Internal and external validation of indocyanine green plasma disappearance rate to discard liver grafts before procurement.

Backgrounds/Aims: Thirty percent of liver grafts in donors after brain death (DBD) in Spain are rejected by procurement surgeons owing to marginal graft quality. Poor donor indocyanine green (ICG) clearance has been associated with graft discard and malfunction. This study aimed to internally and externally validate the predictive value of ICG-plasma disappearance rate (ICG-PDR) to reject grafts before donation and set a cut-off to avoid missing any potential effective donors. Methods: Between March 2017 and August 2023, ICG clearance test was performed immediately before procurement in 71 DBD. The surgeon was blinded to test results. Univariate and multivariate analyses were performed to detect independent predictors of graft discard. Discrimination and calibration of predictors were assessed and a cut-off with 100% specificity was set. External validation was performed on 17 donors evaluated by three other transplantation teams. Results: In the training cohort, 30 of 71 grafts were discarded for transplantation. ICG-PDR was the only donor variable independently associated with graft discard. The area under receiver operating characteristic curve for ICG-PDR was 0.875 (95% confidence interval: 0.768-0.947) and good calibration was observed. Below a PDR of 13.5%/min, no graft was accepted for transplantation. These results were successfully validated using the external cohort of donors. Conclusions: ICG clearance test performed in DBD was internally and externally validated to predict liver graft discard. It could be used as a screening tool before donation to avoid unnecessary costs of travel and human resources.

[Esopheal foreign body impaction]. / Impactación de cuerpo extraño esofágico.

Esophageal ingestion of foreign bodies is a frequent urgency. It occurs more commonly in patients with psychiatric disorders, prisoners and extreme ages of the life. Early upper endoscopy is the method of choice for the treatment of symptomatic patients. Surgery is only considered when a complication is present or the extraction can not be done by the endoscopist. We report a case of a 34-year-old male who voluntarily ingested an uncommon foreign body. Surgical treatment was required because of impaction after endoscopic maneuvers and suspicion of esophageal perforation.

Impact and outcomes of liver resection for hepatocellular carcinoma in patients with clinically significant portal hypertension.

PURPOSE: Clinically significant portal hypertension (CSPH), although not a contraindication for liver resection in cirrhosis, is considered a determinant prognostic factor for post-surgical outcomes. This study aims to investigate the effects of CSPH on short and long-term results after hepatic resection for hepatocellular carcinoma (HCC). METHODS: Single-center retrospective analysis of 126 consecutive hepatic resections for HCC in Child-Pugh A patients, performed between 2008 and 2018. Patients were divided according to the presence of CSPH, defined as a hepatic venous pressure gradient ≥ 10 mmHg. To overcome selection bias, 42 patients with CSPH were matched through propensity score with 42 patients without CSPH. Intraoperative and post-operative outcomes, along with overall and disease-free survival, were compared between the matched groups. RESULTS: Liver decompensation was four-fold in the CSPH group (28.6% vs. 7.1%, p = 0.010), while rate of severe complications, including 90-days mortality, was not statistically different between patients with and without CSPH. Overall and recurrence-free survival was not inferior in patients with CSPH compared to non-CSPH group. CONCLUSIONS: The present study has demonstrated acceptable outcomes of liver resection for HCC in carefully selected Child-Pugh A cirrhotic patients, even in the presence of elevated portal pressure.

OBJETIVOS: La hipertensión portal clínicamente significativa (HPCS), si bien no representa una contraindicación para la resección hepática en la cirrosis, se considera un factor pronóstico determinante en los resultados posoperatorios. Este estudio se propone de estudiar los efectos de la HPCS en los resultados a corto y largo plazo tras la resección hepática por carcinoma hepatocelular (CHC). MÉTODOS: Análisis retrospectivo mono-céntrico de 126 resecciones hepáticas por CHC en pacientes Child-Pugh A, realizadas entre el 2008 y el 2018. Los pacientes se han dividido según la presencia de HPCS, definida como gradiente de presión venoso hepático ≥ 10 mmHg. Para controlar el sesgo de selección, 42 pacientes con HPCS se han apareado con puntaje de propensión con 42 pacientes sin HPCS. RESULTADOS: La tasa de descompensación hepática fue 4 veces superior en los pacientes con HPCS (28.6% vs. 7.1%, p = 0.010), mientras las complicaciones graves, incluyendo la mortalidad a 90 días, no se mostraron diferentes en los pacientes con y sin HPCS. La supervivencia global y libre de recidiva no fueron inferiores en los pacientes con HPCS comparados. CONCLUSIONES: El presente estudio ha demostrado resultados aceptables en la resección hepática en pacientes con cirrosis Child-Pugh A cuidadosamente seleccionados, también en presencia de hipertensión portal.

