Hepaticojejunostomy in Orthotopic Liver Transplant: A Retrospective Case Control Study.

The reported biliary morbidity rate for deceased donor full-size orthotopic liver transplantation is up to 30%. The technique used may be influenced by multiple factors, and in some situations, biliary reconstruction must be carried out through Roux-en-Y hepaticojejunostomy. The aim of our study was to determine the results of the orthotopic liver transplantation according to the technique used in the biliary reconstruction. A retrospective study was performed with the first 1000 orthotopic liver transplants (951 patients) carried out consecutively (1996-2013) with follow-up until 2017. A matched case-control study was designed in 1:3 ratio (47/136) to compare the reconstruction by hepaticojejunostomy vs the end-to-end coledoco-coledocostomy. Hepaticojejunostomy was associated with patients with cholestatic (44.7% vs 3.7%) and ischemic disease (14.9% vs 0%; P < .001) and previous transplant (29.8% vs 1.5%; P = .003). The mean biliary duct reconstruction, surgery, and cold ischemia times were also higher. Vascular complications were significantly more frequent in the hepaticojejunostomy group (36.1% vs 10.4%; P < .001), mainly because of differences in early arterial complications. Nevertheless, there were no differences in the total biliary complication (21.2% vs 16.9%; P = .5). The biliary leakage rate and the biliary stricture rate were also similar. Hepaticojejunostomy in orthotopic liver transplantation presented longer biliary reconstruction, surgery, and cold ischemia times when compared with end-to-end coledoco-coledocostomy. In addition, it was followed by a higher incidence of arterial complications but had similar biliary complication rate and graft survival. Differences could be explained by the fact that hepaticojejunostomy was used more often in cholestatic or ischemic diseases and in retransplant procedures.

Octogenarian Donors in Liver Transplantation.

INTRODUCTION: Due to the disparity between the number of patients on the list for liver transplantation and the availability of organs, the use of older donors has become necessary. The aim of this study was to investigate the outcomes of liver transplantation using octogenarian donors. METHODS: From December 2003 to February 2016, 777 liver transplantations were performed at our institution, 33 of them (4.2%) with donors 80 years old and above. Our policy for the acceptance of these donors is based on preoperative liver function tests, donor hemodynamic stability, and intraoperative normal gross aspect. Octogenarian grafts were deliberately not assigned to retransplantations or to recipients with multiple previous surgical procedures or extensive portal thrombosis. RESULTS: Mean donor age was 82.7 ± 2.1 years, with a range between 80 and 88. Only 12.1% suffered hemodynamic instability during the intensive care unit stay. Three donors (9.1%) had a history of diabetes mellitus. The mean Model for End-Stage Liver Disease score among recipients was 14.7 ± 5.6. Mean cold ischemia time was 302 ± 61 minutes. After a median follow-up of 18.5 months (range 7.5 to 47.5), no graft developed primary nonfunction. We observed hepatic artery thrombosis in 1 patient (3%) and biliary complications in 4 patients (12.5%). There was 1 case of ischemic-type biliary lesion, although it was related to hepatic artery thrombosis. Patient survival at 1 and 3 years was 90.3%, whereas graft survival was 92.6% and 86.4%, respectively. CONCLUSIONS: Excellent mid-term results can be obtained after liver transplantation with octogenarian donors with strict donor selection and adequate graft allocation.

Intraoperative Portal Flow of Less Than 1 Liter per Minute After Orthotopic Liver Transplantation Is Not Associated Per Se With an Increased Rate of Early Graft Dysfunction.

OBJECTIVE: The aim of this study was to determine whether a portal flow of <1,000 mL/min in orthotopic liver transplantation (OLT) is associated with a higher incidence of early graft dysfunction (EGD) and graft loss. METHODS: A retrospective study was performed of 540 OLTs carried out consecutively from December 2004 to December 2013. Patients were divided into 2 groups: group A, portal flow <1,000 mL/min; and group B, portal flow >1,000 mL/min. We studied the incidence of EGD and graft survival. A subanalysis was performed to define the minimum acceptable portal flow/100 g of liver weight to reduce the development EGD and graft loss. RESULTS: Group A included 29 patients and group B, 511 patients. Group A had significantly lower-weight donors and recipients, female recipients with cholestatic disease, lower MELD scores, and lower hepatic artery flow. EGD occurred in 7 patients in group A (24.1%) versus 101 patients in group B (19.8%; P = .43). No significant differences were found in 1- and 5-year graft survival. A portal flow of <80 mL/min/100 g of liver weight was related to a significantly higher risk of developing EGD (odds ratio, 4.35; 95% confidence interval [CI], 1.46-12.91; P = .008) and graft loss (hazard ratio, 4.05; 95% CI, 1.32-12.42; P = .014). CONCLUSIONS: Intraoperative portal flow of <1,000 mL/min in OLT was not related per se with a higher incidence of EGD or graft loss. Significantly higher risk of developing EGD and graft loss was associated with a portal flow of <80 mL/min/100 g of liver weight.

