Luschka Duct Leak: An Unexpected Cause of Choleperitoneum After Liver Transplant.

The anatomic variabilities in ducts of Luschka put patients at risk during hepatobiliary surgery. Clinically relevant bile leakage is the cause of 0.4% to 1.2% of complications of cholecystectomies, with almost one-third of complications caused by an inadvertent injury to the duct of Luschka. However, bile leakage from a duct of Luschka after liver transplant is rare, and only one previously published report has been found. Here, we report a case of a 67-year-old male patient who underwent liver transplant for cirrhosis due to hepatitis C virus infection. After transplant, the patient had a choleperitoneum caused by bile leakage from a duct of Luschka. The donor surgery had been performed by surgeons from another institution, and they had also performed the previous cholecystectomy. Fifteen days after surgery, a cholangiography showed bile leakage near the anastomosis. A new intervention was decided. After confirmation of the integrity of the anastomosis, methylene blue was injected through the Kehr's tube, which escaped from a duct of Luschka. The duct was closed, and an intraoperative cholangiography confirmed that the biliary tree was intact. After this intervention, a new bile leakage was observed, resulting in an endoscopic retrograde cholangiopancreatography scan and sphincterotomy. The Kehr's tube was kept open until leak resolution. Although unusual after liver transplant, this complication should be considered in cases of bile leakage. The ducts of Luschka are difficult to see during cholecystectomy in the graft due to perivesicular edema.

Surgical management of familial adenomatous polyposis: pancreas-sparing duodenectomy or pancreaticoduodenectomy (Whipple procedure).

Duodenal cancer is the main cause of death for patients with FAP syndrome (familial adenomatous polyposis) treated with a colectomy. The disease follows the adenoma to carcinoma sequence and is diagnosed during follow-up in 7-36% of patients. Endoscopic treatment is used during the first treatment stage of the disease and surgery is an adequate therapeutic option when endoscopic control is insufficient.

Poliposis adenomatosa familiar: manejo quirúrgico. Duodenectomía con preservación pancreática o cirugía de Whipple / Surgical management of familial adenomatous polyposis: pancreas-sparing duodenectomy or pancreaticoduodenectomy (Whipple procedure)

No disponible

Current allocation policy is favorable for patients with hepatocellular carcinoma waiting for liver transplantation.

BACKGROUND: Patients with hepatocellular carcinoma (HCC) are a growing population of the transplantation waiting list (WL) for orthotopic liver transplantation (OLT). There is no consensus to prioritize these patients while on the WL. AIMS: To assess whether patients with HCC were more prioritized than non-HCC patients based on their WL survival as primary outcome. METHODS: Restrospective cohort study including patients listed for elective OLT from January 2013 to January 2016. RESULTS: 165 patients with cirrhosis were listed for OLT: 64 in the HCC group (38.78%) and 101 in the non-HCC group (61.22%). Outcomes (HCC vs. non-HCC) were: OLT in 75.51% vs. 64.37%; death or dropout due to worsening in 20.41% vs. 27.59%, and delisting because of improvement in 4.08% vs. 8.05%. HCC patients had a significantly higher WL survival rate (HR = 0.45; 95% CI: 0.21-0.96); lower MELD score at transplantation (21 [20-24] vs. 24 [20-30]; p = 0.021); higher delta-MELD - the difference between MELD at transplantation and MELD at listing time - (3 [2-6] vs. 0 [0-5]; p = 0.024) and longer waiting time until OLT (143 [70-233] vs. 67 [21-164] days; p = 0.008). CONCLUSION: Despite having to wait longer, patients with HCC showed higher WL survival than non-HCC patients.

Surgical management of simple liver cysts.

BACKGROUND: To date there is no consensus about the treatment of choice for symptomatic or complicated simple liver cysts. METHODS: A retrospective study of all patients diagnosed with simple liver cyst surgically managed at Ramon y Cajal Hospital during the period between 1998 and 2008 was performed. RESULTS: We analyzed 21 patients, 18 females (85.7%) and three males (14.3%) with a mean age of 64.2 years. Ten patients (47.6%) were asymptomatic. During follow-up, cyst growth was determined. Three patients (14.3%) presented an infected simple liver cyst. Seven patients (33.3%) presented abdominal pain and one patient (4.8%) reported an abdominal mass during self-examination. Treatment consisted of unroofing and cyst drainage in 18 patients (85.7%) and cyst enucleation in three patients (14.3%). Postoperative complications appeared in two patients (9.6%). There was no mortality. Pathology revealed simple liver cyst in 17 patients (80.9%) and liver cystadenoma in four (19.1%). The latter were reoperated for complete cyst resection. Recurrence rate was 23.5% (four cases) for the simple liver cysts. In all cases, unroofing was performed. CONCLUSION: In some cases, cystadenomas show ultrasonographic and radiological features similar to simple liver cysts, implying an incorrect surgical approach. We recommend performing an intraoperative biopsy of all resected liver cysts to confirm its nature. Unroofing is associated with a high recurrence rate (>20%). Therefore, we propose cyst enucleation as the best surgical treatment.

