Could we reduce adhesions to the intra-abdominal mesh in the first week? Experimental study with different methods of fixation.

BACKGROUND: Adhesion formation is a major problem when a mesh is exposed to intraabodminal viscera, with potential severe complications (bowel occlusion, fistulas or abscesses). New methods for preventing adhesions from a polypropylene mesh placed intra-abdominally or to solve difficult situations, such as when the peritoneum cannot be closed during a TAPP repair for an inguinal hernia, are still being seeked. This study mimics in an animal model a situation that can be found in clinical practice during laparoscopic inguinal hernioplasty. A polypropylene mesh could be exposed to the intra-abdominal cavity even when the peritoneum is closed due to different circumstances, with no options to guarantee the prosthetic material of being exposed to the intrabdominal viscera. Different options have been suggested to solve these situations, being proposed in this study to cover the visceral surface of the mesh with an absorbable sponge containing thrombin, fibrinogen, and clotting factors (Tachosil®, Nycomed, Takeda, Osaka, Japan), to assess its use as a barrier to prevent postoperative adhesion formation. MATERIAL AND METHODS: Thirty Wistar white rats (300-450 mg) were included in this study as experimental animals, being randomized into three groups (A, B, and C). We performed a bilateral prosthetic repair with conventional polypropylene mesh (2 × 2 cm, 82 kD). Prosthesis fixation was performed as follows. Group A: absorbable suture; group B: metal staples; group C: metal tackers. A piece of insulating absorbable sponge (Tachosil® 5 × 5 cm) was placed to cover the visceral surface of mesh placed at the right side of each animal. After 10 days, we performed a gross examination (by laparoscopy and laparotomy), measuring the quantity and the quality of the adhesions. Samples were taken for histopathological analysis. RESULTS: Tachosil®-treated prostheses showed a statistically significant decrease in the quality of the adhesion found (p < 0.05). In addition, a smaller quantity of adhesions was identified in barrier-treated animals, although this lacked statistical significance. The histologic analysis showed no significant differences: more edema with the untreated mesh and increased angiogenesis and a lower degree of necrosis in mesh covered with Tachosil®. CONCLUSIONS: The use of Tachosil® as a barrier material led to the absence of strong adhesions as it prevented direct contact between the mesh and the internal organs, preventing major problems associated with strong adhesions.

Autologous Platelet-Rich Plasma in the Treatment of Perianal Fistula in Crohn's Disease.

AIM: To assess clinical healing in patients with perianal Crohn's disease with local intrafistular injection of autologous platelet-rich plasma. METHOD: The pilot study was conducted at a single centre between January 2013 and December 2015. Autologous platelet-rich plasma was prepared in platelet-rich and platelet-poor fractions for local intrafistular injection in patients with proven, established perianal Crohn's disease. Patients were permitted biological therapies, and the Perianal Crohn's Disease Activity Index was recorded. Patients were followed for 48 weeks for clinical signs of healing (complete, partial or non-healing), monitoring fistula drainage, closure and epithelialization. RESULTS: The study included 29 patients (19 males; mean age 38 ± 12.8 years) with four exclusions in the operating room because surgery was not indicated and four lost to follow-up. Five adverse events were recorded, with two requiring the drainage of abscess collections. Of the 21 patients assessable at 24 weeks, there was complete healing, partial healing and non-healing in 7 (33.3%), 8 (38.1%) and 6 (28.6%) patients, respectively. By 48 weeks, there was complete healing, partial healing and non-healing in 6 (40%), 6 (40%) and 3 (20%) patients, respectively, with a reduction in the number of visible external fistula openings at both time points (P = 0.021). By the end of the study, there was a higher trend of healing if biological therapies were continued (85.7% with biologics vs. 75% without, P = 0.527), but there were no statistically significant differences and no differences in the Perianal Crohn's Disease Activity Index. CONCLUSION: Autologous platelet-rich plasma is safe in patients with perianal Crohn's disease, with an acceptable healing rate over a medium-term follow-up, particularly if biological therapies are used concomitantly.

Liver Cirrhosis From Chronic Hypervitaminosis A Resulting in Liver Transplantation: A Case Report.

