Resolución de colección biliar gigante por fistulización espontánea al colon / Resolution of giant biliary collection by spontaneous colon fistulization

El tratamiento de las colecciones biliares puede consistir en actitud expectante con vigilancia radiológica del tamaño y las características de la colección, drenaje percutáneo guiado por pruebas de imagen (eco/TC), drenaje endoscópico dependiendo de la localización y la accesibilidad de la colección, o tratamiento quirúrgico. Se comenta el caso clínico de un hombre intervenido de forma programada realizándose una hepatectomía derecha, que presentó una colección adyacente al lecho quirúrgico, asintomática, sugestiva de bilioma, con aumento progresivo de tamaño, presentando de forma espontánea disminución hasta su resolución por fistulización al ángulo hepático del colon, confirmado por pruebas radiológicas. La formación de fístulas biliares al colon de manera espontánea se debe a la presión extrínseca de la colección sobre la pared intestinal con necrosis de la zona de contacto, siendo su presentación y documentación radiológica excepcionales

The treatment of bile collections is divided into: expectant attitude with radiological monitoring of the size and characteristics of the collection, percutaneous drainage guided by imaging tests (US/CT), endoscopic drainage depending on location and accessibility and surgical treatment. The clinical case of a man undergoing a scheduled hepatectomy was observerd, who presented a large asymptomatic subcapsular collection suggestive of bilioma, with progressive increase in size, spontaneously presenting a decrease until its resolution by fistulization to the hepatic angle of the colon confirmed by Radiological findings. The spontaneously formation of biliary fistulas to the colon is due to the extrinsic pressure of the collection on the intestinal wall with necrosis of the contact zone, being its presentation and radiological documentation exceptional

Resolution of giant biliary collection by spontaneous colon fistulization. / Resolución de colección biliar gigante por fistulización espontánea al colon.

The treatment of bile collections is divided into: expectant attitude with radiological monitoring of the size and characteristics of the collection, percutaneous drainage guided by imaging tests (US/CT), endoscopic drainage depending on location and accessibility and surgical treatment. The clinical case of a man undergoing a scheduled hepatectomy was observerd, who presented a large asymptomatic subcapsular collection suggestive of bilioma, with progressive increase in size, spontaneously presenting a decrease until its resolution by fistulization to the hepatic angle of the colon confirmed by Radiological findings. The spontaneously formation of biliary fistulas to the colon is due to the extrinsic pressure of the collection on the intestinal wall with necrosis of the contact zone, being its presentation and radiological documentation exceptional.

Differences in the incidence and clinical evolution of early neurotoxicity after liver transplantation based on tacrolimus formulation used in the immunosuppressive induction protocol.

INTRODUCTION: Posttransplant early calcineurin inhibitor (CNI)-induced neurotoxicity (ECIIN) was related to high CNI levels, among other factors. Minimizing exposure could modify its incidence or clinical evolution. OBJECTIVE: To compare the incidence, predisposing factors, and clinical evolution of ECIIN after immunosuppressive induction with low-dose tacrolimus-MR (Advagraf) or conventional dose tacrolimus (Prograf). PATIENTS AND METHODS: We matched 71 patients treated with an immunosuppression induction schedule with basiliximab and low doses of Advagraf (cases group) 1:1 by recipient age and indication for liver transplantation (OLT) with patients treated with a conventional tacrolimus regimen (control group). Baseline characteristics, liver and kidney function, operative technical characteristics, kidney function, and C0 tacrolimus levels at several time points after liver OLT were analyzed. RESULTS: There were 31 cases of ECIIN (21%), 14 in the cases group (20%) and 17 in the control group (24%; P < .001). The incidence of ECIIN was higher in alcoholic liver disease (odds ratio [OR], 8.2; 95% CI, 2.3-28.6; P < .001) and past history of encephalopathy (OR, 2.6; 95% CI, 1.16-5.9; P < .02). Among cases, the incidence of ECIIN was higher when encephalopathy signs were present at time of transplantation (36% vs 12%; P < .001). Control of ECIIN required a switch to cyclosporine therapy in all those in the cases group, whereas this was only needed for 9 cases in the control group (47%; P < .001). CONCLUSION: In this study, although the incidence rate of neurotoxicity induced by Advagraf was lower than the induced by Prograf, it did not respond to routine treatment and required a significantly higher rate of switch to cyclosporine for its control.

