Transplantation-mediated alloimmune thrombocytopenia successfully treated by retransplantation.

INTRODUCTION: Transplantation-mediated alloimmune thrombocytopenia (TMAT) is a rare complication affecting the recipient of an organ from a donor with immune thrombocytopenia (ITP). METHODS: We present a case of TMAT following liver transplantation successfully treated by retransplantation, along with a review of previously published cases.Clinical presentation: The liver donor had lupus and ITP and died from an intracranial hemorrhage. The recipient's platelet count fell to 2x109/L on postoperative day 2. Due to the lack of response to medical treatment, emergency retransplantation was undertaken with a steady recovery of the platelet count within a few days. DISCUSSION: Six additional cases of transplantation-mediated alloimmune thrombocytopenia after liver transplantation have been reported. In all cases, severe thrombocytopenia ensued within 3 days after liver transplantation. Four patients suffered hemorrhagic complications. Three patients died. Early retransplantation was needed in three out of four patients receiving a graft from a donor with ITP and splenectomy. All recovered shortly after the new graft was in place. CONCLUSION: Severe refractory transplantation-mediated alloimmune thrombocytopenia can develop in liver recipients from donors with ITP, especially those with previous splenectomy. Early retransplantation should be considered if there is no rapid response to medical therapy.

Cystic duct cyst: type VI in Todani's classification.

Regarding the article recently published by Junquera E et al. that referenced our work, we agree with the authors that the cystic duct cyst (CDC) is type VI according to Todani's classification, which describes five different types of biliary cysts.

Prognostic value of the nodal ratio in gastric cancer: unicentric analysis of 199 patients.

INTRODUCTION: In the gastric cancer the most widely used classification is the AJCC TNM system. However, it presents limitations, such as staging migration in cases with suboptimal lymphadenectomies. The nodal ratio has been proposed as an alternative system, proving to be a good prognostic predictor of survival. The aim was to assess the influence of the nodal ratio measured in tertiles [tNR] as a prognostic factor and compare with the TNM systems (7th ed.) and log odds of positive lymph nodes [LODDS]. MATERIAL AND METHODS: Retrospective and single-center study on 199 patients operated on with curative intent between 2010 and 2014. For each system an univariate and multivariate analysis was performed and the overall survival rates [OS] were compared by the ROC test. RESULTS: The prognostic factors that showed statistical significance in the multivariate analysis were: tRN2 (HR2.87) and tRN3 (HR7.29); LODDS 2 (HR1.55), LODDS3 (HR2.6) and LODDS4 (HR4.9); pN2 (HR1.84) and pN3 (HR2.91). The 5-year OS was 75.8%, 61.4%, 25.8%, and 3.84% for tRN0, tRN1, tRN2 and tRN3; 72.4%, 60%, 29.1% and 13.9% for LODDS1, LODDS2, LODDS3 and LODDS4; and 77.6%, 59.4%, 28.8% and 25.5% for pN0, pN1, pN2 and pN3, respectively. The three systems behaved as good predictors, with areas under the curve >0.75. CONCLUSION: tNR was an independent prognostic factor for estimating survival in gastric cancer. Furthermore, the ease of its calculation in clinical practice could reduce the effect of staging migration.

Prognostic value of the nodal ratio in gastric cancer: Unicentric analysis pf 199 patients. / Valor pronóstico del ratio nodal en el cáncer gástrico: análisis unicéntrico de 199 pacientes.

INTRODUCTION: In the gastric cancer the most widely used classification is the AJCC TNM system. However, it presents limitations, such as staging migration in cases with suboptimal lymphadenectomies. The nodal ratio has been proposed as an alternative system, proving to be a good prognostic predictor of survival. The aim was to assess the influence of the nodal ratio measured in tertiles [tNR] as a prognostic factor and compare with the TNM systems (7th ed.) and log odds of positive lymph nodes [LODDS]. MATERIAL AND METHODS: Retrospective and single-center study on 199 patients operated on with curative intent between 2010 and 2014. For each system an univariate and multivariate analysis was performed and the overall survival rates [OS] were compared by the ROC test. RESULTS: The prognostic factors that showed statistical significance in the multivariate analysis were: tNR2 (HR 2.87) and tNR 3 (HR 7.29); LODDS 2 (HR 1.55), LODDS3 (HR 2.6) and LODDS4 (HR 4.9); pN2 (HR 1.84) and pN3 (HR 2.91). The 5-year OS was 75.8, 61.4, 25.8 and 3.84% for tNR0, tNR1, tNR2 and tNR3; 72.4, 60, 29.1 and 13.9% for LODDS1, LODDS2, LODDS3 and LODDS4; and 77.6, 59.4, 28.8 and 25.5% for pN0, pN1, pN2 and pN3, respectively. The three systems behaved as good predictors, with areas under the curve >0.75. CONCLUSION: tNR was an independent prognostic factor for estimating survival in gastric cancer. Furthermore, the ease of its calculation in clinical practice could reduce the effect of staging migration.