Hernia inguinocrural: estudio multicéntrico sobre técnicas quirúrgicas / Inguinofemoral hernia: multicenter study of surgical tecniques

Introducción. El presente trabajo lo ha realizado la Asociación Española de Cirujanos, a través de su Sección de Pared Abdominal y Suturas. Está basado en el conocimiento de la realidad actual de la cirugía de las hernias inguinales y crurales en nuestro país y en un estudio multicéntrico anónimo en el que han colaborado diferentes centros hospitalarios nacionales. Material y método. 50 Servicios de Cirugía General de distintos centros quirúrgicos de toda España han contestado a una encuesta anónima durante el año 2000, en la que se recogían aspectos anestésicos, de técnica quirúrgica y complicaciones en el tratamiento de las hernias inguinocrurales. Resultados. El 66% de los centros hospitalarios tenía una unidad específica de pared abdominal y el 24% realizaba cirugía laparoscópica herniaria. Las técnicas protésicas (sobre todo la de Lichtenstein) eran las más utilizadas en el tratamiento de la hernia inguinal primaria (72%) y recidivada (100%). La malla de polipropileno es el material protésico más usado (76%). Sólo el 28% de los servicios encuestados realizaba técnicas anatómicas en la reparación de la hernia inguinal primaria (Shouldice y Bassini). El tratamiento más habitual de la hernia crural es el "Plug" de Lichtenstein (78%). El 68% de los centros encuestados realizaba anestesia regional, el 18% anestesia general y sólo el 14% anestesia local con sedación. Hubo complicaciones graves en el 20% de los servicios. El seguimiento postoperatorio se llevaba a cabo de forma clínica en el 96% de los casos y telefónico en el 4%; el porcentaje de recidiva fue del 1,2% para la hernia inguinal primaria, del 2,7% para la hernia inguinal recidivada y del 0,3% para la hernia crural. Conclusiones. La hernioplastia de Lichtenstein es la técnica quirúrgica más utilizada en nuestro país en el tratamiento de la hernia inguinal, bajo anestesia raquídea y con prótesis de polipropileno. El Plug de Lichtenstein es la técnica más usada en el tratamiento de la hernia crural (AU)

Introduction. The present study was performed by the Spanish Association of surgeons through its abdominal wall and sutures section. The aim was to determine the current situation of inguinofemoral hernias in Spain and was based on an anonymous multicenter study with the participation of various national hospitals. Material and method. Fifty general surgery departments in distinct surgical centers throughout Spain responded to an anonymous survey in 2000. The survey gathered data on anesthetic features, surgical techniques and complications in the treatment of inguinofemoral hernias. Results. Sixty-six percent of hospital centers had a specific abdominal wall unit and 24% performed laparoscopic hernia surgery. Prosthetic techniques (especially Lichtenstein) were the most frequently used in the treatment of primary inguinal hernia (72%) and recurrent hernia (100%). The most frequently used prosthetic material was polypropylene mesh (76%). Only 28% of the departments surveyed performed anatomic techniques in the repair of primary inguinal hernia (Shouldice and Bassini). The most frequent treatment for femoral hernia was the Lichtenstein "plug" (78%). Sixty-eight percent of the centers surveyed performed regional anesthesia, 18% used general anesthesia and only 14% used local anesthesia with sedation. Severe complications were found in 20% of departments. Clinical postoperative follow-up was performed in 96% of the centers and telephone follow-up was used in 4%. The recurrence rate was 1.2% for primary inguinal hernia, 2.7% for recurrent inguinal hernia and 0.3% for femoral hernia. Conclusions. In Spain the most commonly used surgical technique in the treatment of inguinal hernia is Lichtenstein hernioplasty under spinal anesthesia and with polypropylene prosthesis. The Lichtenstein plug is the most commonly used technique in the treatment of femoral hernia (AU)