Late recurrence of hepatocellular carcinoma after liver transplantation: is an active surveillance for recurrence needed?

INTRODUCTION: Liver transplantation (OLT) is considered the most efficient therapeutic option for patients with liver cirrhosis and early stage hepatocellular carcinoma (HCC) in terms of overall survival and recurrence rates, when restrictive selection criteria are applied. Nevertheless, tumor recurrence may occur in 3.5% to 21% of recipients. It usually occurs within 2 years following OLT, having a major negative impact on prognosis. The efficacy of active posttransplantation surveillance for recurrence has not been demonstrated, due to the poor prognosis of recipients with recurrences. AIM: To analyze the clinical, pathological, and prognostic consequences of late recurrence (>5 years after OLT). METHOD: We analyzed the clinical records of 165 HCC patients including 142 males of overall mean age of 58 ± 6.9 years who underwent OLT between July 1994 and August 2011. RESULTS: Overall survival was 84%, 76%, 66.8%, and 57% at 1, 3, 5, and 10 years, respectively. Tumor recurrence, which was observed in 18 (10.9%) recipients, was a major predictive factor for survival: its rates were 72.2%, 53.3%, 26.7%, and 10% at 1, 3, 5, and 10 years, respectively. HCC recurrence was detected in 77.8% of patients within the first 3 years after OLT. Three recipients (100% males, aged 54-60 years) showed late recurrences after 7, 9, and 10 years. In only one case were Milan criteria surpassed after the examination of explanted liver; no vascular invasion was detected in any case. Recurrence sites were peritoneal, intrahepatic, and subcutaneous abdominal wall tissue. In all cases, immunosuppression was switched from a calcineurin-inhibitor to a mammalian target of rapamycin inhibitor. We surgically resected the extrahepatic recurrences. The remaining recipient was treated with transarterial chemoembolization with doxorubicin-eluting beads and sorafenib. Prognosis after diagnosis of recurrence was poor with median a survival of 278 days (range, 114-704). CONCLUSIONS: Global survival, recurrence rate, and pattern of recurrence were similar to previously reported data. Nevertheless, in three patients recurrence was diagnosed >5 years after OLT. Although recurrence was limited and surgically removed in two cases, disease-free survival was poor. Thus, prolonged active surveillance for HCC recurrence beyond 5 years after OLT may be not useful to provide a survival benefit for these patients.

Strategies of immunosuppression for liver transplant recipients with hepatocellular carcinoma.

Liver transplantation is considered to be the most efficient therapeutic option for patients with liver cirrhosis and early stage hepatocellular carcinoma (HCC) in terms of overall survival and recurrence rate. The application of restrictive selection criteria based on tumor size and number of nodules is advised to obtain optimal results. Nevertheless, tumor recurrence occurs in 3.5% to 21% of recipients, despite careful pretransplant staging and patient selection. Post transplant recurrence of hepatocarcinoma clearly has a major negative impact on prognosis. Intuitively, an immunosupressed state is undesirable in cancer patients. Inversely, modulation or minimization of immunosuppressive therapy could influence tumor progression and reduce the negative impact of recurrence on posttransplant survival. Experimental evidence shows that mammalian target of rapamycin (mTOR) inhibitors have antiangiogenic and antiproliferative effects. Thus, their application has been proposed as antineoplastic agents for immunosuppressive protocols in liver transplant recipients with HCC and may reduce the rate or the impact of tumor recurrence. Clinical data about efficacy and safety of mTOR-based immunosuppressant protocols in liver transplant recipients with HCC show promising results, namely low recurrence and higher survival rates compared with standard calcineurin inhibitor-based immunosuppressive protocols, even among patients with extended morphological criteria. The safety profile is regarded generally as adequate.

