over the ability of transjugular intrahepatic portosystemic shunts (TIPS) to increase survival times of patients with cirrhosis and refractory ascites. The high rate of shunt dysfunction with the use of uncovered stents counteracts the benefits of TIPS. We performed a randomized controlled trial to determine the effects of TIPS with stents covered with polytetrafluoroethylene in these patients. METHODS: We performed a prospective study of 62 patients with cirrhosis and at least 2 large-volume paracenteses within a period of at least 3 weeks; the study was performed at 4 tertiary care centers in France from August 2005 through December 2012. Patients were randomly assigned to groups that received covered TIPS (n = 29) or large-volume paracenteses and albumin as necessary (LVP+A, n = 33). All patients maintained a low-salt diet and were examined at 1 month after the procedure then every 3 months until 1 year. At each visit, liver disease-related complications, treatment modifications, and clinical and biochemical variables needed to calculate Child-Pugh and Model for End-Stage Liver Disease scores were recorded. Doppler ultrasonography was performed at the start of the study and then at 6 and 12 months after the procedure. The primary study end point was survival without a liver transplant for 1 year after the procedure. RESULTS: A higher proportion of patients in the TIPS group (93%) met the primary end point than in the LVP+A group (52%) (P = .003). The total number of paracenteses was 32 in the TIPS group vs 320 in the LVP+A group. Higher proportions of patients in the LVP+A group had portal hypertension-related bleeding (18% vs 0%; P = .01) or hernia-related complications (18% vs 0%; P = .01) than in the TIPS group. Patients in LVP+A group had twice as many days of hospitalization (35 days) as the TIPS group (17 days) (P = .04). The 1-year probability of remaining free of encephalopathy was 65% for each group. CONCLUSIONS: In a randomized trial, we found covered stents for TIPS to increase the proportion of patients with cirrhosis and recurrent ascites who survive transplantation-free for 1 year, compared with patients given repeated LVP+A. These findings support TIPS as the first-line intervention in such patients. ClinicalTrials.gov ID: NCT00222014.
Asunto(s)
Ascitis/terapia , Hipertensión Portal/cirugía , Cirrosis Hepática/complicaciones , Paracentesis , Derivación Portosistémica Intrahepática Transyugular , Stents , Albúminas/uso terapéutico , Ascitis/etiología , Femenino , Encefalopatía Hepática/etiología , Hospitalización/estadística & datos numéricos , Humanos , Hipertensión Portal/etiología , Trasplante de Hígado , Masculino , Persona de Mediana Edad , Paracentesis/efectos adversos , Politetrafluoroetileno , Derivación Portosistémica Intrahepática Transyugular/efectos adversos , Estudios Prospectivos , Recurrencia , Índice de Severidad de la Enfermedad , Stents/efectos adversos , Tasa de Supervivencia , Ultrasonografía DopplerRESUMEN
PURPOSE: In the present study, we performed biometric characterization of the temporomandibular joints (TMJs) of clinically normal subjects. METHODS: Fifty-one healthy volunteers underwent high-resolution computerized tomography examination of the TMJs in the position of maximal intercuspidation according to a standardized protocol. Frontal and sagittal reconstructions were then performed to obtain measurements and indexes in three planes of space. RESULTS: Correlations are observed with age, gender, amplitude of mouth opening and presence of dental abrasion. The lateral stability index reflects the degree of mobility of the temporo-discal compartment of the joint. The coverage index reflects how much the mandibular condyle is inserted into the articular fossa and may be related to the risk of occurrence and severity of regressive remodeling phenomena. CONCLUSIONS: This study supports the interest in examining morphological aspects of the TMJ and performing intra-articular measurements. The biometric examination of the TMJ has important applications in the domain of TMJ pathology.
Asunto(s)
Articulación Temporomandibular/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Biometría , Femenino , Humanos , Masculino , Persona de Mediana Edad , Rango del Movimiento Articular , Factores Sexuales , Articulación Temporomandibular/anatomía & histología , Adulto JovenRESUMEN
This study assessed the effect of a 3-month course of pegylated interferon-alpha-2a (Peg-IFN-alpha-2a) in 3 liver transplant patients with chronic active hepatitis E. A virological response was sustained for 6 and 5 months in 2 patients after Peg-IFN-alpha-2a therapy was completed. A relapse was observed in the third patient.