Safety and Efficacy of Early Everolimus When Calcineurin Inhibitors Are Not Recommended in Orthotopic Liver Transplantation.

Our aim was to study the safety and efficacy of immunosuppression with everolimus (EVL) within the 1st month after orthotopic liver transplantation (LT) when calcineurin inhibitors are not recommended. For this purpose, 28 recipients who had been treated with EVL within the 1st month after adult LT were eligible to enter in a retrospective multicenter study. Patients were followed up for 12 months after LT. EVL therapy was initiated at a median of 14 days (range, 4-24) after LT. The reason for early EVL was neurotoxicity in 14 cases, renal dysfunction in 12, and acute cellular rejection combined with renal impairment in 2. In 23 patients, immunosuppression was EVL + mycophenolate mofetil/mycophenolate sodium + steroids, and EVL + tacrolimus + steroids/mycophenolate sodium was used in 4 cases. Neurotoxicity disappeared in all patients. Renal function in patients with renal impairment improved from a median of 32 mL/min/1.73 m2 at the moment of implementation of EVL to 62 mL/min/1.73 m2 at 1 year. Four patients (14.3%) developed acute cellular rejection. We observed incisional hernia in 4 patients (14.3%), hematologic complications in 6 (21.4%), proteinuria in 2 (7.1%), edema and/or effusions in 8 (28.6%), and dyslipidemia in 12 (42.8%). No arterial complications were observed. EVL was withdrawn in 5 patients during the 1st year after LT. One-year patient survival was 92.7%. In conclusion, use of EVL within the 1st month after LT when calcineurin inhibitors are not recommended seems to be an effective therapeutic option with an acceptable safety profile.

Risk factors for biliary complications after orthotopic liver transplantation with T-tube: a single-center cohort of 743 transplants.

BACKGROUND: Despite recent advances in organ preservation, surgical procedures, and immunosuppression, biliary reconstruction after orthotopic liver transplantation (OLT) remains as a major source of morbidity. The purpose of this study was to identify risk factors for the development of biliary complications (BCs) after end-to-end choledochocholedochostomy (EE-CC) with a T-tube as the standard technique for biliary reconstruction after OLT. METHODS: A total of 833 consecutive liver transplantations that took place from February 1996 to April 2010 were retrospectively reviewed. Patients with concomitant hepatic artery complications were excluded, as were those who underwent urgent retransplantation or died within 1 week after transplantation. Finally, the study group comprised 743 patients. RESULTS: The overall BC rate was 9.8% (73 patients), including stricture in 19 patients (2.6%) and bile leakage in 39 patients (5.2%). After univariate analysis, significant risk factors for BCs were surgery time >5 hours, arterial ischemia time >30 minutes, use of a classic transplant technique, transfusion of red blood cells ≥5 units, anti-cytomegalovirus treatment, and period of transplantation between 1996 and 2002. Stepwise logistic regression study was performed, including those variables with a value of P <.200. Multivariate analysis showed that pretransplant serum creatinine (odds ratio = 1.27; 95% confidence interval [CI], 1.03-1.57; P = .025) and arterial ischemia time >30 minutes (odds ratio = 2.44; 95% CI, 1.45-4.12; P = .001) were the only independent risk factors related to the development of BCs after biliary reconstruction with the T-tube. CONCLUSIONS: The performance of different variables in predicting occurrence of BCs was assessed with the use of receiver operating characteristic analysis. The area under the receiver operating characteristic curve of our model was 0.637 (95% CI, 0.564-0.710), and therefore we must conclude that other variables not included in our model may have influence in the development of BCs after OLT with an EE-CC with a T-tube as the procedure for biliary reconstruction.

Direct ageing of Thunnus thynnus from the eastern Atlantic Ocean and western Mediterranean Sea using dorsal fin spines.

