Historical Review of Studies on Sacroiliac Fatty Nodules (Recently Termed "Back Mice") as a Potential Cause of Low Back Pain.

Low back pain is a widespread and poorly understood condition that is frequently diagnosed as non-specific low back pain. We were intrigued by the presence of painful sacroiliac nodules in patients with this condition. We conducted a historical review to elucidate this relationship. This chronicled review summarizes the overlooked literature from different countries, especially from around the 1950s, regarding the diagnosis and management of these painful nodules. Biopsies have confirmed the adipose nature of these nodules and revealed distinct pathological signs, including oedema and fascial fatty herniation. Studies have suggested both intra-nodule local anaesthetic injection and surgery as successful treatments for managing pain on a short- or long-term basis. Recent ultrasound studies have confirmed these findings. The various terms used for these nodules over time are specifically described. We conclude that it may be necessary to reconsider the role of fatty tissue in the aetiology and treatment of low back pain in today's mainstream medicine. This could lead to advances in understanding unexplained musculoskeletal pain disorders beyond low back pain. Meanwhile, despite the remaining questions, the treatments identified in these studies can help physicians manage patients' unresolved pain. We recommend that future research use this review as a foundation for further study.

Endoscopic Cauterization with Pneumatic Distension for Piriform Fossa Sinus Tracts.

INTRODUCTION: Piriform fossa sinus tracts (PFSTs) are a cause of recurrent neck infections in the pediatric population. Conventional management required open resection, but over the last years minimally invasive approaches have been reported in an attempt to endoscopically obliterate the PFST, using different methods such as electrocautery, laser, trichloroacetic acid, or silver nitrate. MATERIALS AND METHODS: We undertook a retrospective review of the medical records of 12 children (aged 4 months to 14 years) with PFSTs treated with endoscopic sclerosis with diathermy (ESD) between 2010 and 2016 at a tertiary care children's hospital. We also present a technical modification of ESD, using continuous infusion of airflow through the gastroscopy, to distend the piriform sinus and facilitate its recognition. PFST obliteration was performed using diathermy through a guide wire. RESULTS: Clinical presentation of the 12 affected children included neck tumor (7 [58%]), neck abscesses (4 [33%]), and thyroiditis (5 [41%]). All lesions occurred on the left side. All patients underwent both ultrasonography and barium esophagography (the latter being positive only in 50%). Two patients were treated with ESD after the open approach had failed. There was no procedure-related morbidity. One patient had a recurrence (positive barium swallow without symptoms). The success rate of this procedure in our series was 91% with one attempt and 100% with two attempts. CONCLUSION: In our experience, treatment of PFST with ESD is a reproducible, noninvasive, and an effective option. ESD could be considered a primary approach and also for revision after open surgery has failed in these patients.

Efficacy of peroral endoscopic myotomy compared with other invasive treatment options for the different esophageal motor disorders.

INTRODUCTION: Peroral endoscopic myotomy (POEM) has been performed since 2008 on more than 5,000 patients. It has proven to be highly effective in the treatment of achalasia and has shown promising outcomes for other esophageal motility spastic disorders. METHODS: A literature review of the efficacy of POEM compared to the previous invasive treatments for different esophageal motility disorders was performed. The application in the pediatric and elderly populations and its role as a rescue therapy after other procedures are also outlined. RESULTS: Short-term outcomes are similar to laparoscopic Heller myotomy (LHM) and pneumatic endoscopic dilation (PD) (clinical success > 90%) for achalasia subtypes I and II. Mid-term outcomes are comparable to LHM and overcome the results obtained after PD (> 90% vs ~50%). With regard to type III achalasia, POEM efficacy is 98% compared to 80.8% for LHM and the PD success remains at 40%. With regard to spastic esophageal disorders (SED), POEM has an effectiveness of 88% and 70% for distal esophageal spasm (DES) and jackhammer esophagus (JE) respectively. A response of 95% in patients with sigmoid esophagus has been reported. POEM has been performed in pediatric and elderly populations and has obtained a higher efficacy than PD in pediatric series (100% vs 33%) without greater adverse events. Previous treatments do not seem to hinder POEM results with excellent response rates, including 97% in post LHM and 100% in a re-POEM series. Final considerations: POEM has shown excellent short and mid-term results for all subtypes of achalasia but long-term results are not yet available. The promising results in SED may make POEM the first-line treatment for SED. A high-safety profile and efficacy have been shown in elderly and pediatric populations. Previous treatments do not seem to diminish the success rate of POEM. Core tip: POEM has emerged as an efficient treatment option for all subtypes of achalasia and other scenarios (including previous treatments and elderly and pediatric populations). Short and mid-term results are comparable to LHM and are better than PD data. The clinical response rate of DES and JE may make POEM the first-line treatment for SED.