Herein we report a case of liver dysfunction caused by consumption of vitamin A supplements leading to liver transplantation. The patient was a 48-year-old male with a medical history of congenital ichthyosiform erythroderma in treatment with vitamin A until 12 years of age, at which point he discontinued the supplements because he had developed ascites. Liver cirrhosis was diagnosed as secondary to hypervitaminosis A on the basis of histologic examination of liver biopsy and the absence of other potential causes of chronic liver disease. Despite interruption of administration of vitamin A, the patient continued to deteriorate over the years, with development of portal hypertension signs. His medical conditions were aggravated with the development of hepatic insufficiency manifested by refractory ascites, renal insufficiency, and severe encephalopathy and he underwent orthotopic liver transplantation, followed by disappearance of all signs of portal hypertension. This case highlights the need to take a careful history of consumption of vitamin A when evaluating a patient with liver failure.

Treatment of transsphincteric fistula-in-ano with growth factors from autologous platelets: results of a phase II clinical trial.

PURPOSE: The aim of this paper is to evaluate to the safety, feasibility and efficacy of a novel treatment for transsphincteric cryptoglandular fistula: injection of autologous plasma rich in growth factors (PRGF) into the fistula tract accompanied by sealing using a fibrin plug created from the activated platelet-poor fraction of the same plasma. METHOD: This article is a prospective, phase II clinical trial. The procedure was externally audited. Thirty-six patients diagnosed with transsphincteric fistula-in-ano were included. All patients underwent follow-up examinations at 1 week and again at 3, 6 and 12 months after discharge. Main outcome measures safety (number of adverse events), feasibility and effectiveness of the treatment. RESULTS: A total of 36 patients received the study treatment, with the procedure found to be feasible in all patients. A total of seven adverse events (AE) related to the injected product or surgical procedure were identified in 4 of 36 patients. At the end of the follow-up period (12 months), 33.3% of patients (12/36) had achieved complete fistula healing and 11.1% of patients (4/36) had achieved partial healing. In total, this amounted to 44.4% of patients (16/36) being asymptomatic at final follow-up. In successfully healed patients, a gradual reduction in pain was observed, as measured using a Visual Analog Scale (VAS) (p = 0.0278). Compared to baseline, a significant improvement in Wexner score was seen in patients achieving total or partial healing of the fistula (p = 0.0195). CONCLUSIONS: The study treatment was safe and feasible, with apparently modest efficacy rates. Continence and pain improvement following treatment may be considered predictive factors for healing.

Survival Outcomes in Liver Transplantation With Elderly Donors: Analysis of Andalusian Transplant Register.

Recently, there has been a large discrepancy between the number of patients on the waiting list for a liver transplant and the availability of deceased donors, with an increase in annual wait list mortality rates. Elderly donor livers are thought to be marginal grafts; however, in recent years, their utilization has constantly increased. The aim of this study is to evaluate the utilization of elderly donors in Andalusia and post-transplant outcomes. This retrospective observational study of 2408 liver transplants, performed in Andalusia between 2000 and 2014, analyzes the outcomes from donors aged 70 plus (n = 423) in terms of survival rates of the graft and the recipient, the type of transplant, donor age, and D-MELD score (product of donor age and preoperative Model for End-stage Liver Disease score). The most frequent indications for transplant were alcoholic cirrhosis (49.2%), hepatitis C cirrhosis (13%), and hepatocellular carcinoma (12.5%). The overall survival at 5 years was 64%, with a significant fall in survival for recipients with a D-MELD greater than 1500 (57%; P = .045). In the 70-year-old-plus donor group, the overall patient survival was 58.4%. The retransplant rate increased proportionately with donor age. In the alcoholic cirrhosis recipient subgroup, the overall survival at 5 years was 67.6% (P < .05) compared with 33.5% in patients with hepatitis C. Use of elderly donors is a safe strategy to reduce the scarcity of donors, provided that a D-MELD score below 1500 is obtained. Retransplant rates increase progressively with donor age. It is necessary to carefully screen recipients of older organs, taking into account that the best results are obtained for alcoholic cirrhosis, negative viral load hepatitis C, and a D-MELD score below 1500.

Outcomes of Liver Transplantation During Adulthood After Kasai Portoenterostomy Due to Biliary Atresia.