This study deals with important methodology issues that affect age estimates of eastern Atlantic bluefin tuna Thunnus thynnus using dorsal fin spines. Nearly 3800 spine sections were used from fish caught in the north-east Atlantic Ocean and western Mediterranean Sea over a 21 year period. Edge type and marginal increment analyses indicated a yearly periodicity of annulus formation with the translucent bands (50% of occurrence) appearing from October to May. Nucleus vascularization seriously affected specimens older than 6 years, with the disappearance of 40-50% of the presumed annuli by that age. An alternate sectioning location was a clear improvement and this finding is an important contribution to the methodology of using this structure for ageing the full-length range of eastern T. thynnus. Finally, there were no significant differences between the coefficients of von Bertalanffy growth model estimated from mean length at age data (L∞ = 327.4; k = 0.097; t0 = -0.838) and those estimated from the growth curves accepted for the eastern and western T. thynnus management units.

"Very early" intrahepatic cholangiocarcinoma in cirrhotic patients: should liver transplantation be reconsidered in these patients?

A retrospective cohort multicenter study was conducted to analyze the risk factors for tumor recurrence after liver transplantation (LT) in cirrhotic patients found to have an intrahepatic cholangiocarcinoma (iCCA) on pathology examination. We also aimed to ascertain whether there existed a subgroup of patients with single tumors ≤2 cm ("very early") in which results after LT can be acceptable. Twenty-nine patients comprised the study group, eight of whom had a "very early" iCCA (four of them incidentals). The risk of tumor recurrence was significantly associated with larger tumor size as well as larger tumor volume, microscopic vascular invasion and poor degree of differentiation. None of the patients in the "very early" iCCA subgroup presented tumor recurrence compared to 36.4% of those with single tumors >2 cm or multinodular tumors, p = 0.02. The 1-, 3- and 5-year actuarial survival of those in the "very early" iCCA subgroup was 100%, 73% and 73%, respectively. The present is the first multicenter attempt to ascertain the risk factors for tumor recurrence in cirrhotic patients found to have an iCCA on pathology examination. Cirrhotic patients with iCCA ≤2 cm achieved excellent 5-year survival, and validation of these findings by other groups may change the current exclusion of such patients from transplant programs.

Biliary complications in orthotopic liver transplantation using choledochocholedochostomy with a T-tube.

Despite significant advances in orthotopic liver transplantation (OLT), biliary tract reconstruction is still a major source of complications. Choledochocholedochostomy with a T-tube used to be the standard procedure for biliary reconstruction after OLT. However, many centers currently avoid use of the T-tube because of the high incidence of complications. Our aim was to study the biliary complications occurring at our center when end-to-end choledochocholedochostomy (EE-CC) over a T-tube was used as the standard procedure for biliary reconstruction. A retrospective review was conducted of all patients who underwent liver transplantation from February 1, 1996, to April 30, 2010. Only patients requiring any therapy to treat biliary complications were considered, whereas those with concomitant hepatic artery complications were excluded. The study cohort consisted of 743 patients who had EE-CC with a T-tube. Of these, 73 patients (9.8%) experienced any biliary complication. Anastomotic strictures occurred in 17 patients (2.3%), and non-anastomotic strictures in 2 (0.3%). Fifteen patients with anastomotic strictures were successfully treated by dilatation and stenting. Bile leakage was diagnosed in 39 patients (5.2%). Leakage occurred at the anastomosis in 15 patients (2%), and at the exit site of the T-tube in 24 patients (3.2%). Tube opening was the only treatment used in 30 patients with bile leakage (76.9%). Seven patients experienced leaks after elective T-tube removal (1%). Overall, repeat surgery to manage biliary complications was needed in 9 patients (1.2%). The mortality rate from biliary complications was 0.13%. In conclusion, EE-CC with a T-tube was followed by a low incidence of biliary complications. The complication rate after elective T-tube removal and the repeat surgery rate were extremely low. These results might challenge the current trend to avoid T-tube stenting in OLT.

Advagraf de novo in liver transplantation: a single-center experience.