Chronic Pancreatitis-Like Changes Detected by Endoscopic Ultrasound in Type 1 Diabetics Are Not Associated With Gastrointestinal Symptoms or Nutritional Deficiencies.

OBJECTIVES: Previous studies have shown changes in the pancreas of type 1 diabetic (T1-DM) patients, similar to those present in patients with chronic pancreatitis. Our aim was to analyze the prevalence of endoscopic ultrasound (EUS) criteria for chronic pancreatitis in T1-DM, to determine the association with factors related to the diabetes and to define its clinical significance. METHODS: Eighty-six T1-DM patients were prospectively included. All of them underwent EUS. Standard criteria were used. Patients were divided into 3 groups according to the number of EUS criteria they met: group A, 0 to 2 criteria; group B, 3 to 4; and group C, more than 4. Association between EUS findings and demographic or clinical factors was studied as well as the relationship between EUS abnormalities and the presence of gastrointestinal symptoms or nutritional deficiencies. RESULTS: Fifty-three patients (61.6%) showed at least 1 morphologic abnormality. Fifty-eight patients were included in group A, 21 in group B, and 7 in Group C. No significant differences were found when comparing the 3 groups. CONCLUSIONS: Chronic pancreatitis-like changes are frequent in the pancreas of T1-DM patients. These changes are not associated with demographic or clinical data. Therefore, the clinical relevance seems to be scarce.

Role of Intraluminal Esophageal Impedance Baseline in the Diagnosis of Esophagitis in Children.

Introduction Low values of esophageal impedance baseline (EIB) have been related to esophagitis. The aim of this study was to evaluate the diagnostic performance of EIB for erosive esophagitis (ErE) and histological esophagitis (HiE) in children studied for gastroesophageal reflux. Material and Methods Children who underwent esophageal multichannel intraluminal impedance-pH monitoring (MII-pH) and upper-endoscopy with esophageal biopsies were studied retrospectively. EIB values were obtained by MII-pH. ErE was assessed by endoscopy following the Hetzel-Dent classification; HiE was defined by basal zone hyperplasia, papillary lengthening, or inflammatory infiltration. EIB was compared between groups. Receiver operating characteristic (ROC) curves were obtained to calculate the global diagnostic performance of EIB and to find cut-off values for sensitivity and specificity. Logistic regression was used for age adjustment. Results Fifty-one patients were studied: 11 had ErE and 23 had HiE. EIB median values were 1,159 in ErE versus 2,583 in non-ErE (U = 80, p < 0.01). The adjusted ROC curve analysis for ErE was 0.85 (95% CI = 0.74-0.96); the EIB cut-off value = 2,379 determined sensitivity = 100% and specificity = 52.6% in children < 4 years old. and sensitivity = 100% and specificity = 63.2% in children > 4 years old. EIB median values were 1,666 in HiE versus 2,669 in non-HiE (U = 80, p < 0.01). The adjusted ROC curve analysis for HiE was 0.75 (95% CI = 0.59-0.90); the EIB cut-off value = 2,296 determined sensitivity = 71.2% and specificity = 83.1% in children < 4 years old, and sensitivity = 75.1% and specificity = 80.1% in children > 4 years old. Conclusion EIB provides statistically significant diagnostic performances for ErE and HiE. It could become a useful tool, especially to discriminate between ErE and non-ErE, avoiding other invasive tests.