Biliary atresia (BA) is a neonatal progressive cholangiopathy of unknown etiology and one of the most common reasons for liver transplantation (LT) in children. Kasai portoenterostomy (KP) improves survival of the native liver, although LT remains the only ultimate treatment. In some cases KP makes it possible to defer the ultimate LT until adulthood. We report our experience regarding 5 cases of BA treated with LT during adulthood. KP was performed in all patients at an average age of 176 days (range, 60-280), which allowed an average survival of the native liver of 19.01 years (range, 14.06-22.32). Five-year survival rate was 100%. Ten-year survival rate did not reach 100% because of a death 9.55 years after LT due to chronic graft rejection, in a patient who was already prepared for a new LT. Our results corroborate that KP remains the first-line treatment of BA. Early performance of the KP provides children with the best chance of survival, allowing the delay of the LT to adulthood. LT during adulthood in these patients achieves good post-LT survival rate; we have not found any data regarding this group of patients in the literature.

Antibiotic embedded absorbable prosthesis for prevention of surgical mesh infection: experimental study in rats.

INTRODUCTION: Ventral hernias are a common problem in a general surgery and hernioplasty is an integral part of a general surgeon's practice. The use of prosthetic material has drastically reduced the risk of recurrence, but has introduced additional potential complications such as surgical wound infections, adhesion formation, graft rejection, etc. The development of a wound infection in a hernia that is repaired with a prosthetic material is a grave complication, often requiring removal of the prosthesis. This experimental study examined efficacy of completely absorbable, hydrophilic, PGA-TMC (polyglycolic acid-trimethylene carbonate) prosthesis impregnated with antibiotic for reduction of infectious complications. METHODS: Antibiotic-impregnated PGA-TMC prostheses were placed intraperitoneally in 90 Wistar white rats that were randomized and distributed into four groups. Group 0 (23 rats): there were placed PGA-TMC prosthesis without antibiotic impregnation (control group). Group 1 (25 rats): meshes were placed and infected later with 1 × 10(8) UFC of S. aureus/1 ml/2 cm(2) (Staphylococcus aureus ATCC 6538 American Type Culture Collection, Rockville, MD). Group 2 (21 rats): cefazolin-impregnated prostheses were placed (1 g × 100 ml, at the rate of 1 ml/cm(2) of prosthesis) and were subsequently infected with the same bacterial inoculate. Group 3 (21 rats): cefazolin-impregnated prostheses with double quantity of cefazolin and infected. A week later these animals were killed and specimens were extracted for bacterial quantification and histological studies. RESULTS: Evident decrease of bacterial colonization was observed in series 2 and 3 [the ones impregnated with cefazolin, in comparison with the group 1 (infected without previous antibiotic impregnation)] with statistically significant results (p < 0.00). Results were really positive when the antibiotic solution had been applied to the mesh. There have been formed adherences to the prosthesis when placing it in contact with intraabdominal viscera. However, cefazolin impregnation of the mesh has reduced an adhesion formation, mostly when the infection reached a minimum, inhibiting the inflammatory answer to the infection in a prosthetic material. CONCLUSION: Impregnation of the absorbable hydrophilic prosthesis PGA-TMC with cefazolin prevents the infection of the prosthesis placed in infected localization. Therefore, we think this option should be considered as a new and useful alternative in case of contaminated and dirty surgical fields or when a replacement of the prosthesis is required.

Impact of the learning curve on the outcome of domino liver transplantation.

Domino liver transplantation (DLT) is a strategy used to increase the number of available grafts. In this procedure, the transplant recipient is a living donor of her own liver. It is mandatory that the graft should be fully functional and the genetic defect should recur with sufficient latency period in the new recipient. Corino-Andrade disease, or familial amyloidotic polyneuropathy (FAP), satisfies these conditions. We retrospectively reviewed our prospective database of DLT. From July 2004 to April 2013, we performed 12 DLTs. We assessed age, sex, real Model for End-Stage Liver Disease (MELD) score, waiting list time, cold and warm ischemia times, intraoperative transfusion requirements, hospital stay, early peritransplantation morbidity (post-reperfusion syndrome, intraoperative cardiac arrest, post-transplantation thrombotic events, and biliary morbidity), acute cellular rejection, retransplantation, mortality, patient and graft survivals. With the intention to study the effect of the learning curve in the global survival results (including both donors and recipients of livers with FAP), we divided our series into 2 periods: the early period (from 2004 to 2008) and the present period (from 2009 to 2013). The crude mortality was 40% vs 0% (P = .042) in the early and present periods, respectively. The cumulative patient survival was also significantly in favor of the present period (P = .049). The graft loss prevalence was 60% vs 7.1% (P = .019) in the early and present periods, respectively. The cumulative graft survival was also significantly in favor of the present period (P = .030; Fig 2). In conclusion, we consider DLT to be a complex procedure, whose initial results are conditioned by the learning curve.