UNLABELLED: Advagraf, a prolonged release formulation of tacrolimus, is administered once daily in the morning. The aim of this study was to show the results obtained in our center, analyzing the safety, efficacy, blood trough levels, and drug doses. METHODS: We analyzed 50 consecutive recipients of a first liver transplantation with 6 months follow-up. Efficacy and safety variables were collected as the incidence of acute rejection episodes, patient and graft survivals, kidney function as well as incidences of diabetes mellitus and arterial hypertension de novo. RESULTS: The incidence of biopsy proven acute rejection episodes was 10% (n = 5), none 7 of which were steroid resistant and all resolved favorably. The rate of diabetes mellitus de novo was 22% (n = 11), 7 of whom required insulin. Hypertension developed in 9 patients (18%), all of whom were treated with a single drug. The mean serum creatinine level was 1.08 ± 0.25 mg/dL, with 3 patients (6%) displaying a value ≥ 1.5 mg/dL. Patient and graft survivals were 100%. CONCLUSION: Advagraf is an effective immunosuppressant in liver transplantation with a low incidence of biopsy-confirmed acute rejection episodes. The good results for patient and graft survival with few side effects make it a useful drug for de novo liver transplantation.

Once-daily prolonged-release tacrolimus (ADVAGRAF) versus twice-daily tacrolimus (PROGRAF) in liver transplantation.

The efficacy and safety of dual-therapy regimens of twice-daily tacrolimus (BID; Prograf) and once-daily tacrolimus (QD; Advagraf) administered with steroids, without antibody induction, were compared in a multicenter, 1:1-randomized, two-arm, parallel-group study in 475 primary liver transplant recipients. A double-blind, double-dummy 24-week period was followed by an open extension to 12 months posttransplant. The primary endpoint, event rate of biopsy-proven acute rejection (BPAR) at 24 weeks, was 33.7% for tacrolimus BID versus 36.3% for tacrolimus QD (Per-protocol set; p = 0.512; treatment difference 2.6%, 95% confidence interval -7.3%, 12.4%), falling within the predefined 15% noninferiority margin. At 12 months, BPAR episodes requiring treatment were similar for tacrolimus BID and QD (28.1% and 24.7%). Twelve-month patient and graft survival was 90.8% and 85.6% for tacrolimus BID and 89.2% and 85.3% for tacrolimus QD. Adverse event (AE) profiles were similar for both tacrolimus BID and QD with comparable incidences of AEs and serious AEs. Tacrolimus QD was well tolerated with similar efficacy and safety profiles to tacrolimus BID.

Management of hepatocellular carcinoma recurrence after liver transplantation.

UNLABELLED: Management of patients with hepatocellular carcinoma (HCC) recurrence after liver transplantation (OLT) is not well established. We conducted a retrospective analysis of our results in the treatment of HCC recurrence after OLT Patients. The 23 HCC recurrences developed after 182 OLT performed for HCC within Milan criteria, had an average follow-up of 60 months. RESULTS: The median time to recurrence was 23.4 months. Surgical resection of the recurrence was possible in 11 patients, but an R-0 resection was obtained in 8 patients. Four of these 8 patients developed another recurrence, with 3 succumbing due to tumor recurrence and 1 alive at 12 months with recurrence. The other 4 patients without recurrences, include 3 who are alive at 19, 31, and 86 months and 1 who died at 32.6 months due to hepatitis C recurrence. The 3 patients with palliative resections developed recurrences. Twelve patients were rejected for surgery: 8 were treated symptomatically, 2 with systemic chemotherapy, and 2 with everolimus and sorafenib. This last treatment was also prescribed for 2 patients after R-0 surgery who are alive at 19 and 31 months and for 1 patient after R-1 surgery who is alive at 19 months. Of 15 patients who died, 13 succumbed to HCC recurrence. The average survival from transplantation was 61.7 +/- 37.5 and 48 +/- 34.3 months for patients without and with recurrence, respectively (P < .001). The survival from the recurrence was significantly higher among patients with R-0 surgery: 32.3 +/- 21.5 versus 11.9 +/- 6.9 months (P = .006). CONCLUSIONS: HCC recurrence after OLT of patients within Milan criteria was low but had a great impact on survival. Few cases are amenable to R-0 resection, but when possible it was associated with a significantly increased survival, although with an high incidence of a new recurrence. There is a rationale for the use of sorafenib and mammalian target of rapamycin based immunosuppression, which warrants randomized studies.

Incidence and clinical relevance of bacterial contamination in preservation solution for liver transplantation.