Liver transplantation following hepatic artery avulsion in a trauma patient.

BACKGROUND: Hepatic artery avulsion following politrauma is an extremely rare condition with a very high mortality rate. Management is based on damage control surgery given the precarious situation of these patients. Ligating the artery is one option under such circumstances, despite potential consequences including ischemic cholangiopathy (IC). Ischemic cholangiopathy, which can be caused by an insufficient blood supply to the bile duct, generally results in stricture and recurrent cholangitis, and the need for a liver transplant in extreme cases. CASE PRESENTATION: We present the case of a 37-year-old male with multiple traumas after falling from the third floor of a building. He was hemodynamically unstable upon arrival at the emergencies department, with no improvement on administration of aggressive fluid therapy. A Echo-FAST exam evidenced fluid in all quadrants, so the patient was transferred to the operating room where a 4-litre hemoperitoneum secondary to total avulsion of the proper hepatic artery was observed. The patient required massive transfusion and vasoactive drugs, with instability throughout the intervention; therefore, we decided to ligate the proper hepatic artery. Hepatic dysfunction and diffuse IC with multiple episodes of recurrent cholangitis were observed during the postoperative period. Given the irreversible clinical picture, we opted for a liver transplant 70 days after the patient's initial admission. The patient died on Day 34 post-transplant due to irreversible ischemic brain damage and a right occipital hemorrhage. CONCLUSIONS: Hepatic artery avulsion due to trauma is very rare and its management very complex, and in certain situations the artery must be ligated. The main consequence of ligating the hepatic artery is IC, which is more frequently observed secondary to iatrogenic lesions or systemic diseases, while very few cases have been published in which IC is secondary to hepatic artery avulsion caused by hepatic trauma. Treatment depends on the extent of ischemia, and when the damage is diffuse, as in our case, it may involve a liver transplant.

Hematoma retroperitoneal espontáneo en pacientes con neumonía grave por SARS-CoV-2 / Spontaneous retroperitoneal hematoma in patients with severe SARS-CoV-2 pneumonia

Recientemente se han publicado varios casos de hematomas retroperitoneales espontáneos (Hre) en el contextode infección por SarS-CoV-2. este estudio presenta una revisión sistemática de la literatura con el objetivo deprofundizar en esta infrecuente asociación. Se identificaron 32 casos de Hre, el 28,1 % con enfermedad COVID-19 crítica. el 68,7 % recibió anticoagulacióncon HBpM y el 15,6 % con heparina sódica. La mediana de días hasta el diagnóstico fue de 10,5 (rango de 0-38).en el 31,2 % de los casos se optó por manejo conservador, mientras que otro 31,2 % requirió angioembolización. Se comunicaron 10 exitus (31,2 %), 6 probablemente relacionados con el Hre.existen hipótesis acerca de la relación entre la infección por SarS-CoV-2 y los fenómenos hemorrágicos. Se handescrito dos mecanismos que explicarían la coagulopatía: la unión al receptor aCe2 y la acción directa del virussobre el endotelio vascular. Por otra parte, la disfunción plaquetaria, la trombocitopenia inmune y la respuesta alSIrS, así como los microtraumas secundarios al esfuerzo tusígeno, la ventilación mecánica invasiva o los cambiosposturales, sugieren un origen multicausal del Hre.La literatura sobre esta asociación es escasa. Dado el exceso de morbimortalidad que supone, se considera nece-sario profundizar en su investigación.(AU)

Recently, cases of spontaneous retroperitoneal haematomas (SrH) in the context of SarS-CoV-2 infection havebeen published. this study presents a systematic review with the aim of further investigating this rare association. Thirty-two cases were identified, with a 28,1 % of critical patients. a total of 68,7 % received anticoagulation withLMWH, and a 15,6 % with UFH. the median number of days to diagnosis was 10,5 (0-38). Conservative manage-ment was chosen in 31,2 %, while another 31,2 % required angio-embolisation. ten exitus (31,2 %) were reported,6 related to SrH. There are hypotheses on the link between SarS-CoV-2 infection and haemorrhagic phenomena. two mechanismshave been described that would explain coagulopathy: the binding of SarS-CoV-2 to the aCe2 receptor and itsdirect action on the vascular endothelium. Furthermore, the platelet dysfunction, immune thrombocytopenia andSIrS, added to the endothelial disruption in retroperitoneal vessels, as well as microtrauma secondary to coughstress, invasive mechanical ventilation and/or postural changes, suggest a multicausal origin of SrH. The literature concerning this association is scarce. Given the excess morbidity and mortality involved, it is consid-ered necessary to investigate it further.(AU)