Surgical Findings in Transfusion-Associated Necrotizing Enterocolitis.

Introduction The extent of intestinal damage in transfusion-associated necrotizing enterocolitis (TNEC) has been scarcely studied. The aim of this investigation was to study surgical findings in TNEC and determine their severity considering the extent of the disease and risk of bowel perforation. Materials and Methods Neonates who required surgical treatment for necrotizing enterocolitis (NEC) were studied retrospectively. Patients who developed NEC within 48 hours after a red blood cell transfusion (RBCT) formed group TR48 and patients who did not receive a RBCT 48 hours before the diagnosis of NEC became group CN (conventional NEC). Both groups were compared: main outcomes were the extent of the disease (isolated, multifocal, or panintestinal), the existence of perforated NEC, and mortality. Categorical variables were analyzed with the chi-square test and continuous variables with the Mann-Whitney u-test. The relationship between RBCTs 48 hours before the diagnosis and the extent of intestinal disease was evaluated by ordinal logistic regression. Results Forty-seven patients were included in the study: 16 patients in TR48 and 31 in CN. The odds ratio of multifocal or panintestinal NEC for patients in TR48 was 0.5 (95% CI: 0.148-1.68). Neonates in TR48 had a relative risk (RR) of perforated NEC of 1.2 (95% CI: 0.76-1.85). The RR of death was 1.55 (95% CI: 0.76-3.14) in group TR48. Conclusion No differences in surgical findings between TR48 and CN could be demonstrated in this investigation; therefore, the hypothesis that intestinal damage might be more severe in TNEC was not confirmed.

Acute recurrent pancreatitis secondary to hepatocellular carcinoma invading the biliary tree.

Hepatocellular carcinoma rarely invades the biliary tree. Clots or tumor embolus passing though the bile duct can cause pancreatitis by a mechanism similar to gallstone pancreatitis. We present the case of a patient with recurrent acute pancreatitis, initially suspicious of biliary origin. Despite cholecystectomy he had new episodes of acute pancreatitis. Hepatocellular carcinoma was diagnosed after the third episode. ERCP findings suggested the presence of a fistula connecting the tumor and the biliary tree. The patient was operated and the hepatocellular carcinoma was resected. Its pathological analysis confirmed the communication between the tumor and the biliary duct.

Role of endoscopic ultrasound in the diagnosis of pancreatic cancer.

Endoscopic ultrasonography (EUS) with or without fine needle aspiration has become the main technique for evaluating pancreatobiliary disorders and has proved to have a higher diagnostic yield than positron emission tomography, computed tomography (CT) and transabdominal ultrasound for recognising early pancreatic tumors. As a diagnostic modality for pancreatic cancer, EUS has proved rates higher than 90%, especially for lesions less than 2-3 cm in size in which it reaches a sensitivity rate of 99% vs 55% for CT. Besides, EUS has a very high negative predictive value and thus EUS can reliably exclude pancreatic cancer. The complication rate of EUS is as low as 1.1%-3.0%. New technical developments such as elastography and the use of contrast agents have recently been applied to EUS, improving its diagnostic capability. EUS has been found to be superior to the recent multidetector CT for T staging with less risk of overstaying in comparison to both CT and magnetic resonance imaging, so that patients are not being ruled out of a potentially beneficial resection. The accuracy for N staging with EUS is 64%-82%. In unresectable cancers, EUS also plays a therapeutic role by means of treating oncological pain through celiac plexus block, biliary drainage in obstructive jaundice in patients where endoscopic retrograde cholangiopancreatography is not affordable and aiding radiotherapy and chemotherapy.

¿Influye el posible cansancio del endoscopista en la frecuencia de colonoscopias incompletas y de las lesiones polipoideas diagnosticadas? / Does endoscopist fatigue play a role in incomplete colonoscopies and detection of polypoid lesions?

