Assuntos
Neoplasias dos Ductos Biliares/diagnóstico por imagem , Tomada de Decisão Clínica , Simulação por Computador , Imageamento Tridimensional , Tumor de Klatskin/diagnóstico por imagem , Software , Neoplasias dos Ductos Biliares/patologia , Neoplasias dos Ductos Biliares/cirurgia , Humanos , Tumor de Klatskin/patologia , Tumor de Klatskin/cirurgia , Imageamento por Ressonância Magnética , Medicina de Precisão , Cuidados Pré-Operatórios , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Nab-paclitaxel and gemcitabine have demonstrated a survival benefit over gemcitabine alone in advanced pancreatic cancer (PDA). This study aimed to investigate the clinical, biological, and imaging effects of the regimen in patients with operable PDA. METHODS: Patients with operable PDA received two cycles of nab-paclitaxel and gemcitabine before surgical resection. FDG-PET and CA19.9 tumour marker levels were used to measure clinical activity. Effects on tumour stroma were determined by endoscopic ultrasound (EUS) elastography. The collagen content and architecture as well as density of cancer-associated fibroblasts (CAFs) were determined in the resected surgical specimen and compared with a group of untreated and treated with conventional chemoradiation therapy controls. A co-clinical study in a mouse model of PDA was conducted to differentiate between the effects of nab-paclitaxel and gemcitabine. RESULTS: A total of 16 patients were enrolled. Treatment resulted in significant antitumour effects with 50% of patients achieving a >75% decrease in circulating CA19.9 tumour marker and a response by FDG-PET. There was also a significant decrement in tumour stiffness as measured by EUS elastography. Seven of 12 patients who completed treatment and were operated had major pathological regressions. Analysis of residual tumours showed a marked disorganised collagen with a very low density of CAF, which was not observed in the untreated or conventionally treated control groups. The preclinical co-clinical study showed that these effects were specific of nab-paclitaxel and not gemcitabine. CONCLUSION: These data suggest that nab-paclitaxel and gemcitabine decreases CAF content inducing a marked alteration in cancer stroma that results in tumour softening. This regimen should be studied in patients with operable PDA.
Assuntos
Adenocarcinoma/tratamento farmacológico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Fibroblastos/patologia , Neoplasias Pancreáticas/tratamento farmacológico , Adenocarcinoma/metabolismo , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Albuminas/administração & dosagem , Albuminas/farmacologia , Animais , Antígeno CA-19-9/sangue , Colágeno/efeitos dos fármacos , Desoxicitidina/administração & dosagem , Desoxicitidina/análogos & derivados , Desoxicitidina/farmacologia , Modelos Animais de Doenças , Técnicas de Imagem por Elasticidade , Endossonografia , Feminino , Fibroblastos/efeitos dos fármacos , Humanos , Masculino , Camundongos , Pessoa de Meia-Idade , Terapia Neoadjuvante , Paclitaxel/administração & dosagem , Paclitaxel/farmacologia , Neoplasias Pancreáticas/metabolismo , Neoplasias Pancreáticas/patologia , Tomografia por Emissão de Pósitrons , GencitabinaRESUMO
A high throughput screening for anticancer activity of FDA approved drugs identified mycophenolic acid (MPA), an inhibitor of inositol monophosphate dehydrogenase (IMPDH) as an active agent with an antiangiogenesis mode of action. Exposure of pancreatic cancer cell lines to MPA resulted in growth inhibition and reduced the expression of VEGF that was reversed by supplementing the media with guanosine supporting and IMPDH-dependant mechanism. In preclinical in vivo study, MPA showed a moderate inhibition of tumor growth in a panel of 6 human derived pancreatic cancer xenografts but reduced the expression of VEGF. To investigate the effects of MPA in human pancreatic cancer, a total of 12 patients with resectable pancreatic cancer (PDA) received increasing doses of mycophenolate mofetil (MMF) in cohorts of 6 patients each from 5-15 days prior to surgical resection. Treatment was well tolerated with one episode of grade 1 muscle pain, one episode of grade 2 lymphopenia (2 gr/day dose) and one episode of grade 2 elevantion in LFT (all in the 2 gr./day dose). Patients recovered from surgery uneventfully with no increased post-operative complications. Assessment of CD31, VEGF, and TUNEL in resected specimens compared to a non treated control of 6 patients showed no significant variations in any of the study endpoints. In conclusion, this study shows the feasibility of translating a preclinical observation to the clinical setting and to explore a drug mechanism of action in patients. MPA, however, did not show any hints of antiangiogenesis of anticancer clinical activity questioning if this agent should be further developed in PDA.
