Spontaneously ruptured hepatocellular carcinoma on non-cirrhotic liver: A prospective case series.

BACKGROUND AND AIMS: Spontaneous ruptured hepatocellular carcinoma is an uncommon complication, and there are scarce data about non-cirrhotic patients. Tumor treatment is not standardized and the risk of peritoneal dissemination is unclear. AIM: we analyzed the treatment and survival in patients with rHCC on non-cirrhotic liver. METHODS: One hundred and forty-one non-cirrhotic patients with hepatocellular carcinoma diagnosed by histology were included in a multicenter prospective registry (2018-2022). Seven of them (5%) presented with hemoperitoneum due to spontaneous rupture. RESULTS: Liver disease was associated in three patients (42.9%). A single nodule was detected in three cases (42.9%). One patient had vascular invasion and none extrahepatic spread. Initial hemostatic therapy and sequential treatment was individualized. Patients with single nodule were treated: resection (one case) with recurrence at 4 months treated with TACE and sorafenib. TACE/TAE followed by surgery (two cases) one in remission 43 months later, the other had liver recurrence at 18 months and was transplanted. Patients with multiple lesions were treated: TAE/emergency surgery and subsequent systemic therapy (two cases), one received lenvatinib (1-year survival) and the other sorafenib (5-month survival). TAE and surgery with subsequent systemic therapy (one case). Initial hemostatic surgery, dying on admission (one case). No patient developed intraperitoneal metastasis. All patients with multiple lesions died by tumor. The 3-year survival rate was 42.9%. CONCLUSIONS: Initial hemostasis was achieved in all patients by TAE/TACE or surgery. Subsequent treatment was individualized, based on tumor characteristics, regardless of rupture. Long-time remission could be achieved in single nodule patients.

Retrieval and treatment of patients with primary biliary cholangitis who are lost in the health system.

INTRODUCTION: hepatitis C patients loss to follow-up in the health care system has been shown to have negative consequences. This study aimed to investigate this issue as regards primary biliary cholangitis. METHODS: the databases (immunology, biochemistry, clinical reports, drug dispensation, appointments) of 4 reference hospitals in Spain (serving a population of 1,450,000 inhabitants) were analyzed. The diagnosis of primary biliary cholangitis was based on an antimitochondrial antibody titer ≥ 1:80, chronically elevated alkaline phosphatase, and the absence of other liver disease. Patients were classified as lost in the absence of reports indicating a diagnosis, specific medical follow-up, and/or treatment with bile salts. RESULTS: a total of 1372 patients with antimitochondrial antibody titers ≥ 1:80 were included between January 2010 and June 2019. A total of 697 (50.8 %) were classified as having primary biliary cholangitis, and 100 patients (14.3 %; 95 % CI: 11.8-17.2) were identified as lost. Of these, 30 were contacted and retrieved. The median age was 70 years, 93 % were female, median alkaline phosphatase was 185 IU/L, 10 % had pruritus, and 27 % had a transient elastography value > 9.5 kPa. The disease was confirmed and ursodeoxycholic acid was started in all 30 patients. Death was liver-related in 6 of the 100 patients classified as lost. CONCLUSION: up to 14.3 % of patients (1 out of 7) with a definitive diagnosis of primary biliary cholangitis remain undiagnosed, thus preventing monitoring and treatment. More than a quarter are at risk of advanced liver disease and its complications. Patients lost in the system must be identified and retrieved, and searching hospital databases is a suitable approach to meet this goal.

Functional gastrointestinal disorders: real-life results of a multidisciplinary non-pharmacological approach based on group-consultations.