INTRODUCCIÓN: Actualmente sigue discutiéndose el posible efecto del cansancio del explorador sobre los resultados de las colonoscopias. Pretendemos analizar posibles diferencias en cuanto a exploraciones completas e índice de pólipos y adenomas diagnosticados en las endoscopias, según fueran efectuadas al principio o al final de cada sesión de trabajo continuado, y valorar la influencia del número de orden de realización de la colonoscopia (queue position) sobre los índices de lesiones detectadas. PACIENTES Y MÉTODOS: Estudio retrospectivo de 1.000 colonoscopias ambulatorias, sucesivas y divididas en 2 grupos: «inicial» y «final». Tras excluir 95 exploraciones mal preparadas y comprobar la homogeneidad de los grupos en cuanto a características y antecedentes de los pacientes, comparamos la frecuencia de exploraciones completas y el índice de pólipos y adenomas entre ambos bloques. Analizamos posibles diferencias en la frecuencia de lesiones polipoideas, según el número de orden de realización de la colonoscopia. RESULTADOS: Los índices globales de pólipos y adenomas fueron 44,2 y 30,5%, respectivamente, sin diferencias significativas entre los 13 exploradores; pólipos: p = 0,21, y adenomas: p = 0,63. Comparando los grupos «inicial» (n = 532) y «final» (n = 373), no encontramos diferencias en cuanto a exploraciones completas (97,2 versus 99,4% [p = 0,92]), ni índice de pólipos (45,9 versus 41,8% [p = 0,23], ni adenomas (30,8 versus 30% [p = 0,80] o adenomas serrados (2,1 versus 1,6% [p = 0,62]). El índice de lesiones detectadas no varió en relación con la queue position: pólipos, p = 0,60, y adenomas, p = 0,83. CONCLUSIONES: En nuestro medio, el posible cansancio del explorador al final de la agenda de trabajo no influyó en el porcentaje de colonoscopias completas, ni en los índices de pólipos o adenomas diagnosticados. Tampoco registramos diferencias en cuanto a lesiones polipoideas detectadas en relación con el número de orden de realización de la colonoscopia

INTRODUCTION: Nowadays, the possible effect of endoscopist fatigue on the results of colonoscopies is under discussion. We aimed to analyze possible differences in cecal intubation and the polyp and adenoma detection rate, depending on whether colonoscopies were performed at the beginning or at the end of the daily endoscopy session and to analyze the influence of the queue position on the detection rate. PATIENTS AND METHODS: A retrospective study was performed with 1,000 ambulatory and consecutive colonoscopies, divided into 2 groups: «early» and «late» procedures. A total of 95 colonoscopies were excluded due to poor colon cleansing. After confirming that patient characteristics were homogenous in the two groups, we compared the frequency of complete colonoscopies and the polyp and adenoma detection rate. Possible differences between the 2 groups in the polyp detection rate according to the colonoscopy schedule were analyzed. RESULTS: The overall polyp and adenoma detection rates were 44.2 and 30.5%, respectively, with no significant differences among 13 different endoscopists; polyps: p = 0.21; adenomas: p = 0.63. No significant differences were found between the «early group» (n = 532) and the «late group» (n = 373) in the rates of complete colonoscopies [97.2 vs 99.4% (p = 0.92)], the polyp detection rate [45.9 vs 41.8% (p = 0.23)], the adenoma detection rate [30.8 vs 30% (p = 0.80)] or the serrated adenoma rate [2.1% vs 1.6% (p = 0.62)]. The lesion detection rate did not vary in relation to the «queue position»: polyps [p = 0.60, and adenomas: p = 0.83. CONCLUSIONS: In our series, endoscopist fatigue at the end of the day had no influence on the complete colonoscopy rate or on the polyp and adenoma detection rate. There were no differences in the number of polypoid lesions detected according to the timing of the colonoscopy Schedule

[Does endoscopist fatigue play a role in incomplete colonoscopies and detection of polypoid lesions?]. / ¿Influye el posible cansancio del endoscopista en la frecuencia de colonoscopias incompletas y de las lesiones polipoideas diagnosticadas?