Fifteen years of follow-up of a liver transplant recipient with glycogen storage disease type Ia (Von Gierke disease).

Von Gierke's disease or glycogen storage disease type Ia (GSD-Ia) is an infrequent metabolic disease caused by an atypical accumulation of glycogen. The principal cause of this pathology is deficiency of the glucose-6-phosphatase enzyme. Herein we have reported a case of a young man with a history of Von Gierke's disease (GSD-Ia) since childhood who developed hepatocellular adenomatosis brought to light by ultrasounds and TACs. The patient began to develop early chronic renal failure, necessitating simultaneous liver and kidney transplantation. Years later continuous reviews at the nephrology and hepatobiliopancreatic surgery services show he has a good quality of life and a normal hepatorenal profile.

Modigraf administration through jejunostomy in liver transplant recipient: case report.

We report our experience with a 61-year-old patient with alcoholic and hepatitis C cirrhosis who underwent liver transplantation. On the 3rd postoperative day he presented a mediastinitis secondary to esophageal perforation produced by a Linton tube. An esophagectomy with jejunostomy was performed. Tacrolimus granules for oral suspension (Modigraf) were administered through the jejunostomy. This case report highlights the use of Modigraf and the absence of secondary effects. We observed biochemical parameters during the jejunostomy period. We discuss the administration strategy applied and whether tacrolimus granules for oral suspension by jejunostomy affect the bioavailability and its side effects.

Liver transplantation due to fulminant hepatic failure.

OBJECTIVES: To analyze the epidemiology, causes, complications, and mortality of liver transplants following fulminant hepatic failure over the last 16 years. MATERIALS AND METHODS: We completed a descriptive analysis of 21 patients with fulminant hepatic failure and a liver transplant. In almost half of the cases, the origin of liver failure was unknown. RESULTS: The mean age was 36 years; the study group was 47.61% female (n = 10) and 52.39% male (n = 11). The most common early complication was transplant rejection, which occurred in 33.3% of all patients (n = 7) and was confirmed by liver biopsy; the most frequent long-term complication was autoimmune hepatitis. Two retransplantations were necessary. The total mortality rate was 38.1% (n = 8) with late mortality in three patients (14.3%). CONCLUSIONS: Orthotopic liver transplantation as a treatment for fulminant hepatitis has a higher mortality rate than orthotopic liver transplantation due to other causes. It does, however, enable the survival of 62% of the patients who otherwise would have died due to liver failure. The etiology of most of the cases was unknown. We should point out the high incidence rates for transplant rejection and late autoimmune hepatitis, in addition to the possibility of hemorrhagic colonic diseases that may be associated with the condition causing liver failure. Multidisciplinary control over the patient is useful for deciding at which time a liver transplant would become the only treatment option.

Spontaneous clearance of HCV in HIV-hepatitis C virus coinfected liver transplant patients: prospective study.