Assuntos
Carcinoma Ductal Pancreático/tratamento farmacológico , Imunossupressores/uso terapêutico , Ácido Micofenólico/análogos & derivados , Neoplasias Pancreáticas/tratamento farmacológico , Idoso , Animais , Carcinoma Ductal Pancreático/metabolismo , Carcinoma Ductal Pancreático/patologia , Linhagem Celular Tumoral , Feminino , Guanosina Trifosfato/metabolismo , Humanos , Imunossupressores/sangue , Imunossupressores/farmacologia , Masculino , Camundongos , Pessoa de Meia-Idade , Ácido Micofenólico/sangue , Ácido Micofenólico/farmacologia , Ácido Micofenólico/uso terapêutico , Neoplasias Pancreáticas/metabolismo , Neoplasias Pancreáticas/patologia , Resultado do Tratamento , Carga Tumoral/efeitos dos fármacos , Ensaios Antitumorais Modelo de XenoenxertoRESUMO
To demonstrate the efficacy of radiofrequency for pancreatic stump closure in reducing the incidence of postoperative pancreatic fistula (POPF) in distal pancreatectomy (DP) compared with mechanical transection methods. Despite all the different techniques of pancreatic stump closure proposed for DP, best practice for avoiding POPF remains an unresolved issue, with an incidence of up to 30% regardless of center volume or surgical expertise. DP was performed in a cohort of patients by applying radiofrequency to stump closure (RF Group) and compared with mechanical closure (Control Group). A propensity score (PS) matched cohort study was carried out to minimize bias from nonrandomized treatment assignment. Cohorts were matched by PS accounting for factors significantly associated with either undergoing RF transection or mechanical closure through logistic regression analysis. The primary end-point was the incidence of clinically relevant POPF (CR-POPF). Of 89 patients included in the whole cohort, 13 case patients from the RF-Group were 1:1 matched to 13 control patients. In both the first independent analysis of unmatched data and subsequent adjustment to the overall propensity score-matched cohort, a higher rate of CR-POPF in the Control Group compared with the RF-Group was detected (25.4% vs 5.3%, p = 0.049 and 53.8% vs 0%; p = 0.016 respectively). The RF Group showed better outcomes in terms of readmission rate (46.2% vs 0%, p = 0.031). No significant differences were observed in terms of mortality, major complications (30.8% vs 0%, p = 0.063) or length of hospital stay (5.7 vs 5.2 days, p = 0.89). Findings suggest that the RF-assisted technique is more efficacious in reducing CR-POPF than mechanical pancreatic stump closure.
Assuntos
Pancreatectomia , Fístula Pancreática , Estudos de Coortes , Humanos , Pâncreas/cirurgia , Pancreatectomia/efeitos adversos , Pancreatectomia/métodos , Fístula Pancreática/epidemiologia , Fístula Pancreática/etiologia , Fístula Pancreática/prevenção & controle , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/cirurgia , Pontuação de Propensão , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Pancreatectomy plus celiac axis resection (CAR) is performed in patients with locally advanced pancreatic cancer. The morbidity rates are high, and no survival benefit has been confirmed. It is not known at present whether it is the type of pancreatectomy, or CAR itself, that is the reason for the high complication rates. METHODS: Observational retrospective multicenter study. INCLUSION CRITERIA: patient undergoing TP, PD or DP plus CAR for a pancreatic cancer. RESULTS: Sixty-two patients who had undergone pancreatic cancer surgery (PD,TP or DP) plus CAR were studied. Group 1: 17 patients who underwent PD/TP-CAR (13TP/4PD); group 2: 45 patients who underwent DP-CAR. Groups were mostly homogeneous. Operating time was longer in the PD/TP group, while operative complications did not differ statistically in the two groups. The number of lymph nodes removed was higher in the PD/TP group (26.5 vs 17.3), and this group also had a higher positive node ratio (17.9% vs 7.6%). There were no statistical differences in total or disease-free survival between the two groups. CONCLUSION: It seems that CAR, and not the type of pancreatectomy, influences morbidity and mortality in this type of surgery. International multicenter studies with larger numbers of patients are now needed to validate the data presented here.