Asunto(s)
Antivirales/uso terapéutico , Hepatitis E/tratamiento farmacológico , Hepatitis Crónica/tratamiento farmacológico , Interferón-alfa/uso terapéutico , Polietilenglicoles/uso terapéutico , Adulto , Humanos , Interferón alfa-2 , Trasplante de Hígado , Masculino , Persona de Mediana Edad , Proteínas Recombinantes , Prevención SecundariaRESUMEN
The body of an unidentified elderly woman was found trapped in a floodgate. Prior to autopsy, full-body multislice computed tomography (MSCT) was performed for study of bone lesions and cause of death. Age was estimated by analysis of the sternal end of the fourth rib and of the pubic symphyseal medial articular surfaces. The results were then compared with the autopsy findings. MSCT was superior to autopsy in diagnosis of traumatic bone lesions and also revealed dental anomalies and signs of drowning. Age estimation gave a similar result for both methods. This case report illustrates the potential value of MSCT for medico-legal investigations of death: diagnosis of injuries, possibility of determining the cause of death, and anthropological study in order to estimate age or to visualize features likely to enable identification of a corpse.
Asunto(s)
Autopsia/métodos , Ahogamiento/patología , Patologia Forense/métodos , Anciano , Resultado Fatal , Femenino , Antropología Forense/métodos , Humanos , Tomografía Computarizada por Rayos X/métodos , Tomografía Computarizada por Rayos X/normasRESUMEN
An 80% dysfunction rate at 2 years limits the use of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of complications of portal hypertension. The use of covered stents could improve shunt patency; however, long-term effect and safety remain unknown. Eighty patients randomized to be treated by TIPS either with a covered stent (Group 1) or an uncovered prosthesis (Group 2) were followed-up for 2 years. Doppler US was performed every 3 months. Angiography and portosystemic pressure gradient measurement were performed every 6 months or whenever dysfunction was suspected. Actuarial rates of primary patency in Groups 1 and 2 were 76% and 36% respectively (P=0.001). Clinical relapse occurred in four patients (10%) in Group 1 and 12 (29%) in Group 2 (P<0.05). Actuarial rates of being free of encephalopathy were 67% in Group 1 and 51% in Group 2 (P<0.05). Probability of survival was 58% and 45% at 2 years, respectively, in Groups 1 and 2 (NS). The mean Child-Pugh score improved only in Group 1 (from 8.1+/-1.6 to 7+/-2.2 at 2 years -P<0.05). We also compared the Doppler-US parameters between patent and dysfunctioning shunts. In patent shunts, the mean velocity within the portal vein was significantly higher but the performance of Doppler-US was not accurate enough to predict shunt dysfunction. In conclusion, the improvement in TIPS patency by using covered prostheses is maintained over time with a decreased risk of encephalopathy, while the risk of death was not increased.