The future of liver transplantation.

Liver transplantation has been a positive impact on both the survival and the quality of life of patients with advanced liver diseases. Progressive, spectacular improvements in the results of liver transplantation have been observed since the preliminary studies by Thomas Starzl in the United States and Roy Calne in Europe. This improvement is related to better knowledge of the natural history of liver diseases, allowing more adequate recipient selection, improvement of surgical techniques, progress in postoperative management, availability of potent antibacterial, antiviral, and antifungal drugs, as well as introduction of new immunosuppressive agents and protocols. These advances have occurred in the short interval of 45 years, suggesting future improvements in the liver transplantation field. The main investigative efforts in liver transplantation have been directed as follows: First attenuation of disproprortion between the numbers of available liver grafts versus waiting list recipients, by increasing the donor pool applying bioartificial support systems, or rendering grafts compatible by the use of stem cells. Second, improved knowledge about the biology of primary liver tumors establishes indications for and optimal moments of transplantation. Third, application of individualized immunosuppressive protocols, adapted to clinical status of the recipient, as well as the development of more selective, less toxic new immunosuppressive agents.

Improvement of renal function after conversion to mycophenolate mofetil combined with low-level calcineurin inhibitor in liver transplant recipients with chronic renal dysfunction.

INTRODUCTION: Calcineurin inhibitors (CNI) are the main pathogenic factors for renal dysfunction in solid organ transplant recipients. Introduction of non-nephrotoxic immunosuppressive drugs, such as mycophenolate mofetil (MMF), may allow discontinuation or reduction of CNI treatment, thereby improving renal function. The aim of this study was to assess the feasibility, efficacy and safety of MMF introduction and CNI dosage reduction in the maintenance immunosuppressive protocol to improve renal function in liver transplant recipients with chronic renal dysfunction. PATIENTS AND METHODS: We prospectively included 88 liver transplant recipients including 74 men and an overall mean age of 58.8 +/- 10.3 years who all displayed chronic renal dysfunction (creatinine >1.4 mg/dL) and proteinuria <1 g/d. They were subdivided into 3 groups according to the basal creatinine value 1.4-1.7 mg/dL (group I; n = 41); 1.8-2.0 mg/dL (group II; n = 28); and >2 mg/dL (group III; n = 19). MMF was initiated at 1.5-2.0 g/d. Reduction of tacrolimus or cyclosporine dosage was performed to achieve respective target trough levels of <5 ng/mL or <50 ng/mL. We performed periodic determinations of arterial pressure, liver function tests, serum creatinine, blood cells count, CNI levels, and proteinuria. RESULTS: Creatinine values after conversion were 1.4 +/- 0.5 mg/dL in the overall group. Improvement of renal function was more frequent among groups I (80.4%) and II (92.8%) versus III (73.6%). Normalization of creatinine values was more frequent in group I (68.2%) with respect to cohorts II (21.4%) and III (10.5%). Rejection was not detected. CONCLUSION: Application of an immunosuppressive protocol with MMF and low-level CNI in liver transplant recipients with chronic renal dysfunction was associated with improvement or normalization of creatinine, without an increased risk of rejection. Early conversion is needed to achieve the best results.

Valganciclovir-induced leukopenia in liver transplant recipients: influence of concomitant use of mycophenolate mofetil.