Assuntos
Artéria Celíaca/cirurgia , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Índice de Massa Corporal , Intervalo Livre de Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Excisão de Linfonodo/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica/patologia , Duração da Cirurgia , Pancreatectomia/efeitos adversos , Pancreatectomia/mortalidade , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Complicações Pós-Operatórias , Estudos Retrospectivos , Espanha , Resultado do TratamentoRESUMO
BACKGROUND: Preemptive therapy required highly predictive tests for CMV disease. CMV antigenemia assay (pp65 Ag) has been commonly used for rapid diagnosis of CMV infection. Amplification methods for early detection of CMV DNA are under analysis. OBJECTIVES: To compare two diagnostic methods for CMV infection and disease in this population: quantitative PCR (qPCR) performed in two different samples, plasma and leukocytes (PMNs) and using a commercial diagnostic test (COBAS Amplicor Monitor Test) versus pp65 Ag. STUDY DESIGN: Prospective study conducted in liver transplant recipients from February 2000 to February 2001. RESULTS: Analyses were performed on 164 samples collected weekly during early post-transplant period from 33 patients. Agreements higher than 78% were observed between the three assays. Optimal qPCR cut-off values were calculated using ROC curves for two specific antigenemia values. For antigenemia >or=10 positive cells, the optimal cut-off value for qPCR in plasma was 1330 copies/ml, with a sensitivity (S) of 58% and a specificity (E) of 98% and the optimal cut-off value for qPCR-cells was 713 copies/5x10(6) cells (S:91.7% and E:86%). Using a threshold of antigenemia >or=20 positive cells, the optimal cut-off values were 1330 copies/ml for qPCR-plasma (S 87%; E 98%) and 4755 copies/5x10(6) cells for qPCR-cells (S 87.5%; E 98%). Prediction values for the three assays were calculated in patients with CMV disease (9 pts; 27%). Considering the assays in a qualitative way, the most sensitive was CMV PCR in cells (S: 100%, E: 54%, PPV: 40%; NPV: 100%). Using specific cut-off values for disease detection the sensitivity, specificity, PPV and NPV for antigenemia >or=10 positive cells were: 89%; 83%; 67%; 95%, respectively. For qPCR-cells >or=713 copies/5x10(6) cells: 100%; 54%; 33% and 100% and for plasma-qPCR>or=1330 copies/ml: 78%, 77%, 47%, 89% respectively. CONCLUSIONS: Optimal cut-off for viral load performed in plasma and cells can be obtained for the breakpoint antigenemia value recommended for initiating preemptive therapy with high specificities and sensitivities. Diagnostic assays like CMV pp65 Ag and quantitative PCR for CMV have similar efficiency and could be recommended as methods of choice for diagnosis and monitoring of active CMV infection after transplantation.
Assuntos
Infecções por Citomegalovirus/diagnóstico , Citomegalovirus/isolamento & purificação , Transplante de Fígado , Reação em Cadeia da Polimerase/métodos , Antígenos Virais/sangue , Citomegalovirus/genética , Citomegalovirus/fisiologia , DNA Viral/sangue , Humanos , Leucócitos/virologia , Plasma/virologia , Valor Preditivo dos Testes , Sensibilidade e Especificidade , Espanha , Carga Viral , Replicação ViralRESUMO
Renal cell carcinoma with inferior vena cava thrombus is relatively uncommon and complicates radical nefrectomy. During the past twenty years our hospital have substantially contributed to the surgical stratification of renal cell carcinoma with extension into inferior vena cava through different techniques. The reason for this article is to discuss the mote efficient and appropiate surgical technique for this pathology. We believe that the diagnosis of vena caval invasion and level of tumoral extension is based on radiological examinations and it is crucial for the success of the surgery. We consider that the use of vena caval filter applied preoperatively could prevent the risk of thromboembolism during and after the surgery. The use of prosthetic grafts is unusual, because the long standing obstruction caused by the tumor thrombus will develope extensive collateral circulation which works as a natural veno-venous bypass. Finally, we try to avoid the use of veno-venous and cardiopulmonar bypass with or without complete hypothermic circulatory arrest due to the high association with adverse outcomes and mortality.