OBJECTIVE: Postoperative infection is considered one of the most important causes of morbidity and mortality after liver transplantation. We prospectively studied the incidence and significance of infections in preservation solutions for liver transplantation. MATERIALS AND METHODS: From March 2007 to March 2008, we cultured the University of Wisconsin preservation solution for 60 consecutive liver transplantations. Fluid samples were obtained at the beginning and at the end of the back table procedure. Our posttransplant infection prophylactic protocol consisted of ampicillin and cefotaxime for 48 hours. RESULTS: Cultures were positive in 59 patients (98.4%). Seventy-five percent of the isolates were superficial saprophytic flora (SSF; Staphylococcus coagulase negative, Streptococcus viridans, and Corynebacterium), nevertheless in 15 cases (25.1%) we isolated high virulence pathogens (Staphylococcus aureus, Klebsiella, Escherichia coli, Enterobacter, and Pseudomonas aeruginosa). There were neither anaerobic nor fungal isolates. Sixteen patients (36%) from the group with SSF developed postoperative fever, including 12 with negative posttransplant cultures, while 4 patients showed positive cultures for various microorganisms distinct from those isolated from the preservation solution. Five patients (30%) with high virulence pathogens in the preservation solution developed posttransplant fever, although no pathogen was isolated. CONCLUSIONS: Positive cultures of preservation fluids were observed in 98% of patients, although most of them (75%) were SSF. Microorganisms isolated from posttransplant cultures did not match the ones obtained from the preservation solution. Our results did not support routine culturing of the preservation solution provided that one administrator an adequate posttransplant antibiotic prophylactic regimen.

Survival and hepatitis C virus recurrence after liver transplantation in HIV- and hepatitis C virus-coinfected patients: experience in a single center.

INTRODUCTION: Posttransplant hepatitis C virus (HCV) recurrence has been shown to negatively impact graft and patient survivals. It has been suggested that HCV recurrence among HIV- and HCV-coinfected transplant recipients is even more aggressive. OBJECTIVE: To compare the histological severity and survival of posttransplant HCV recurrence between HIV- and HCV-coinfected and HCV-monoinfected patients. PATIENTS AND METHODS: Among 72 adult patients who underwent primary liver transplantation at our institution for HCV-related cirrhosis between October 2001 and April 2007. We excluded one coinfected patient who died on postoperative day 5 leaving 12 HIV- and HCV-coinfected patients for comparison with 59 monoinfected patients. When listed, all coinfected patients fulfilled the criteria of the Spanish Consensus Document for transplantation in HIV patients. Immunosuppression did not differ between the two groups: all were treated with tacrolimus + steroids (slow tapering). Aggressive HCV recurrence was defined as cholestatic hepatitis and/or a fibrosis grade > or =2 during the first posttransplant year. RESULTS: Coinfected patients were younger than monoinfected patients: 45 +/- 6 years vs 55 +/- 9 years (P = .0008). There were no differences in Child score, Model for End-stage Liver Disease score, donor age, graft steatosis, ischemia time, HCV pretransplant viral load or genotype between the groups. Significant rejection episodes were also equally distributed (25% vs 14%; P = .38). Seven coinfected patients and 29 monoinfected patients developed aggressive HCV recurrences (58% vs 49%; P = .75). Median follow-up was 924 days. Global survival at 3 years was 80%. Survivals at 1, 2, and 3 years were 83%, 75%, 62% in the coinfected vs 98%, 89%, 84% in the monoinfected patients, respectively (log-rank test = 0.09). CONCLUSIONS: The severity of histological recurrence was similar among HIV- and HCV-coinfected and monoinfected HCV liver recipients in the first posttransplant year. Mortality attributed to recurrent HCV was similar in the groups. There were no short-term (3-year) differences in survival between the two groups of patients.

[Psychometric properties of a quality of life questionnaire specific to liver transplant]. / Propiedades psicométricas de un cuestionario específico de calidad de vida en trasplante hepático.