INTRODUCTION: An increased incidence and magnitude of leukopenia during concomitant treatment with valganciclovir (VGC) and mycophenolate mofetil (MMF) has been reported. OBJECTIVE: To evalute the incidence and severity of leukopenia and neutropenia among liver recipients treated with VGC and related factors. PATIENTS AND METHODS: Retrospective analysis of clinical and analytical data related to leukopenia (<3000 leukocytes/mm(3)) and neutropenia (<900 neutrophils/mm(3)) in liver transplant patients who were treated with VGC from 2003 to 2007. We examined the influence of concomitant administration of MMF and development of subsequent infections. RESULTS: Among 209 liver transplants, 40 treatments with VGC were prescribed in 37 patients (17.7%), 12 of which (30%) were associated with MMF. The patients has an average age of 49.7 +/- 12.7, body mass index (BMI) of 27.28 +/- 5.17, and Model for End-stage Liver Disease Score (MELD) 12.45 +/- 7.5. The daily average dose of VGC was 1440 +/- 446.5 mg and MMF, 1454.5 +/- 350.3 mg. We observed a decrease of 30% in initial leukocyte count (5353.7 +/- 2706.6) and 40% in neutrophil count (3600 +/- 2182.1). With no relationship to total dose or BMI-adjusted dose of VGC nor concomitant administration of MMF. The initial leukocyte count was significantly lower (4411 +/- 1930 vs 6206 +/- 3053; P = .03) and underwent a main drop (2344.7 +/- 1974.3 vs 898.1 +/- 2435.6; P = .04) when leukopenia developed. In the induced neutropenia group, previous leukocyte count (3797.1 +/- 1223.9 vs 5683.9 +/- 2829.3; P = .01), MELD (18.7 +/- 8.8 vs 11.1 +/- 6.6; P = .01), and the creatinine pretreatment (1.44 +/- 0.4 vs 1.09 +/- 0.3; P = .01) were significantly different. Subsequent infections induced by the leukopenia were not observed. CONCLUSIONS: In our series, the concomitant use of VGC and MMF was not associated with a greater incidence of leukopenia and/or neutropenia than VGC administration alone. Previous leukocyte count was associated with them. MELD and renal dysfunction are factors related to severe neutropenia. Leukopenia was not associated with a greater incidence of infections.

Poliquistosis hepática / Polycystic liver disease

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Trasplante hepático en el hepatocarcinoma: criterios expandidos de California / No disponible

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[Surgical complications after kidney transplantation. Research based on 185 cases]. / Complicaciones quirúrgicas post-trasplante renal. Estudio en 185 casos.

OBJECTIVE: To analyze the incidence of surgical complications its diagnosis and treatment after renal transplantation. METHODS: A retrospective study measuring the incidence of surgical complications and reviewing its diagnosis and treatment in 185 renal single transplants. RESULTS: 185 transplants, 27% had surgical complications. Only one patient lost the graft due to surgical complications and there was no associated mortality. Cold ischemia time 20 hours. Double J stenting in 19%, under surgeon's opinion. Vascular complications 3.2% (all of them renal artery stenosis). Urological complications 6.4%. Perinephric haematoma 7%. Lymphocele 4.9%. Peritoneum related complications 4%. Other 4%. The diagnosis was clinical and radiological in most of cases. 14% needed any kind of intervention. CONCLUSIONS: Our results are similar to those reported in other recent series. Only one surgical team involved and the same technique for vascular and vesico-ureteric anastomosis probably makes lower our complications rate. Early postoperative abdominal ultrasonography contributes to the diagnosis of surgical complications. The initial treatment approach is the endoscopic-conservative one, with exceptions.