Assuntos
Carcinoma de Células Renais/secundário , Neoplasias Renais/patologia , Neoplasias Vasculares/secundário , Veia Cava Inferior/patologia , Carcinoma de Células Renais/cirurgia , Humanos , Neoplasias Renais/cirurgia , Invasividade Neoplásica , Estadiamento de Neoplasias , Procedimentos Cirúrgicos Urológicos/métodos , Neoplasias Vasculares/cirurgiaRESUMO
BACKGROUND: Liver granulomatosis is an occasional finding in posttransplant liver biopsies. Its diagnosis is made more difficult by the variety of conditions that can lead to it. In the nontransplant setting, the association of liver granulomatosis and hepatitis C virus (HCV) infection has occasionally been described. METHODS: We describe the case of a patient with a liver transplantation for an HCV-associated cirrhosis who developed an alteration of liver tests. Granulomatosis was detected on the liver biopsy. RESULTS: Other causes of granulomatosis were satisfactorily excluded. The development of the lesions coincided with a viral flare-up. CONCLUSION: We think that HCV can be listed among the possible causes of liver granulomas in the posttransplant setting and that it must be considered in the differential diagnosis of this condition.
Assuntos
Granuloma/virologia , Hepatite C/complicações , Hepatopatias/virologia , Transplante de Fígado , Complicações Pós-Operatórias , Adulto , Biópsia , Granuloma/patologia , Humanos , Fígado/patologia , Cirrose Hepática/cirurgia , Cirrose Hepática/virologia , Hepatopatias/patologia , MasculinoRESUMO
The aim of this study was to analyze the donor risk factors associated with second orthotopic liver transplantation (reOLT) and graft loss after OLT within 1 month. A total of 649 OLTs performed in 11 centers in Spain during the period from 1992 to 1993 were analyzed retrospectively. Eleven donor and recipient variables were studied. Biochemical evolution of the OLT, biliary and arterial complications, patient status (alive, retransplanted, or dead), and follow-up were also recorded. Bivariate study demonstrated that extended preservation ( > 12 hr) was associated with increased biliary complications (P = 0.02), and lower prothrombin time (P = 0.04). In a logistic model regression for biliary complications, ischemia > 12 hr was an independent risk factor (odds ratio = 2.2, 95% confidence interval [CI] = 1.1-4.3). The multivariate Cox proportional model of potential risk factors showed that only urgent reOLT (relative risk [RR] = 2.7, 95% CI = 1.4-5.4) was independently associated with higher 30-day mortality. Donor plasma sodium > 155 mmol/L (RR = 1.4, 95% CI = 1.0-2.2) and incompatible ABO graft (RR = 3.2, 95% CI = 1.3-7.9) were independently associated with increased rate of reOLT before 30 days. Donor plasma sodium > 155 mmol/L (RR = 2, 95% CI = 1.1-3.6) and incompatible graft (RR = 3.3, 95% CI = 1.4-8.2) were independently associated with graft loss (death or reOLT) before 1 month. We conclude that cold ischemia should be kept less than 12 hr in order to avoid biliary complications. Donors over 60 years old or with plasma sodium > 155 should be carefully evaluated before OLT.
Assuntos
Transplante de Fígado , Preservação de Órgãos/métodos , Sódio/sangue , Doadores de Tecidos , Adolescente , Adulto , Humanos , Transplante de Fígado/efeitos adversos , Pessoa de Meia-Idade , Análise Multivariada , Preservação de Órgãos/efeitos adversos , Prognóstico , Reoperação , Fatores de Risco , Fatores de TempoRESUMO
AIM: Analyze the results of a paediatric intestinal transplantation (IT) program in Spain. PATIENTS: During an 5-year period, 18 children were included as candidates for IT. The causes for intestinal failure (IF) were short bowel syndrome (n=13), motility disorders (n=3), and congenital epithelial disorders (n=2). Nine children were admitted for a combined liver-small bowel transplant (LSBT), seven for an isolated intestinal transplantation (IIT) and two for a multivisceral transplantation (MVT). In three of the candidates for IIT the indication had to be changed to LSBT because of progression of the liver damage. RESULTS: Eight candidates are on the waiting list: four for LSBT, two for IIT, and two for MVT. Four children died before transplantation. All were children under 1 year and candidates for LSBT. One child died during an attempted MVT. Five children underwent transplantation. Grafts were IIT in two and LSBT in three. Of these children, two are on a normal diet (respective follow-up times: 40 and 18 months), two died, both with functioning liver and intestinal grafts (hemorrage after liver biopsy and lymphoproliferative disease), and one developed an untreatable rejection that lead to loss of the intestinal graft; currently, she is on the waiting list for LSBT. CONCLUSIONS: The morbidity and mortality of IT are high, but it is the only possible treatment for children in IF who cannot be adequately managed with parenteral nutrition. A severe problem is the the scarcity of suitable donors for the very low weight children who are candidates for LSBT.