Indocyanine green clearance test as a predictor of chemotherapy liver toxicity and post-operative complications in patients with colorectal liver metastases.

OBJECTIVE: This study aims to investigate the relationship between the pre-operative indocyanine green (ICG) test, the chemotherapy-associated liver injury (CALI), and the development of severe post-operative complications (POC) in patients operated of colorectal liver metastases (CRLMs). MATERIALS AND METHODS: Sixty-nine patients previously treated with chemotherapy and submitted to liver resection for CRLM were retrospectively studied. Two pathologists independently reviewed the pathological specimens and assessed the presence of CALI. The correlation between ICG clearance and specific pathological features was analyzed. In addition, a logistic regression analysis was performed to seek for pre-operative factors associated with severe complications. RESULTS: After a mean of 10.6 (± 7.5) chemotherapy cycles, 44 patients (63.8%) developed CALI. ICG retention rate at 15 min (ICG-R15) was not statistically different between patients with and without CALI and it could only discriminate the presence of centrilobular fibrosis. Rate of severe complications was almost 6-fold in patients with CALI compared to patients without CALI (p = 0.024). ICG-R15 ≥ 10% was the only independent risk factor associated with severe POC at multivariable logistic regression (OR = 4.075 95% CI: 1.077-15.422, p = 0.039). CONCLUSIONS: Pre-operative ICG clearance test, although not useful to identify patients with hepatic drug toxicity, is a strong predictor for the development of severe post-hepatectomy complications.

OBJETIVO: Investigar la relación entre el test de aclaramiento del verde de indocianina (ICG) preoperatorio, las alteraciones patológicas derivadas de la quimioterapia (CALI) y el desarrollo de complicaciones posoperatorias en los pacientes sometidos a resección hepática por metástasis de cáncer colorrectal (MCCR). MATERIAL Y MÉTODOS: Sesenta y nueve pacientes previamente tratados con quimioterapia y operados de MCCR se estudiaron de manera retrospectiva. Dos patólogas revisaron independientemente el parénquima hepático no tumoral de los especímenes y determinaron la presencia de daño quimio-inducido. Se analizó la correlación entre el aclaramiento de ICG y las diferentes alteraciones anatomo-patológicas encontradas. Además, se realizó un análisis de regresión logística para identificar los factores preoperatorios asociados con las complicaciones posoperatorias. RESULTADOS: Tras una media de 10.6 (± 7.5) ciclos de quimioterapia, 44 pacientes (63.8%) desarrollaron CALI. La tasa de retención de ICG a los 15 minutos (ICG-R15) no fue estadísticamente diferente entre los pacientes con y sin CALI y solo pudo discriminar la presencia de fibrosis centrolobulillar. La tasa de complicaciones severas posoperatorias fue 6 veces superior en los pacientes con CALI, comparada con aquella de los pacientes sin CALI (p = 0.024). Un ICG-R15 ≥ 10% fue el único factor de riesgo independiente asociado a complicaciones severas (OR = 4.075 95% CI: 1.077-15.422, p = 0.039). CONCLUSIONES: La prueba preoperatoria de aclaramiento del ICG, a pesar de no identificar eficazmente los pacientes con daño por quimioterapia, es un fuerte predictor de desarrollo de complicaciones severas posoperatorias.

Usefulness of Indocyanine Green Plasma Disappearance Rate in Liver Donors and Recipients: A Prospective Observational Study.