Reparación de la hernia inguinal primaria: Lichtenstein frente a Shouldice. Estudio prospectivo y aleatorizado sobre el dolor y los costes hospitalarios / Repair of primary inguinal hernia: Lichtenstein versus Shouldice techniques. Prospective randomized study of pain and hospital costs

Introducción. La afección herniaria es uno de los procesos mejor estudiados en el que la búsqueda de la excelencia se ha convertido en el objetivo final, aunque todavía quedan muchas controversias por resolver. El objetivo de este estudio es analizar el dolor postoperatorio y los costes de 2 técnicas de reparación de la hernia inguinal primaria. Pacientes y método. Estudio prospectivo aleatorizado de 54 pacientes intervenidos de hernia inguinal entre junio de 2001 y mayo de 2002 mediante la técnica de Lichtenstein o de Shouldice. Se analizaron las siguientes variables: edad, localización y tipo de hernia, valoración de la tolerancia a la anestesia local, técnica quirúrgica, duración de la intervención, dolor el primero, tercero y quinto días del postoperatorio, consumo de analgésicos, días transcurridos hasta empezar a conducir, días de baja y tipo de profesión. Resultados. Grupos de pacientes comparables sin diferencias significativas respecto a la edad, la localización y el tipo de hernia. Para la hernioplastia de Lichtenstein, el tiempo de operación fue menor (p < 0,01) y la valoración del dolor no mostró diferencias significativas al primer y el tercer días postoperatorios, pero fue superior al quinto día (p = 0,064). No hubo diferencias significativas en el consumo de analgésicos, el tiempo de inicio de la conducción y los días de baja. Los pacientes con profesiones autónomas se reintegraron antes a su actividad laboral, con independencia de la técnica realizada. El coste de la técnica de Lichtenstein fue de 235 euros, frente a los 180 euros de la de Shouldice; esta diferencia fue estadísticamente significativa (p < 0,05). Conclusión. En manos de cirujanos expertos, con la técnica de Shouldice como técnica de elección de reparación anatómica en todas las hernias no recidivadas en que sea factible, se obtienen los mismos resultados satisfactorios que en la hernioplastia de Lichtenstein y, además, es un procedimiento con un menor coste hospitalario (AU)

Introduction. Hernia is one of the most widely studied processes, and the search for excellence has be-come the final aim. However, many controversies remain to be resolved. The objective of the present study was to analyze postoperative pain and costs using two techniques of primary inguinal hernia repair. Patients and method. We performed a prospective, randomized study of 54 patients who underwent surgical repair of inguinal hernia through either the Lichtenstein or the Shouldice technique between June 2001 and May 2002. The following variables were analyzed: age, location and type of hernia, evaluation of tolerance to local anesthesia, surgical technique, operating time, pain at days 1, 3 and 5 after surgery, analgesic consumption, days until driving could be resumed, days off work, and occupation. Results. The patient groups were similar, with no significant differences in age, location or type of hernia. For Lichtenstein hernioplasty, operating time was lower (p < 0.01); pain evaluation showed no significant differences on days 1 and 3 after surgery but was higher on day 5 (p = 0.064). No significant differences were found in analgesic consumption, time before driving could be resumed, or days off work. Freelance patients returned to work earlier, independently of the surgical technique performed. The cost of the Lichtenstein technique was 235 euros compared with 180 euros for the Shouldice technique and this difference was statistically significant (p < 0.05). Conclusion. In the hands of expert surgeons, the Shouldice technique is the procedure of choice in the repair of primary hernias. The results are just as satisfactory as those obtained with Lichtenstein hernioplasty and hospital costs are lower (AU)

[Inguinofemoral hernia: multicenter study of surgical techniques]. / Hernia inguinocrural: estudio multicéntrico sobre técnicas quirúrgicas.