Assuntos
Intestinos/transplante , Síndrome do Intestino Curto/cirurgia , Transplante Homólogo , Adolescente , Criança , Pré-Escolar , Humanos , Lactente , Estudos Retrospectivos , Espanha , Resultado do Tratamento , Listas de EsperaRESUMO
AIM: The aim of this study was to analyze the results of living donor in a pediatric liver transplantation program. PATIENTS: Twenty-six living donor liver transplantations were performed in children from 0.5 to 14.8 years of age. The main indication was biliary atresia (72%) followed by tumors (2 hepatoblastomas and 1 hepatocarcinoma). Left lateral segments were used in 23 (1 transformed into a monosegment), 1 left lobe was used in 1, and right lobes were used in 2. Arterial reconstruction employed saphenous venous grafts in the first 3 cases and end-to-end anastomoses with a microsurgical technique in the following 22 cases. RESULTS: There has been no major morbidity in the donors, with a median hospitalization of 6 days. Four grafts have been lost; 2 in the first 3 cases. In only 1 case, the graft loss was related to the procedure saphenous venous graft thrombosis). Early biliary complications were frequent (23%). Six month, 1 year, and 5 year graft and patient survival rates were 91%, 85%, and 85% and 100%, 96%, and 96%, respectively. CONCLUSIONS: Living donor liver transplantation is an excellent option for transplantation in children.
Assuntos
Hepatopatias/cirurgia , Transplante de Fígado/fisiologia , Doadores Vivos/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Hepatectomia/métodos , Humanos , Lactente , Hepatopatias/classificação , Complicações Pós-Operatórias/epidemiologia , Coleta de Tecidos e Órgãos , Resultado do TratamentoRESUMO
INTRODUCTION: Palliative treatment for nondisseminated irresectable hilar cholangiocarcinoma (HCC) carries a 0% 5-year survival rate. The role of orthotopic liver transplantation (OLT) in these patients is controversial because the survival rate is lower than that for other indications for transplantation and the lack of available donor organs. The aim of this paper was to review the Spanish experience in OLT for HCC and identify prognostic factors for survival. METHODS: We retrospectively reviewed 36 patients undergoing OLT for HCC over 13 years. RESULTS: The actuarial survival rate at 1, 3, and 5 years was 82%, 53%, and 30%, respectively. The main cause of death was tumor recurrence (53%). In the univariate analysis, the factors for a poor prognosis were vascular invasion (P<.001) namely 0% survival at 3 years when present versus 63% and 35% at 3 and 5 years, respectively, when it was not; and stages III to IVA (P<.05), namely 15% survival at 5 years versus 47% for stages I to II. Lymph node and perineural invasion also reduce survival. In the multivariate analysis, the factors for poor prognosis included vascular invasion (P<.01) and stages III to IVA (P<.01). CONCLUSION: OLT for nondisseminated irresectable HCC has higher survival rates at 3 and 5 years than palliative treatments, especially with initial stage tumors, which means that more information is needed to better select cholangiocarcinoma patients for transplantation.
Assuntos
Neoplasias dos Ductos Biliares/cirurgia , Ductos Biliares Intra-Hepáticos , Colangiocarcinoma/cirurgia , Transplante de Fígado/mortalidade , Seguimentos , Humanos , Estadiamento de Neoplasias , Cuidados Paliativos , Estudos Retrospectivos , Análise de Sobrevida , Fatores de TempoRESUMO
INTRODUCTION: Palliative treatment for nondisseminated unresectable peripheral cholangiocarcinoma (PCC) carries a 0% 5-year survival rate. The role of orthotopic liver transplantation (OLT) in these patients is controversial because the survival rate is lower than with other indications for transplantation and the lack of available donor organs. The aim of this paper was to review the Spanish experience in OLT for PCC to identify prognostic factors for survival. METHODS: We retrospectively reviewed 23 patients undergoing OLT in Spain for PCC over a period of 13 years. RESULTS: The actuarial survival rates were 77%, 65%, and 42% at 1, 3, and 5 years, respectively. The main cause of death was tumor recurrence (35%). Prognotic factors for an adverse outcome were pTNM classification (P<.05) in the univariate analysis and perineural invasion (P<.05) and stages III or IVA (P<.05) in the multivariate analysis. CONCLUSIONS: OLT for nondisseminated irresectable PCC displays higher survival rates at 3 and 5 years than palliative treatments, especially for tumors in the initial stages, which means that more information is needed to help better select PCC patients for transplantation.