BACKGROUND: Determination of indocyanine green (ICG) plasma disappearance rate (PDR) is a simple, inexpensive, and noninvasive tool to assess liver perfusion, absorption, and elimination. Its application in the liver transplant process has not been widely incorporated in clinical practice. This study aims to assess the usefulness of ICG PDR in the donor selection setting and in the early post-transplant phase and to analyze its variation between these 2 time points. METHODS: We performed a single-center prospective observational study. ICG clearance test was performed in 50 brain-dead donors (T0-PDR) to assess concordance with graft suitability. Rejected grafts biopsy specimens were analyzed to correlate histology with T0-PDR. In the recipients, ICG PDR was performed before wound closure (T1-PDR). The association of T0, T1, and T0-T1 variation with the development of early allograft dysfunction (EAD) was investigated. RESULTS: A total of 23 of 50 grafts were discarded because of poor macroscopic quality. A T0-PDR below 15.5%/min could predict graft rejection with 100% specificity and 69.6% sensitivity. All the biopsy specimens from donors with PDR < 10 %/min showed liver fibrosis. A total of 25 of the remaining 27 grafts were implanted; 5 patients (20%) developed EAD. T1-PDR performed better than T0-T1 variation to predict dysfunction. CONCLUSIONS: ICG PDR could be used in the donors as a filter to discard poor-quality grafts before procurement and, in the early post-transplant phase, to predict EAD.

Hepatic resection with thrombectomy in the treatment of hepatocellular carcinoma associated with macrovascular invasion. / Resección hepática con trombectomía en el tratamiento del carcinoma hepatocelular con invasión vascular macroscópica.

INTRODUCTION: Macrovascular invasion (MVI) in patients with hepatocellular carcinoma (HCC) is a very poor prognostic factor. Treatment in such cases is still a matter of debate. The goal of this study is to assess short- and long-term results of liver resection and thrombectomy in a series of patients with HCC and MVI. METHODS: Retrospective cohort study of patients who underwent liver resection for HCC in the period 2007-2015 (n=120). Of all the patients, 108 did not have MVI, while 12 presented with MVI: 1patient in the common portal vein (Vp4), 8patients in first-order portal branches (Vp3), 1patient in a sectorial branch (Vp2), 1patient in a segmental branch (Vp1); another patient presented with tumor thrombus in a main hepatic venous branch in the confluence with the vena cava (Vv2). RESULTS: Patients with MVI needed major hepatic resection more frequently than patients without MVI (83.3% vs 25.9%, P<.0001), with no differences in postoperative mortality or severe morbidity. Patients with MVI required a longer operative time and developed more frequently postoperative ascites (33.3% vs 9.3%, P=.034). Global survival at 1, 3 and 5years was 66.7%, 33.3% and 22.2% in patients with IMV, and 90.7%, 72.4% and 52.2% in patients without IMV (P=.009), respectively. CONCLUSIONS: Hepatectomy associated with thrombectomy might be justified in a selected group of patients with HCC and MVI, offering a potential benefit in survival with acceptable morbidity.

Resección hepática con trombectomía en el tratamiento del carcinoma hepatocelular con invasión vascular macroscópica / Hepatic resection with thrombectomy in the treatment of hepatocellular carcinoma associated with macrovascular invasión

Introducción: La invasión macrovascular (IMV) en los pacientes con carcinoma hepatocelular (CHC) es un factor de muy mal pronóstico. El tratamiento de estos casos es todavía controvertido. El objetivo de este estudio es valorar los resultados a corto y a largo plazo de la resección hepática asociada a trombectomía en una serie de pacientes con CHC asociado a IMV. Métodos: Estudio retrospectivo de cohortes en los pacientes sometidos a resección hepática por CHC durante el período 2007-2015 (n=120). Del total, 108 pacientes no presentaban IMV, mientras 12 presentaban al diagnóstico IMV: 1paciente presentaba IMV en la porta común (Vp4), 8pacientes en ramas portales de primer orden (Vp3), 1paciente en ramas sectoriales (Vp2), 1 paciente en ramas segmentarias (Vp1), y además 1paciente presentaba trombosis en una vena suprahepática principal hasta la entrada en vena cava (Vv2). Resultados: Los pacientes con IMV necesitaron con mayor frecuencia una hepatectomía mayor frente a los sin IMV (83,3% vs 25,9%, p < 0,0001), sin diferencias en cuanto a mortalidad y morbilidad grave postoperatoria. Los casos con IMV requirieron un tiempo operatorio más largo y desarrollaron con más frecuencia ascitis postoperatoria (33,3% vs 9,3%, p = 0,034). La supervivencia global a 1, 3 y 5 años fue del 66,7, del 33,3 y del 22,2%, respectivamente, en los pacientes con IMV, y del 90,7, del 72,4 y del 52,2% en el grupo sin IMV (p = 0,009). Conclusión: La hepatectomía asociada a trombectomía parece estar justificada en un grupo seleccionado de pacientes con CHC e IMV, pudiendo aportar un beneficio de supervivencia con una aceptable tasa de morbilidad