BACKGROUND: Hepatitis C virus (HCV) clearance is an independent predictive factor for long-term survival in HIV-HCV liver transplantation patients. After 46 months of antiviral therapy it is achieved in up to 80% of cases. Little is known, however, about spontaneous viral clearance. We performed prospective study of HIV-HCV coinfected liver transplant patients. METHODS: Between January 1, 2001, and December 31, 2011, we analyzed the parameters from among HIV-HCV coinfected liver transplant patients of donor and recipient ages, transplant cause, Model for End-Stage Liver Disease (MELD) score, donor and recipient serology, transplant date, viral load before and after transplantation, immunosuppressive therapy, HCV recurrence, HCV viral clearance (spontaneous and duration), retransplant cause, and viral load before and after retransplant, as well as survival. RESULTS: The seven transplanted HIV-HCV coinfected patients had most commonly HCV-related hepatocarcinoma (n = 5, 71.42%). Three subjects (42.85%) developed HCV recurrences. Two patients (28.57%) were retransplanted, both due to HCV recurrence with one of them developing a spontaneous clearance of HCV (14.28%). This patient showed a preoperative HIV viral load < 50 copies IU/mL, CD4+ count 486/µL, HCV-RNA 2564 IU copies/mL, Anti-HBc+, and MELD 30. The donor was an 81-year-old female who was Anti-HBc+. Immunosuppressive therapy consisted of cyclosporine, mycophenolate, and prednisone. One month after transplantation, the patient developed an acute cellular rejection episode with progression of liver disease secondary to the HCV recurrence (56.5 × 105 copies IU/mL). He started antiviral treatment (α-interferon and ribavirin), but due to side effects and interactions with the antiretrovirals, they were stopped after four doses. The viral load decreased spontaneously and progressively until it became negative at 146 days after transplantation; he was retransplanted and HCV-RNA has continued to be negative after 772 days. CONCLUSION: Spontaneous clearance of HCV among HIV-HCV coinfected liver transplant patients is possible. Despite no treatment, one patient still has no detectable HCV viral load after retransplantation.

[State of acute phase markers and oxidative stress in patients with kidney stones in the urinary tract]. / Estado de los marcadores de fase aguda y estrés oxidativo en los enfermos con litiasis de la vía urinaria.

OBJECTIVE: This present study has aimed to assess the state of acute phase markers and oxidative stress in patients with kidney stones. MATERIAL AND METHODS: A prospective study was carried out on 100 patients with kidney stones and 25 healthy controls. Albumin, ß2 microglobulin, Gamma-glutamyl transpepsidase, Lactate dehydrogenase, Tumor necrosis factor alpha, Interleukin 1 and Interleukin-6 were evaluated as acute phase markers and lipid peroxidation products, Superoxide dismutase and Glutathione peroxidase levels acted as oxidative stress markers. RESULTS: An increase in renal cell damage markers as expressed by the ß2 microglobulin (p=0.04), albumin (p=0.004), Lactate dehydrogenase (p=0.001) and Gamma glutamyl transpepsidasa (p=0.01) was observed in the patient group. There was a direct correlation between levels of ß2 microglobulin and stone size (r=0.3, p=0.03). The association between stone size and cytokine activation was observed to be stronger in patients with staghorn calculi. In these patients, Tumor necrosis factor alpha (p=0.011), Interleukin 1 (p=0.004) and Interleukin 6 (p=0.004) were significantly higher. Patients with stones in the urinary tract showed data of significantly higher oxidative stress, expressed as an increase in levels of lipid peroxidation products (p=0.03) and a decrease in the antioxidant activity of Superoxide dismutase (p=0.03) and Glutathione peroxidase (p=0.002). CONCLUSIONS: Patients undergoing urolithiasis showed an elevation of acute phase markers, associated with oxidative stress as expressed by an increase in lipid peroxidation products and a decrease in the antioxidant enzyme activity.

Consolidation of enteric drainage for exocrine secretions in simultaneous pancreas-kidney transplant.

INTRODUCTION: Management of the exocrine drainage of the pancreatic graft in simultaneous pancreas kidney (SPK) transplantation has been a matter of debate for years. There is currently a trend toward a more physiological enteric drainage (ED). This study compared short- and long-term complications and graft survival in patients with enteric versus bladder exocrine secretion drainage. PATIENTS AND METHODS: Between January 1995 and November 2005, we performed 75 SPK transplants: 55 with ED and 20 with bladder drainage (BD). The rates of complications and graft survival were monitored over at least 36 months after transplantation. RESULTS: Mean posttransplant follow-up was 119.5 +/- 6.6 months. Urinary infection, hematuria, reflux pancreatitis, and repeat surgery rates were all significantly higher among the BD area. There was no intergroup difference in rejection rates or in the incidence of graft thrombosis, transplantectomy, anastomotic dehiscence, or intra-abdominal abscesses. Pancreas and kidney graft survival rates were similar in the two groups. CONCLUSIONS: In our experience, ED was more physiological than BD, and was associated with fewer complications.