INTRODUCTION: The present study was performed by the Spanish Association of surgeons through its abdominal wall and sutures section. The aim was to determine the current situation of inguinofemoral hernias in Spain and was based on an anonymous multicenter study with the participation of various national hospitals. MATERIAL AND METHOD: Fifty general surgery departments in distinct surgical centers throughout Spain responded to an anonymous survey in 2000. The survey gathered data on anesthetic features, surgical techniques and complications in the treatment of inguinofemoral hernias. RESULTS: Sixty-six percent of hospital centers had a specific abdominal wall unit and 24% performed laparoscopic hernia surgery. Prosthetic techniques (especially Lichtenstein) were the most frequently used in the treatment of primary inguinal hernia (72%) and recurrent hernia (100%). The most frequently used prosthetic material was polypropylene mesh (76%). Only 28% of the departments surveyed performed anatomic techniques in the repair of primary inguinal hernia (Shouldice and Bassini). The most frequent treatment for femoral hernia was the Lichtenstein "plug" (78%). Sixty-eight percent of the centers surveyed performed regional anesthesia, 18% used general anesthesia and only 14% used local anesthesia with sedation. Severe complications were found in 20% of departments. Clinical postoperative follow-up was performed in 96% of the centers and telephone follow-up was used in 4%. The recurrence rate was 1.2% for primary inguinal hernia, 2.7% for recurrent inguinal hernia and 0.3% for femoral hernia. CONCLUSIONS: In Spain the most commonly used surgical technique in the treatment of inguinal hernia is Lichtenstein hernioplasty under spinal anesthesia and with polypropylene prosthesis. The Lichtenstein plug is the most commonly used technique in the treatment of femoral hernia.

[Repair of primary inguinal hernia: Lichtenstein versus Shouldice techniques. Prospective randomized study of pain and hospital costs]. / Reparación de la hernia inguinal primaria: Lichtenstein frente a Shouldice. Estudio prospectivo y aleatorizado sobre el dolor y los costes hospitalarios.

INTRODUCTION: Hernia is one of the most widely studied processes, and the search for excellence has become the final aim. However, many controversies remain to be resolved. The objective of the present study was to analyze postoperative pain and costs using two techniques of primary inguinal hernia repair. PATIENTS AND METHOD: We performed a prospective, randomized study of 54 patients who underwent surgical repair of inguinal hernia through either the Lichtenstein or the Shouldice technique between June 2001 and May 2002. The following variables were analyzed: age, location and type of hernia, evaluation of tolerance to local anesthesia, surgical technique, operating time, pain at days 1, 3 and 5 after surgery, analgesic consumption, days until driving could be resumed, days off work, and occupation. RESULTS: The patient groups were similar, with no significant differences in age, location or type of hernia. For Lichtenstein hernioplasty, operating time was lower (p < 0.01); pain evaluation showed no significant differences on days 1 and 3 after surgery but was higher on day 5 (p = 0.064). No significant differences were found in analgesic consumption, time before driving could be resumed, or days off work. Freelance patients returned to work earlier, independently of the surgical technique performed. The cost of the Lichtenstein technique was 235 euros compared with 180 euros for the Shouldice technique and this difference was statistically significant (p < 0.05). CONCLUSION: In the hands of expert surgeons, the Shouldice technique is the procedure of choice in the repair of primary hernias. The results are just as satisfactory as those obtained with Lichtenstein hernioplasty and hospital costs are lower.

Influencia de las características de los donantes en el desarrollo de una disfunción primaria en los pacientes sometidos a trasplante hepático / Influence of donor characteristics on the development of primary dysfunction after liver transplantation

Introducción. La disfunción primaria (DP) y su forma más grave, el fallo primario (FP), siguen siendo un problema muy importante en los pacientes sometidos a un trasplante hepático (TH), ya que se trata de una entidad de origen desconocido, con una incidencia elevada y con una gran repercusión en su evolución. Los objetivos de nuestro estudio son conocer la incidencia de la DP y la capacidad de 20 características de los donantes para inducir este cuadro. Pacientes y método. Se han estudiado de forma prospectiva los 248 TH realizados consecutivamente durante 79 meses en el Hospital Ramón y Cajal de Madrid en 206 pacientes. Los enfermos fueron clasificados en normofunción primaria y disfunción primaria, y en esta última se reagruparon los casos de FP y función primaria inadecuada. Se definió normofunción primaria o función primaria inadecuada según si las cifras de transaminasas y la actividad de protrombina eran superiores o inferiores a 2.000 U/ml y al 50 por ciento, respectivamente, entre los días segundo y séptimo tras el trasplante hepático. Resultados. La incidencia de DP fue del 9,3 por ciento (23 trasplantes hepáticos), de los cuales 12 (4,8 por ciento) casos fueron un fallo primario. El análisis univariable relacionó significativamente la edad del donante y la causa de la muerte cerebral de él con una mayor frecuencia de DP. El estudio multivariable únicamente lo relacionó con esta última variable (p = 0,04), con una odds ratio (OR) de 4,25 (intervalo de confianza [IC] del 95 por ciento, 1,13-16,0). Conclusiones. La DP es una entidad clínica con una incidencia importante. El único factor que ha demostrado su influencia en el desarrollo de una DP es una causa de muerte cerebral diferente de un traumatismo craneoencefálico (AU)