Valor pronóstico del ratio nodal en el cáncer gástrico: análisis unicéntrico de 199 pacientes / Prognostic value of the nodal ratio in gastric cancer: Unicentric analysis pf 199 patients

IntroducciónEl sistema de clasificación ganglionar más utilizado en el cáncer gástrico es el TNM. No obstante presenta limitaciones, como la «migración de estadificación» en los casos con linfadenectomías subóptimas, por ello se han planteado distintos sistemas. Asimismo, el objetivo fue valorar la influencia del ratio nodal medido en terciles [RNt] como factor pronóstico, y compararlo con los sistemas TNM (7.ª ed.) y log odds of positive lymph nodes [LODDS].Material y métodosSe trata de un estudio retrospectivo y unicéntrico sobre 199 pacientes con neoplasia gástrica intervenidos con intención curativa entre 2010 y 2014. Se realizó un análisis univariante y multivariante de cada sistema, y se compararon las tasas de supervivencia global [SG] obtenidas mediante test ROC.ResultadosLos factores pronóstico que mostraron significación estadística en el análisis multivariante fueron: RNt2 (HR 2,87) y RNt3 (HR 7,29); LODDS 2 (HR 1,55), LODDS3 (HR 2,6) y LODDS4 (HR 4,9); pN2 (HR 1,84) y pN3 (HR 2,91). La SG a 5 años fue del 75,8, 61,4, 25,8 y 3,84% para RNt0, RNt1, RNt2 y RNt3; 72,4, 60, 29,1 y 13,9% para LODDS1, LODDS2, LODDS3 y LODDS4; y 77,6, 59,4, 28,8 y 25,5% para pN0, pN1, pN2 y pN3, respectivamente. Los 3 sistemas se comportaron como buenos predictores, con áreas bajo la curva >0,75.ConclusiónEl RNt fue un factor pronóstico independiente para la estimación de la supervivencia en el cáncer gástrico. Además, la facilidad de su cálculo en la práctica clínica podría disminuir el efecto de migración de estadificación (AU)

IntroductionIn the gastric cancer the most widely used classification is the AJCC TNM system. However, it presents limitations, such as staging migration in cases with suboptimal lymphadenectomies. The nodal ratio has been proposed as an alternative system, proving to be a good prognostic predictor of survival. The aim was to assess the influence of the nodal ratio measured in tertiles [tNR] as a prognostic factor and compare with the TNM systems (7th ed.) and log odds of positive lymph nodes [LODDS].Material and methodsRetrospective and single-center study on 199 patients operated on with curative intent between 2010 and 2014. For each system an univariate and multivariate analysis was performed and the overall survival rates [OS] were compared by the ROC test.ResultsThe prognostic factors that showed statistical significance in the multivariate analysis were: tNR2 (HR 2.87) and tNR 3 (HR 7.29); LODDS 2 (HR 1.55), LODDS3 (HR 2.6) and LODDS4 (HR 4.9); pN2 (HR 1.84) and pN3 (HR 2.91). The 5-year OS was 75.8, 61.4, 25.8 and 3.84% for tNR0, tNR1, tNR2 and tNR3; 72.4, 60, 29.1 and 13.9% for LODDS1, LODDS2, LODDS3 and LODDS4; and 77.6, 59.4, 28.8 and 25.5% for pN0, pN1, pN2 and pN3, respectively. The three systems behaved as good predictors, with areas under the curve >0.75.ConclusiontNR was an independent prognostic factor for estimating survival in gastric cancer. Furthermore, the ease of its calculation in clinical practice could reduce the effect of staging migration (AU)

Recidiva parietal de colangiocarcinoma hiliar. ¿Es el drenaje biliar transparietohepático el de elección en los pacientes con colangiocarcinoma hiliar? / Parietal recurrence of hiliar cholangiocarcinoma: Is percutaneous transhepatic biliary drainage the best choice in patients with hiliar cholangiocarcinoma?

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Síndrome de la pinza aorto-mesentérica (Sind. de Wilkie). Análisis de una serie de 7 casos / Superior mesenteric artery syndrome (Wilkie syndrome): Analysis of a series of 7 cases

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Artefacto radioopaco en un segmento hepático / Radiopaque artifact in a liver segment

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