Asunto(s)
Várices Esofágicas y Gástricas/cirugía , Hemorragia Gastrointestinal/cirugía , Hipertensión Portal/complicaciones , Derivación Portosistémica Intrahepática Transyugular/instrumentación , Stents , Grado de Desobstrucción Vascular , Adulto , Anciano , Velocidad del Flujo Sanguíneo , Várices Esofágicas y Gástricas/complicaciones , Várices Esofágicas y Gástricas/etiología , Várices Esofágicas y Gástricas/mortalidad , Várices Esofágicas y Gástricas/fisiopatología , Femenino , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/mortalidad , Hemorragia Gastrointestinal/fisiopatología , Encefalopatía Hepática/etiología , Encefalopatía Hepática/fisiopatología , Humanos , Hipertensión Portal/fisiopatología , Hipertensión Portal/cirugía , Estimación de Kaplan-Meier , Circulación Hepática , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Politetrafluoroetileno , Presión Portal , Vena Porta/diagnóstico por imagen , Vena Porta/fisiopatología , Derivación Portosistémica Intrahepática Transyugular/efectos adversos , Modelos de Riesgos Proporcionales , Diseño de Prótesis , Recurrencia , Medición de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Doppler DúplexRESUMEN
OBJECTIVE: The purpose of our study was to evaluate the feasibility and the safety of transjugular intrahepatic portosystemic shunts (TIPS) with a new expanded-polytetrafluoroethylene-covered stent and the influence of the covering on occlusion rate. SUBJECTS AND METHODS: Twenty cirrhotic patients (57 +/- 11 years old) admitted with a history of esophageal variceal bleeding (n = 11), refractory ascites (n = 5), or both (n = 4) were included. Five of the patients were treated for TIPS revision, and 15 as de novo TIPS placements. The endoprostheses used were composed of a 2-cm noncovered nitinol stent and a 4- to 8-cm expanded-polytetrafluoroethylene graft covering, and were placed from the portal vein to the ostium of the hepatic vein. Patients underwent Doppler sonography at discharge and again at 1, 3, 6, 9, 12, and 15 months and underwent venography with portosystemic pressure gradient measurement at 6 months and whenever necessary. RESULTS: At the time of this writing, complications included three TIPS restenoses and one recurrent ascites successfully treated by balloon dilation, two cases of segmentary liver ischemia, and one patient with encephalopathy that required shunt reduction. After TIPS placement, the portosystemic pressure gradient dropped from 18 +/- 5 to 5 +/- 4 mm Hg. Primary and secondary patency rates were 80% and 100%, respectively, at 387 days. CONCLUSION: These results clearly show the feasibility of TIPS placement with the Gore TIPS endoprosthesis stent-graft and its improved patency compared with results in the literature for bare stents. These preliminary results must be certified further with randomized comparative trials between covered and noncovered TIPS stents.
Asunto(s)
Materiales Biocompatibles Revestidos , Várices Esofágicas y Gástricas/terapia , Hemorragia Gastrointestinal/terapia , Cirrosis Hepática/terapia , Politetrafluoroetileno , Derivación Portosistémica Intrahepática Transyugular/instrumentación , Stents , Adulto , Anciano , Aleaciones , Várices Esofágicas y Gástricas/diagnóstico , Estudios de Factibilidad , Femenino , Hemorragia Gastrointestinal/diagnóstico , Humanos , Cirrosis Hepática/diagnóstico , Masculino , Persona de Mediana Edad , Presión Portal/fisiología , Portografía , Resultado del Tratamiento , Ultrasonografía DopplerRESUMEN
BACKGROUND & AIMS: A 50% dysfunction rate at 1 year is one of the main drawbacks of the transjugular intrahepatic portosystemic shunt procedure. Preliminary experimental and clinical studies suggest that the use of stents covered with polytetrafluoroethylene could tremendously decrease this risk. METHODS: Eighty patients with cirrhosis and uncontrolled bleeding (n = 23), recurrent bleeding (n = 25), or refractory ascites (n = 32) were randomized to be treated by transjugular intrahepatic portosystemic shunts with either a polytetrafluoroethylene-covered stent (group 1; 39 patients) or a usual uncovered prosthesis (group 2; 41 patients). Follow-up Doppler ultrasound was scheduled at day 7, at 1 month, and then every 3 months for 2 years. Angiography and portosystemic pressure gradient measurements were performed 6, 12, and 24 months after the transjugular intrahepatic portosystemic shunt procedure and whenever dysfunction was suspected. Dysfunction was defined as a >50% reduction of the lumen of the shunt at angiography or a portosystemic pressure gradient >12 mm Hg. RESULTS: After a median follow-up of 300 days, 5 patients (13%) in group 1 and 18 (44%) in group 2 experienced shunt dysfunction (P < 0.001). Clinical relapse occurred in 3 patients (8%) in group 1 and 12 (29%) in group 2 (P < 0.05). Actuarial rates of encephalopathy were 21% in group 1 and 41% in group 2 at 1 year (not significant). Estimated probabilities of survival were 71% and 60% at 1 year and 65% and 41% at 2 years in groups 1 and 2, respectively (not significant). CONCLUSIONS: The use of polytetrafluoroethylene-covered prostheses improves transjugular intrahepatic portosystemic shunt patency and decreases the number of clinical relapses and reinterventions without increasing the risk of encephalopathy.