INTRODUCTION: Nowadays, the possible effect of endoscopist fatigue on the results of colonoscopies is under discussion. We aimed to analyze possible differences in cecal intubation and the polyp and adenoma detection rate, depending on whether colonoscopies were performed at the beginning or at the end of the daily endoscopy session and to analyze the influence of the queue position on the detection rate. PATIENTS AND METHODS: A retrospective study was performed with 1,000 ambulatory and consecutive colonoscopies, divided into 2 groups: «early¼ and «late¼ procedures. A total of 95 colonoscopies were excluded due to poor colon cleansing. After confirming that patient characteristics were homogenous in the two groups, we compared the frequency of complete colonoscopies and the polyp and adenoma detection rate. Possible differences between the 2 groups in the polyp detection rate according to the colonoscopy schedule were analyzed. RESULTS: The overall polyp and adenoma detection rates were 44.2 and 30.5%, respectively, with no significant differences among 13 different endoscopists; polyps: p = 0.21; adenomas: p=0.63. No significant differences were found between the «early group¼ (n= 532) and the «late group¼ (n = 373) in the rates of complete colonoscopies [97.2 vs 99.4% (p=0.92)], the polyp detection rate [45.9 vs 41.8% (p=0.23)], the adenoma detection rate [30.8 vs 30% (p=0.80)] or the serrated adenoma rate [2.1% vs 1.6% (p=0.62)]. The lesion detection rate did not vary in relation to the «queue position¼: polyps [p = 0.60, and adenomas: p = 0.83. CONCLUSIONS: In our series, endoscopist fatigue at the end of the day had no influence on the complete colonoscopy rate or on the polyp and adenoma detection rate. There were no differences in the number of polypoid lesions detected according to the timing of the colonoscopy schedule.

Ectopia tiroidea retroperitoneal / Ectopic retroperiotoneal thyroid gland

La ectopia tiroidea subdiafragmática es un hallazgo muy infrecuente, del cual hemos identificado únicamente 15 casos tras una revisión de la literatura médica. Su manejo no se encuentra establecido, si bien es frecuente su extirpación por la sospecha de enfermedad neoplásica. Presentamos el caso de una mujer de 76 años que presenta una ectopia tiroidea mesentérica en forma de masa retroperitoneal extirpada quirúrgicamente y que evolucionó de manera favorable (AU)

The presence of subdiaphragmatic thyroid tissue is a very rare finding. We reviewed the literature and found only 15 published cases. The most appropriate management of this entity has not been established, but surgical removal is common to exclude malignancy. We present the case of a 76-year-old woman with an ectopic mesenteric thyroid gland forming a retroperitoneal mass that was surgically removed. Outcome was favorable (AU)

[Ectopic retroperitoneal thyroid gland]. / Ectopia tiroidea retroperitoneal.

The presence of subdiaphragmatic thyroid tissue is a very rare finding. We reviewed the literature and found only 15 published cases. The most appropriate management of this entity has not been established, but surgical removal is common to exclude malignancy. We present the case of a 76-year-old woman with an ectopic mesenteric thyroid gland forming a retroperitoneal mass that was surgically removed. Outcome was favorable.

Could clinical scores guide the surgical treatment of necrotizing enterocolitis?

PURPOSE: Test the diagnostic reliability of the score for neonatal acute physiology-perinatal extension-II (SNAPPE-II) and the metabolic derangement acuity score (MDAS) as predictors of surgery in patients with necrotizing enterocolitis (NEC). METHODS: The SNAPPE-II and the MDAS were applied to 99 patients with NEC. Both the scores were calculated at the moment of diagnosis (T(0)) and when surgical assessment was required (T(1)). The main outcome was the need of surgical revision. Comparison between models was made through their receiver operator characteristics (ROC) curves. RESULTS: Thirty-five patients required surgical treatment (group A) and 64 responded to medical therapy (group B). Median SNAPPE-II was 22 versus 5 for group A (U test 621, p = 0.002) at T(0); and 22 versus 10 for group A (U test 487, p = 0.01) at T(1). Measuring the value of the SNAPPE-II as a predictor of surgery, the ROC curve was 0.69 (CI 95%, 0.57-0.80) at T(0) and 0.67 (CI 95%, 0.55-0.80) at T(1). Median MDAS were 2 for both groups A and B at T(0) (U test 890.5, p = 0.113) and 2 versus 1.5 for group A at T(1) (U test 570, p = 0.043). The ROC curve for MDAS was 0.59 (CI 95%, 0.47-0.71) at T(0) and 0.64 (CI 95%, 0.52-0.77) at T(1). CONCLUSIONS: The diagnostic performance of the SNAPPE-II offers mild results in the moment of the diagnosis of NEC, and at T(1). The MDAS is non significant at T(0) and obtains moderate results at T(1). These results do not encourage using the SNAPPE-II and the MDAS as definite tools to decide for surgical treatment of the patients affected by NEC.