INTRODUCTION: functional gastrointestinal disorders are prevalent and resource consuming. The use of group-consultations in these diseases is limited and no specific multidisciplinary programs have been developed. METHODS: a multidisciplinary approach was used in patients with diverse functional gastrointestinal disorders attending group-consultations (group A). Five two-hour sessions were scheduled over a four-month period. Sessions consisted of a theoretical introduction (Pathophysiology, Low fodmap diet, Over the counter medications, Mediterranean diet, and Laughter therapy workshop) followed by relaxation techniques. This group was compared to a similar group of patients who received written information covering the topics discussed during the group-consultations (group B). Severity of digestive and psychological symptoms, use of drugs and adherence to the diet were the main outcomes measured. RESULTS: the mean age of participants was 43 (± 1.38) years, 78 % were female and 73 % had at least two functional gastrointestinal disorders. Sixty-two patients were included in group A and 17 in group B. The severity of gastrointestinal and psychological symptoms at baseline was similar in both groups. Globally, there was an improvement in all symptoms in both groups. The proportion of participants with severe baseline gastrointestinal symptoms or pathologic anxiety scores that showed improvement was significantly higher in group A (74 % vs 23 %, p = 0.005; 47 % vs 8 %, p = 0.02, respectively). Symptoms were reassessed at six and 12 months after the intervention in participants from group A who attended ≥ 80 % sessions and a sustained response was observed. CONCLUSIONS: group-consultations are useful and efficient to alleviate gastrointestinal and psychological symptoms in patients with functional gastrointestinal disorders.

Final incision size after cataract surgery with toric intraocular lens implantation using 2 techniques.

PURPOSE: To analyze the changes in incision sizes after implantation of a toric intraocular lens (IOL) using 2 methods. SETTING: Department of Ophthalmology, Clínica Universidad de Navarra, Pamplona, Spain. DESIGN: Prospective case series. METHODS: Coaxial phacoemulsification and IOL implantation through a 2.2 mm clear corneal incision using a cartridge injector were performed. Wound-assisted or cartridge-insertion techniques were used to implant the IOLs. The results were analyzed according to IOL spherical and cylindrical powers. Corneal hysteresis (CH) and the corneal resistance factor (CRF) were measured and evaluated based on the changes in incision size. RESULTS: Incision size increased in 30 (41.7%) of 72 eyes in the wound-assisted group and 71 (98.6%) of 72 eyes in the cartridge-insertion group. The mean incision size after IOL implantation was 2.27 mm ± 0.06 (SD) and 2.37 ± 0.05 mm, respectively (P<.01). The final incision size and IOL spherical power in the wound-assisted technique group (P=.02) and the cartridge-insertion technique group (P=.03) were correlated significantly; IOL toricity was not (P=.19 and P=.28, respectively). The CH and CRF values were not correlated with the final incision size. CONCLUSIONS: The final incision size and the changes in incision size after IOL implantation were greater with the cartridge-insertion technique than with the wound-assisted technique. The increase was related to IOL spherical power in both groups but not to IOL toricity. Corneal biomechanical properties were not correlated with the final incision size.

Is the use of prophylactic hemoclips in the endoscopic resection of large pedunculated polyps useful? A prospective and randomized study.

BACKGROUND: The methods for preventing post-polypectomy bleeding (PPB) are not standardised and there are groups that use hemoclips for this purpose. OBJECTIVE: To study whether the use of hemoclips reduces PPB complications. MATERIALS AND METHODS: Prospective, randomised study of patients with pedunculated polyps larger than 10 mm. The patients were included in two groups (hemoclip before polypectomy -HC- and standard polypectomy -SP-). This study has been registered with the trial registration number NCT01565993. RESULTS: 105 polypectomies were performed (98 patients), 66 (62.9%) in the HC group. The total rate of complications was 10,6% in the HC group (4.5% early bleeding, 1.5% severe delayed bleeding, 4,5% mucosal burns, 1.5% perforation). In the SP group, the rate of total complications was 7,7%, (7,7% early bleeding, no significant differences). In view of the unexpected increase in the morbidity of the hemoclip group, the study was suspended without reaching the sample size. In an ad hoc analysis, which includes the standard polypectomy patients who refused to participate in the study (35 polyps), the total morbidity was 5,7% (no perforations and 2 patients with premature bleeding).When we compared the morbidity of the HC group to the morbidity of SP group plus R group (74 polyps), we also failed to detect any significant differences in terms of PPB, but did in terms of perforation. CONCLUSION: The prophylactic use of hemoclips in polypectomies of large pedunculated polyps leads to a further risk of mucosal burns and perforation that is not acceptable, and does not reduce the risk of PPB.