[Urologic complications of pancreas-kidney simultaneous transplantation]. / Complicaciones urológicas en el trasplante simultáneo de pancreas-riñón.

Pancreas Transplantation (PT) is the only available therapy today for diabetes that allows an insulin-independent euglycemic state with complete normalization of glycosilated haemoglobin levels. Survival of patient, pancreatic graft and renal graft is 93%, 86% and 90% respectively at one year and 90%, 84% and 85% at three years. The most accepted method for exocrine drainage in most centres where simultaneous pancreas-kidney transplantation is being performed is vesical drainage. In spite of the improvements achieved in graft and patient survival, it is evident that a most frequent use of this type of technique involves a greater number of urological complications (repeat infections, haematuria, fistulae or leakage, reflux pancreatitis, urethral stenosis and disruption, dehydration and acidosis, previous diabetic bladder) and the familiarization of the urologist with this type of disease in immunodepressed patients. This paper reviews the current situation and illustrates the general approach regimes in our Pancreas-Kidney Transplantation Unit with regard to each complication.

[Evaluation of body fluid compartments and their relationship with water-electrolyte changes in obstructive jaundice]. / Evaluación de los compartimientos corporales y su relación con las alteraciones hidroelectrolíticas en la ictericia obstructiva.

BACKGROUND: The alteration of the mechanisms of water and sodium preservation may be an important factor in the development of acute postoperative renal failure in obstructive jaundice (OJ). Experimental OJ has been associated with a depletion of the extracellular volume and alteration of the mechanisms of regulation of hydrosaline metabolism. The aim of this study was to evaluate the distribution of the body volumes and the regulating hormones of hydrosaline metabolism in human OJ. PATIENTS AND METHOD: A prospective, clinical study evaluating 18 patients with OJ (9 females and 9 males) with a mean age of 69 +/- 8.9 years was performed. The plasma levels of antinatriuretic peptide (ANP), aldosterone and renin were determined. The body volumes were evaluated by tetrapolar bioimpedanciometry. The results of the patients with OJ were compared with a control group (CG) of 12 healthy subjects, matched for age and sex (6 females and 6 males with a mean age of 64.5 +/- 14 years). RESULTS: High ANP values were observed in 87.5% of the patients. The results of the hormonal studies compared with the CG were: ANP (117.33 +/- 37.7 vs 41.31 +/- 16.8 pg/ml; p < 0.001), aldosterone (185.68 +/- 82.1 vs 44.3 +/- 21.6 pg/ml; p < 0.001) and renine (57.18 +/- 69.9 vs 16.08 +/- 9.7 microU/ml; p < 0.05). Depletion of extracellular volume was found in 75% of the patients. CONCLUSIONS: Human obstructive jaundice is associated with an important alteration in the hormonal mechanisms of water and sodium regulation. This alteration is accompanied by a marked depletion of extracellular volume.

[Long-term results of the surgical treatment of chronic pancreatitis]. / Resultados a distancia en el tratamiento quirúrgico de la pancreatitis crónica.

We analized the long-term results after surgical treatment in 41 patients with chronic pancreatitis. Twenty one of them underwent resection: 19 pancreaticoduodenectomy (11 Whipple procedure and 8 Traverso Longmire); total pancreatectomy (1) and near-total pancreatectomy (1). In the remaining 20 patients a drainage procedure was carried out: Puestow-Duval (5); Partington (7); double derivation: pancreatic and biliar (5); triple derivation: pancreatic, biliar, gastric (2) and Nardi procedure+quisteduodenostomy in one patient. The following were evaluated: persistent pain; chronic alcoholism; nutrition status; exocrine function (syntomatic steatorrea, use of pancreatic enzyme preparation and fecal determination of glucide, protids and lipids) and endocrine function (glucose and insulin levels and glucose oral test). Surgery failed to relieve pain in 15.6% of the patients; failures were associated chronic alcoholism (p < 0.05); 18 patients (44%) required oral pancreatic enzymes. There weren't significant differences between resection and drainage procedures regarding the exocrine function. However, endocrine function was significantly worse (p < 0.05) after pancreaticoduodenectomy than after drainages procedures. Among the late, the endocrine function was better after Partington operation than after the Puestow-Duval.