Trasplante celular hepático: un nuevo tratamiento en las enfermedades hepáticas / Hepatic cell transplantation: A new therapy in liver diseases

El transplante hepático es el único tratamiento efectivo existente para las enfermedades hepáticas en fase terminal. La desproporción entre la demanda y la oferta de órganos constituye su principal limitación y plantea la necesidad de buscar alternativas al trasplante hepático. El trasplante celular hepático o trasplante de hepatocitos humanos constituye, en el momento actual, la mejor opción terapéutica sustitutiva. Consiste en trasplantar hepatocitos humanos totalmente diferenciados a un órgano receptor, en cantidad suficiente para que estos sobrevivan y restauren la función hepática normal, basándose en la capacidad de regeneración hepática. Este tratamiento está en fase clinicoexperimental, y se ha realizado en pacientes con errores congénitos del metabolismo, fallo hepático fulminante y fallo hepático agudo o crónico como puente al trasplante convencional. En el Hospital La Fe de Valencia hemos puesto en marcha y llevado a cabo el primer trasplante celular hepático en España, por tanto, esto abre una nueva línea de trabajo dentro del Programa de Trasplante Hepático (AU)

Liver transplantation has been remarkably effective in the treatment in patients with end-stage liver disease. However, disparity between solid-organ supply and increased demand is the greatest limitation, resulting in longer waiting times and increase in mortality of transplant recipients. This situation creates the need to seek alternatives to orthotopic liver transplantation.Hepatocyte transplantation or liver cell transplantation has been proposed as the best method to support patients. The procedure consists of transplanting individual cells to a recipient organ in sufficient quantity to survive and restore the function. The capacity of hepatic regeneration is the biological basis of hepatocyte transplantation. This therapeutic option is an experimental procedure in some patients with inborn errors of metabolism, fulminant hepatic failure and acute and chronic liver failure, as a bridge to orthotopic liver transplantation. In the Hospital La Fe of Valencia, we performed the first hepatocyte trasplantation in Spain creating a new research work on transplant program (AU)

[Hepatic cell transplantation: a new therapy in liver diseases]. / Trasplante celular hepático: un nuevo tratamiento en las enfermedades hepáticas.

Liver transplantation has been remarkably effective in the treatment in patients with end-stage liver disease. However, disparity between solid-organ supply and increased demand is the greatest limitation, resulting in longer waiting times and increase in mortality of transplant recipients. This situation creates the need to seek alternatives to orthotopic liver transplantation.Hepatocyte transplantation or liver cell transplantation has been proposed as the best method to support patients. The procedure consists of transplanting individual cells to a recipient organ in sufficient quantity to survive and restore the function. The capacity of hepatic regeneration is the biological basis of hepatocyte transplantation. This therapeutic option is an experimental procedure in some patients with inborn errors of metabolism, fulminant hepatic failure and acute and chronic liver failure, as a bridge to orthotopic liver transplantation. In the Hospital La Fe of Valencia, we performed the first hepatocyte transplantation in Spain creating a new research work on transplant program.

Z-line examination by the PillCam SB: prospective comparison of three ingestion protocols.