OBJECTIVE: To translate and evaluate the psychometric properties of a quality of life questionnaire specific to liver transplant patients. MATERIAL AND METHODS: The questionnaire was administered to 60 patients on the waiting list for liver transplant in the Cruces Hospital Transplant Unit, and again at 6 months after the transplant. The reliability, validity, sensitivity to change, and minimum detectable change (MDC) were studied. Two questionnaires, the SF-36 (Health Survey Short Form 36) and HADS (Hospital Anxiety and Depression Scale), were used to evaluate the convergent validity. RESULTS: The specific questionnaire presented a Cronbach s alpha coefficient of over 0.7. The factor analysis demonstrates a single dimension. Correlations with the areas of SF-36 varied between -0.34 and -0.71 in the preoperative phase, and between -0.21 and -0.67 at 6 months. With respect to the HAD-anxiety scale, the coefficients were 0.44 in the preoperative phase and 0.51 at 6 months, and for the HAD-depression scale these were 0.64 and 0.39, respectively. Discriminant validation studies confirm that the questionnaire shows differences between patients with cirrhosis of various etiologies and severities. In the study of sensitivity to change, values were obtained for the SES (standardised effect size) and SRM (standardised response mean) indices of 0.92 and 0.99, respectively. Furthermore, 58.33% of patients had scores higher than MDC. CONCLUSIONS: The specific questionnaire has adequate psychometric properties. Its use in these patients may therefore be recommended as another scale for evaluating the results of this intervention.

Propiedades psicométricas de un cuestionario específico de calidad de vida en trasplante hepático / Psychometric properties of a quality of life questionnaire specific to liver transplant

Objetivo: traducir y evaluar las propiedades psicométricas de un cuestionario de calidad de vida específico para pacientes sometidos a trasplante hepático. Material y métodos: el cuestionario fue administrado a 60 pacientes en lista de espera de trasplante hepático de la Unidad de Trasplante del Hospital de Cruces, y a los 6 meses tras la intervención. Se estudió la fiabilidad, la validez, la sensibilidad al cambio y el mínimo cambio detectable (MCD). Para evaluar la validez convergente se utilizaron dos cuestionarios, SF-36 (Health Survey Short Form 36) y el HAD (Hospital Anxiety and Depression Scale). Resultados: el cuestionario específico presenta un coeficiente alfa de Cronbach superior a 0,7. El análisis factorial demuestra una única dimensión. Las correlaciones con las áreas del SF-36 oscilaron entre -0,34 y -0,71 en el preoperatorio, y entre -0,21 y -0,67 a los 6 meses. Respecto al HAD-ansiedad, los coeficientes eran 0,44 en el preoperatorio y 0,51 a los 6 meses, y para HADdepresión de 0,64 y 0,39 respectivamente. Los estudios de validez discriminante confirman que el cuestionario muestra diferencias entre pacientes con cirrosis de diversas etiologías o gravedad. En el estudio de la sensibilidad al cambio se obtuvieron unos valores para los índices TEE (tamaño del efecto estandarizado) y MRE (media de respuesta estandarizada) de 0,92 y 0,99 respectivamente. Además, un 58,33% de los pacientes superaba el MCD. Conclusiones: el cuestionario específico posee adecuadas propiedades psicométricas, lo cual puede aconsejar su utilización en estos pacientes, como otra medida más para evaluar los resultados de esta intervención

Objective: to translate and evaluate the psychometric properties of a quality of life questionnaire specific to liver transplant patients. Material and methods: the questionnaire was administered to 60 patients on the waiting list for liver transplant in the Cruces Hospital Transplant Unit, and again at 6 months after the transplant. The reliability, validity, sensitivity to change, and minimum detectable change (MDC) were studied. Two questionnaires, the SF-36 (Health Survey Short Form 36) and HADS (Hospital Anxiety and Depression Scale), were used to evaluate the convergent validity. Results: the specific questionnaire presented a Cronbach's alpha coefficient of over 0.7. The factor analysis demonstrates a single dimension. Correlations with the areas of SF-36 varied between -0.34 and -0.71 in the preoperative phase, and between -0.21 and -0.67 at 6 months. With respect to the HAD-anxiety scale, the coefficients were 0.44 in the preoperative phase and 0.51 at 6 months, and for the HAD-depression scale these were 0.64 and 0.39, respectively. Discriminant validation studies confirm that the questionnaire shows differences between patients with cirrhosis of various etiologies and severities. In the study of sensitivity to change, values were obtained for the SES (standardised effect size) and SRM (standardised response mean) indices of 0.92 and 0.99, respectively. Furthermore, 58.33% of patients had scores higher than MDC. Conclusions: the specific questionnaire has adequate psychometric properties. Its use in these patients may therefore be recommended as another scale for evaluating the results of this intervention

[Symbiotics: a new strategy in critically ill patients treatment]. / Simbióticos: una nueva estrategia en el tratamiento de pacientes críticos.