Complicaciones quirúrgicas post-trasplante renal. Estudio en 185 casos / Surgical complications after kidney transplantation. Research based on 185 cases

Objetivo: Análisis de incidencia, diagnóstico y tratamiento de complicaciones quirúrgicas en el trasplante renal. Método: Estudio retrospectivo de la incidencia de complicaciones quirúrgicas en 185 trasplantes renales únicos, revisando su diagnóstico y tratamiento. Resultados: En 185 trasplantes se producen un 27% de complicaciones quirúrgicas. Sólo un paciente perdió el injerto secundario a éstas y su mortalidad asociada fue nula. Tiempo medio de isquemia fría 20horas. Utilización de catéter doble J (19%), a criterio del cirujano. Complicaciones vasculares 3,2% (todas estenosis de arteria renal). Complicaciones urológicas 6,4% (en similar porcentaje estenosis y fístulas). Hematomas perirrenales 7%. Linfoceles 4,9%. Complicaciones peritoneales 4%. Otras 4%. Diagnóstico clínico-radiológico en la mayoría de los casos. Requirieron intervención (endo-radiológica o quirúrgica) el 14%, individualizada según el caso. Conclusiones: Nuestros resultados no difieren de los de otras grandes series publicadas. La implicación de un único equipo de cirujanos manteniendo la misma técnica vascular y de ureteroneocistostomía parece influir en nuestra baja incidencia de complicaciones. La ecografía-doppler abdominal sistemática como control en los primeros días post-trasplante contribuye al diagnóstico de las complicaciones quirúrgicas. El tratamiento inicial de elección, salvo excepciones, es endoscópico-conservador (AU)

Objective: To analyze the incidence of surgical complications its diagnosis and treatment after renal transplantation. Methods: A retrospective study measuring the incidence of surgical complications and reviewing its diagnosis and treatment in 185 renal single transplants. Results: 185 transplants, 27% had surgical complications. Only one patient lost the graft due to surgical complications and there was no associated mortality. Cold ischemia time 20 hours. Double J stenting in 19%, under surgeon’s opinion. Vascular complications 3,2% (all of them renal artery stenosis). Urological complications 6,4%. Perinephric haematoma 7%. Lymphocele 4,9%. Peritoneum related complications 4%. Other 4%. The diagnosis was clinical and radiological in most of cases. 14% needed any kind of intervention. Conclusions: Our results are similar to those reported in other recent series. Only one surgical team involved and the same technique for vascular and vesico-ureteric anastomosis probably makes lower our complications rate. Early postoperative abdominal ultrasonography contributes to the diagnosis of surgical complications. The initial treatment approach is the endoscopic-conservative one, with exceptions (AU)

[De novo hepatitis B with anti-HBc negative in a liver transplant recipient [corrected]]. / Hepatitis B de novo con anticuerpo frente al HBcAg negativo en un trasplantado hepático.

De novo hepatitis B was diagnosed in a 47-year-old man 15 months after liver transplantation for end-stage alcoholic cirrhosis. Serum antibodies to hepatitis B core antigen (anti-HBc) were negative, and remained undetectable over 20 months of follow-up. The possible causes of negative serum anti-HBc despite of active hepatitis B virus infection are reviewed. Immunosuppression may underlie this phenomenon in similar cases.

[Ureteral implantation in peritoneum. Exceptional complication in renal transplantation]. / Implantación ureteral en peritoneo. Una complicación excepcional en el trasplante renal.

Because of the extraperitoneal location, generally used for renal grafting, intraperitoneal urine leaks are a rare complication after transplantation. We report a patient on peritoneal dialysis who developed ascites, abdominal pain, anuria and shock suddenly after renal transplantation. The patient was immediately taken back to the operating room. An abnormal implantation of ureter into the peritoneum overlying the bladder when carrying out an unstented parallel incision extravesical ureterone-ocystostomy was identified. After correcting ureter implantation the patient had immediate diuresis, renal function rapidly improved, with no further complications. Contributing causes were poor exposure, thickened peritoneum secondary to recurrent peritonitis, and the presence of residual peritoneal dialysis fluid.