AIM: To evaluate the Z-line visualization by the PillCam SB2 using three different ingestion protocols. METHODS: Ninety consecutive patients undergoing small bowel capsule endoscopy (SBCE) between January and May 2008 were included in the study. They swallowed the capsule in the standing (Group A = 30), supine (Group B = 30) and right supine positions (Group C = 30). Baseline patient characteristics, difficulties in capsule ingestion, esophageal transit times (ETT) and Z-line visualization were noted. RESULTS: No significant differences were found between the groups with regard to baseline patient characteristics, ingestion difficulties and complete SB examinations (P > 0.05). At least 1 frame of the Z-line was detected in 15.8%, 46.7% and 90% of patients in groups A, B and C, respectively (P < 0.001). The average number of Z-line images was 0.21 +/- 0.53, 3.23 +/- 6.59 and 5.53 +/- 7.55 and the mean % of the Z-line detected was 71.3, 25.1 and 8.3, in groups A, B and C, respectively (both P < 0.001). ETT times were longer in the supine group followed by the right supine and the standing groups (median of 237 s vs 64 s and 39 s, respectively; P < 0.001). CONCLUSION: Z-line visualization in patients undergoing SBCE can be accurately achieved in most cases when the capsule is swallowed in the right supine position.

Lessons learned from anatomic variants of the hepatic artery in 1,081 transplanted livers.

The aim of this study is to contribute our experience to the knowledge of the anatomic variations of the hepatic arterial supply. The surgical anatomy of the extrahepatic arterial vascularization was investigated prospectively in 1,081 donor cadaveric livers, transplanted at La Fe University Hospital from January 1991 to August 2004. The vascular anatomy of the hepatic grafts was classified according to Michels description (Am J Surg 1966;112:337-347) plus 2 variations. Anatomical variants of the classical pattern were detected in 30% of the livers (n=320). The most common variant was a replaced left artery arising from the left gastric artery (9.7%) followed by a replaced right hepatic artery arising from the superior mesenteric artery (7.8%). In conclusion, the information about the different hepatic arterial patterns can help in reducing the risks of iatrogenic complications, which in turn may result in better outcomes not only following surgical interventions but also in the context of radiological treatments.

Hepatocellular carcinoma: Can it be considered a controversial indication for liver transplantation in centers with high rates of hepatitis C?

Hepatocellular carcinoma (HCC) is still considered a controversial indication for liver transplantation (LT), mainly because of long waiting times and underlying viral cirrhosis. The goal was to evaluate the outcome of LT in 104 patients with HCC and cirrhosis, mainly hepatitis C virus (HCV)-related, in a center with a short waiting time (median, 105 days). Four groups were formed according to the HCC and HCV status: HCV positive with HCC (group 1, n = 81), HCV negative with HCC (group 2, n = 23), HCV positive without HCC (group 3, n = 200), and HCV negative without HCC (group 4, n = 207). Predictive factors of tumor recurrence were demographics, tumor related (size or number of nodules, capsule, bilobar involvement, vascular or lymphatic invasion, clinical and pathologic TNM staging, pre-LT percutaneous ultrasound-guided ethanol injection or transarterial chemoembolization, alpha-fetoprotein levels), donor and surgery related, and year of transplantation. The same variables and "tumor recurrence (yes/no)" were applied to evaluate the effect on survival. The median follow up was 29 months (range, 0 to 104 months). Patient survival was 70% at 1 year and 59% at 5 years for group 1, 87% at 1 year and 77% at 5 years for group 2, 81% at 1 year and 64% at 5 years for group 3, and 88% at 1 year and 77% at 5 years for group 4 (P =.013). Survival was significantly lower in patients with HCC than in those without (74% and 63% versus 85% and 70%, at 1 and 5 years, respectively; P =.05). The causes of death in those with and without HCC were tumor recurrence (24%) and recurrent HCV (8%) versus sepsis (34%) and recurrent HCV (14%). HCC recurrence occurred in 12 patients (11.5%) at a median of 14 months (range, 3 to 60 months) with a probability increasing from 8% at 1 year to 16% at 5 years. In patients with HCC, tumor recurrence was associated with vascular invasion (P =.0004) by multivariate analysis; variables predictive of survival were donor old age (P =.01), viral-related etiology (P =.02), and tumor recurrence (P =.001). Although LT still remains an adequate indication for HCC in centers with high prevalence of HCV infection and short waiting times, both tumor and HCV-related recurrent diseases hamper significantly the outcomes of these patients.