Maintenance of the gut environment is a key factor in determining outcome in the care of critically ill and postoperative patients. It is especially important to maintain both gastrointestinal secretions, full o anti-infectious and anti-inflammatory compounds, and the gut flora. Prebiotics, usually polysaccharides, exhibit strong bio-activity and the ingestion of prebiotics has been shown to reduce the rate of infection and restore health in sick and postoperative patients. Probiotics may have at least five functions, all of great importance to the sick patients: the reduction or elimination of potentially pathogenic micro-organism of various kinds; the reduction or elimination of various toxins, mutagens, carcinogens, etc.; modulation of the innate and adaptive immune defence mechanisms; the promotion of apoptosis; and the release of numerous nutrient, antioxidant, growth, coagulation and other factors necessary for recovery. A combination of pre and probiotics is referred to as "synbiotics". Our experience of synbotic treatment in critically ill patients is limited, but cutting-edge results from studies of severe acute pancreatitis, chronic hepatitis and liver transplantation offer great hope for the future. This is especially importante as pharmaceutical treatment, including the use of antibiotics, has largely failed, and the medical world is in much need of new treatment paradigms.

[Effects of glutamine on antioxidants systems and hepatic detoxification in rats: influence of formulation]. / Influencia de la formulación de la glutamina en sus efectos sobre los sistemas antioxidantes y de destoxificación hepática en la rata.

GOALS: The goal of this study is to assess the effect that supplementing parenteral diets with L-glutamine or with L-alanyl-L-glutamine has on the balance of oxidants/antioxidants in the liver and on detoxification systems mediated by P-450 cytochrome in rats. MATERIAL AND METHODS: Central catheters were inserted in the animals (n = 60) and they were randomly assigned to one of the following groups: a control group (C) with oral feeding and I.V. infusion of saline solution, a total parenteral nutrition group without glutamine (TPN without GLN), a parenteral nutrition group with glutamine supplement (TPN GLN), and a total parenteral nutrition group with a supplement of alanine-glutamine dipeptide (20 g/L) (TPN ALA-GLN). The parenteral nutrition provided was all isocaloric and isonitrogenated, and the infusions were administered at a speed of 2 ml/h over 5 days. RESULTS: In the animals of the group without GLN, the liver concentration of glutathione was reduced while the levels of thiobarbituric acid reaction products (TBARS) increased. Supplementing with either glutamine or alanine-glutamine normalized the levels of glutathione but the TBARS levels only fell in the group with the dipeptide. This effect was parallel to the partial recovery of the antioxidant enzyme activities analyzed. The liver concentrations of P-450 cytochrome, P-450 cytochrome dependent mono-oxygenases and the clearance of antipyrine were not modified by the supplements of glutamine or alanine-glutamine. CONCLUSIONS: Our data suggest a greater protection by alanine-glutamine supplements against the injury produced by free radicals during TPN and the absence of any effect with either glutamine or alanine-glutamine supplements on the oxidative metabolism of the liver.

[Enteral nutrition: past and future]. / Nutrición enteral: pasado y futuro.

Perioperative nutrition has during the last century been transformed from a tool to provide calorie and nitrogen support to a tool to boost the immune system and increase resistance to complications. Despite all progress in medicine and surgery has perioperative morbidity, rate of infections, thrombosis and development of serosal adhesions remained the same as long as can be judged or at least during the last eighty years. Most prone to develop complications are persons above the age of 65 and persons with depressed immunity. About eighty percent of the immune system is localised in the gastrointestinal tract, which offers great opportunities for modulation through enterar nutrition. As the stomach has a tendency to develop postoperative paralysis, tube feeding is often necessary. Andresen demonstrated already in 1918 the advantages of enteral nutrition, which starts already on the table. Mulholland et al and Rhoads and co-workers demonstrated during the 1940s certain advantages of enteral tube feeding. Also works by Alexander, Fischer, Ryan and their co-workers supported the value of early enteral feeding, and suggested enteral feeding as an effective tool to boost the immune system. It was, however, works published in the early nineties by Moore et al and by Kudsk et al, which made surgeons more aware of the advantages of early enteral nutrition. Major surgery is known to have a high rate of complications. Uninterrupted perioperative nutrition, eg nutrition during the night before, during surgery and immediately after offers a strong tool to prevent complications. It is essential that the nutrition provides food also for the colon, e.g. fibres and healthy bacteria (probiotics) to ferment the fibre and boost the immune system.