Introduction: Macrovascular invasion (MVI) in patients with hepatocellular carcinoma (HCC) is a very poor prognostic factor. Treatment in such cases is still a matter of debate. The goal of this study is to assess short- and long-term results of liver resection and thrombectomy in a series of patients with HCC and MVI: Methods: Retrospective cohort study of patients who underwent liver resection for HCC in the period 2007-2015 (n=120). Of all the patients, 108 did not have MVI, while 12 presented with MVI: 1patient in the common portal vein (Vp4), 8 patients in first-order portal branches (Vp3), 1patient in a sectorial branch (Vp2), 1patient in a segmental branch (Vp1); another patient presented with tumor thrombus in a main hepatic venous branch in the confluence with the vena cava (Vv2). Results: Patients with MVI needed major hepatic resection more frequently than patients without MVI (83.3% vs 25.9%, P < .0001), with no differences in postoperative mortality or severe morbidity. Patients with MVI required a longer operative time and developed more frequently postoperative ascites (33.3% vs 9.3%, P = .034). Global survival at 1, 3 and 5years was 66.7%, 33.3% and 22.2% in patients with IMV, and 90.7%, 72.4% and 52.2% in patients without IMV (P = .009), respectively. Conclusions: Hepatectomy associated with thrombectomy might be justified in a selected group of patients with HCC and MVI, offering a potential benefit in survival with acceptable morbidity

Déficits atentivos e antidepressores / Attention deficits and antidepressants

Os autores apresentam alguns conceitos de atençäo, os sistemas neuroanatômicos envolvidos, comentando estudos onde foram observados déficts atentivos na depressäo e o comprometimento cognitivo-atentivo ocasionado por diferentes classes de antidepressores

Deficits mnemicos associados ao uso de antidepressores

E apresentada uma abordagem integrada sobre os sistemas de memoria, suas conexoes com estruturas cerebrais, os deficits mnemicos encontrados na depressao e o efeito das drogas antidepressivos na cognicao.

A ética na pesquisa clínica / Ethics in clinical research

A pesquisa médica envolvendo "anima nobile" está presa, desde a declaração de Helsinque, a um conjunto de normas, regulamentações nacionais, resoluções e portarias específicas. É imprescindível proficiência neste emaranhado de exigências e suas relações com a ética médica, para correta execução de qualquer projeto de pesquisa clínica. Os autores revisam os aspectos importantes da legislação, sua confluência com o bem estar e segurança dos pacientes que aceitam participar destes projetos, analisando os riscos e benefícios, análise correta dos dados por todos os participantes da equipe que, necessariamente, devem conhecer não só os pormenores legais como avaliar os efeitos benéficos, a importância do efeito placebo, as reações indesejáveis ou adversas, o que irá influenciar indelevelmente os resultados finais e determinar a utilidade da pesquisa realizada

Deficits atentivos e antidepressores

Os autores apresentam alguns conceitos de atencao, os sintomas neuroanatomicos envolvidos, comentando estudos onde foram observados deficts atentivos na depressao e o comprometimento cognitivo-atentivo ocasionado por diferentes classes de antidepressores.

Depressão como fator gerador de absenteísmo / Depression as a cause for absenteeism

O presente estudo tem por finalidade apresentar um fenômeno de grande relevância que é a depressão como fato gerador de absenteísmo, sendo que uma das situações que causam a depressão é o assédio moral existente na relação de emprego. Consiste em uma conduta abusiva, cruel e humilhante, capaz de atentar contra a dignidade física, psíquica e emocional do trabalhador. Apesar de atualmente ser alvo de debates e reportagens é uma prática bastante antiga e que sempre se faz presente. Esse tipo de violência pode vir a produzir, danos tanto na saúde psicofísica do trabalhador, afrontando sua dgnidade e direito de personalidade, quanto prejuízo às estruturas organizacionais das empresas.