Is the use of prophylactic hemoclips in the endoscopic resection of large pedunculated polyps useful? A prospective and randomized study.

BACKGROUND: The methods for preventing post-polypectomy bleeding (PPB) are not standardised and there are groups that use hemoclips for this purpose. OBJECTIVE: To study whether the use of hemoclips reduces PPB complications. MATERIALS AND METHODS: Prospective, randomised study of patients with pedunculated polyps larger than 10 mm. The patients were included in two groups (hemoclip before polypectomy -HC- and standard polypectomy -SP-). This study has been registered with the trial registration number NCT01565993. RESULTS: 105 polypectomies were performed (98 patients), 66 (62.9%) in the HC group. The total rate of complications was 10,6% in the HC group (4.5% early bleeding, 1.5% severe delayed bleeding, 4,5% mucosal burns, 1.5% perforation). In the SP group, the rate of total complications was 7,7%, (7,7% early bleeding, no significant differences). In view of the unexpected increase in the morbidity of the hemoclip group, the study was suspended without reaching the sample size. In an ad hoc analysis, which includes the standard polypectomy patients who refused to participate in the study (35 polyps), the total morbidity was 5,7% (no perforations and 2 patients with premature bleeding).When we compared the morbidity of the HC group to the morbidity of SP group plus R group (74 polyps), we also failed to detect any significant differences in terms of PPB, but did in terms of perforation. CONCLUSION: The prophylactic use of hemoclips in polypectomies of large pedunculated polyps leads to a further risk of mucosal burns and perforation that is not acceptable, and does not reduce the risk of PPB.

Intraoperative ERCP: What role does it have in the era of laparoscopic cholecystectomy?

In the treatment of patients with symptomatic cholelithiasis and choledocholithiasis (CBDS) detected during intraoperative cholangiography (IOC), or when the preoperative study of a patient at intermediate risk for CBDS cannot be completed due to the lack of imaging techniques required for confirmation, or if they are available and yield contradictory radiological and clinical results, patients can be treated using intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during the laparoscopic treatment or postoperative ERCP if the IOC finds CBDS. The choice of treatment depends on the level of experience and availability of each option at each hospital. Intraoperative ERCP has the advantage of being a single-stage treatment and has a significant success rate, an easy learning curve, low morbidity involving a shorter hospital stay and lower costs than the two-stage treatments (postoperative and preoperative ERCP). Intraoperative ERCP is also a good salvage treatment when preoperative ERCP fails or when total laparoscopic management also fails.

Is outpatient ERCP suitable, feasible, and safe? The experience of a Spanish community hospital.

BACKGROUND: We wanted to evaluate the safety of outpatient endoscopic retrograde cholangiopancreatography (ERCP). The follow-up of an ERCP outpatient during a short observation period could be a feasible and safe approach. METHODS: To evaluate the safety of outpatient ERCP, we assessed the rate of post-ERCP complications found and missed during a 6-h observation period after therapeutic ERCP. RESULTS: We performed 236 ERCPs on an outpatient basis, with a failure rate of 3.7% but with an overall completion rate for the intended treatment of 90.7%. Seventy-eight percent of the ERCPs were primarily therapeutic. The age of the patients was 63.9 years and 61.9% were females. One hundred seventy-seven (74.5%) patients were discharged from the hospital after the observation period. Thirty-three (14.1%) patients were admitted without further delay due to unexpected ERCP findings or for early detection of complications. Twenty-seven (11.4%) patients had a prolonged hospital stay because of complications during the observation period. Just two patients previously discharged developed later complications: cholangitis and pancreatitis (0.84% of the ERCPs and 7.4% of the overall complications). There were 27 ERCP complications (12.1%). Of the overall complications, 29.6% were diagnosed very early after the procedure and 62.9% were diagnosed during the observation period. 8.9% out of the 12.1% of the ERCP complications were mild to moderate. There was no mortality. CONCLUSION: Twenty-five (92.6%) of ERCP complications occurred during the first 6 h, making the use of this short observation period safe for an early discharge. The evolution of the patients who developed delayed complications was unremarkable. Whenever outpatient ERCP is feasible, it should be done to help cut costs.