Implantación ureteral en peritoneo. Una complicación excepcional en el trasplante renal / Ureteral implantation into periotoneum. An unusual complication of kidney transplantation

En el trasplante renal la fuga de orina intraperitoneal es una complicación rara, debido a la implantación habitual en retroperitoneo. Informamos del caso de un paciente en diálisis peritoneal que inmediatamente al trasplante presenta ascitis, dolor abdominal, anuria y shock. Con rapidez es llevado de nuevo a quirófano. Se identificó una implantación del uréter en peritoneo y no en vejiga, en el curso de una ureteroneocistostomía extravesical no tutorizada. Después de corregir la implantación ureteral el paciente recuperó la diuresis, mejoró rápidamente su función renal, sin más complicaciones. Fueron factores contribuyentes la limitada exposición, el engrosamiento peritoneal secundario a peritonitis recurrente y la presencia de fluido de diálisis peritoneal residual (AU)

[Epidermoid cyst: a rare cause of cystic liver disease]. / Quiste epidermoide: una causa infrecuente de patología quística hepática.

We present the case of a 42-year-old male patient with a large hepatic cyst, simulating a hydatid cyst. Subtotal cystectomy was performed. Thirteen months after this procedure the patient relapsed and a second laparotomy and total cystectomy were performed. A histopathological diagnosis of epidermoid cyst of the liver was made. The differential diagnosis of epidermoid cysts of the liver is broad and definitive diagnosis is usually only obtained after pathological examination of the surgical specimen. For this reason, and because of the potential for neoplasia, complete resection of the hepatic lesion should be attempted.

[Technical solution in kidney retransplantation in a patient with femoro-femoral bypass]. / Solución técnica en el retrasplante renal de un paciente portador de un by-pass femoro-femoral.

Over the last decade kidney transplantation has become a common therapeutic procedure for patients with end-stage renal diseases. Between 1988 and 1998 donors rate per million population has dramatically increased in our environment, thus providing us with more chances to offer kidney transplantation to a larger number of patients. The technico-surgical difficulties that have to be faced however, are increasingly frequent and require a search for new approaches and innovative changes to the usual surgical techniques for our patient's benefit.

Solución técnica en el retrasplante renal de un paciente portador de un by-pass femoro-femoral / Technical solution in the kidney retransplant of a patient with a femoro-femoral by-pass

El trasplante renal se ha convertido en la última década en una forma de tratamiento habitual para los pacientes con enfermedades renales terminales. Entre 1988 y 1998 la tasa de donantes por millón de habitantes ha aumentado espectacularmente en nuestro medio, ello implica que cada vez es posible ofrecer un trasplante renal a un número mayor de pacientes, de modo que las dificultades técnico-quirúrgicas con las que debemos enfrentarnos son cada vez más frecuentes, siendo preciso buscar e incorporar nuevos enfoques y modificaciones imaginativas de la técnica quirúrgica en beneficio de nuestros pacientes. (AU)

[Cancer of the gallbladder: survival and life quality depending on the type of surgical treatment]. / Cáncer de vesícula: supervivencia y calidad de vida según el tipo de tratamiento quirúrgico.

An analysis is made of the survival and life quality of 47 patients diagnosed by histopathology as gallbladder cancer, in relation to surgical treatment. The 47 patients, with a mean age of 70 years and a male female ratio of 1:3.7, were classified according to the Nevin stages: there were no stage I patients, 1 stage II, 8 III-IV and 38 V. The operations performed were 20 simple cholecystectomies with excision of a portion of adjacent hepatic tissue; 11 radical cholecystectomies; 10 surgical intubations; 3 percutaneous endoprosthesis; 2 gastroenteroanastomoses and 1 exploratory laparotomy. The results showed: 1) Radical cholecystectomy was the best therapeutic method, providing the longest survival (433 days) with the smallest proportion of days of poor life quality (10%). 2) In patients in stages II, III, IV, simple cholecystectomy with excision of the adjacent liver tissue yielded a survival of more than a year, even in patients of advanced age (greater than 80 years). 3) Although percutaneous and surgical intubation achieved a similar survival, the first technique produced a better quality of life. 4) In view of the diversity of the surgical techniques practiced in patients in stage V, a revaluation of this stage is necessary to individualize treatment.