Assuntos
Neoplasias dos Ductos Biliares/cirurgia , Ductos Biliares Intra-Hepáticos , Colangiocarcinoma/cirurgia , Neoplasias dos Ductos Biliares/mortalidade , Neoplasias dos Ductos Biliares/patologia , Colangiocarcinoma/mortalidade , Colangiocarcinoma/patologia , Seguimentos , Humanos , Transplante de Fígado , Metástase Neoplásica , Cuidados Paliativos , Recidiva , Estudos Retrospectivos , Análise de Sobrevida , Fatores de TempoRESUMO
UNLABELLED: Minimal hepatic encephalopathy is often present in patients with chronic liver disease. The aim of this work was to determine changes in the dynamics of sleep electroencephalogram (EEG) in cirrhotic patients without overt encephalopathy. Twenty such cirrhotic subjects included in the protocol of hepatic transplantation of our hospital were studied and compared with 20 age-matched healthy volunteers. Spectral analysis of all-night EEG was estimated by computing the fast-Fourier transform in 2-second epochs, and averaging every 60 seconds. Artifacts were off-line suppressed, sleep stages (stage 2, stage 3-4 and REM) were determined, and the EEG mean dominant frequency (MDF) was calculated in each of these stages. Results show that in cirrhotic patients, nocturnal MDF evolution discloses a clear alteration of the ultradian EEG frequency oscillations present in controls. Also, the mean value of MDF in REM episodes was larger in cirrhotics than the corresponding value in controls. CONCLUSIONS: 1) sleep EEG evidences the existence of minimal hepatic encephalopathy; 2) the spectral analysis of EEG in minimal hepatic encephalopathy showed that the changes of MDF during sleep are an early marker of cerebral dysfunction in cirrhotic patients.
Assuntos
Eletroencefalografia/métodos , Encefalopatia Hepática/fisiopatologia , Fases do Sono/fisiologia , Humanos , Cirrose Hepática/fisiopatologiaRESUMO
The Liver Transplant Program was begun at "La Paz" Children's Hospital on January 1986 after a long period of experimental activities. This was the first experience in the Madrid Community. From January 1986 to June 1989 we made 32 orthotopic liver transplants in 25 patients, seven received a second graft and one them received a liver segment because the donor had a large liver. 114 patients were evaluated but only 84 were considered candidates for liver transplantation. The different diseases of the transplants were: biliary atresia (9), Alagille syndrome (4), deficit alpha 1-antitrypsin (3), autoimmune hepatitis (2), neonatal hepatitis (1), Byler disease (1), Wolman disease (1). absent bile ducts (1), Wilson disease (1). Surgical technique was the same that has been described by Starzl using Eurocollins and lactate Ringer. In the 100% we made multiorgan procurement, liver and kidneys, 7% with heart and two heart-lung with hypothermia. In one occasion the donor operation was done out of the country (RFA--Düsseldorf). We never used by-pass during anhepatic phase. Arterial reconstruction was done by end-to-end anastomosis and in five patients we used aortic graft. Our arterial thrombosis rate was 18%. In one patient the portal vein was atrophic and we used a femoral graft between superior mesenteric vein and donor portal vein. For biliary reconstruction we used Roux-en-Y with intraluminal stent in 18 cases and choledocho-choledochus anastomosis in seven cases. Four patients had biliary complications: two biliary fistulas secondary to arterial thrombosis, biliary stenosis and bowel perforation by the intraluminal stent.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Transplante de Fígado/métodos , Criança , Seguimentos , Rejeição de Enxerto , Humanos , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Transplante de Fígado/estatística & dados numéricos , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Reoperação/estatística & dados numéricos , Espanha/epidemiologiaRESUMO
Currently, the incidence of one episode of infection after liver transplantation is 83 for 100 and 50 for 100 of them are severe. We have studied 30 patients who underwent liver transplantation, ten of them received a second graft. All patients were treated prophylactic with antibiotics 48 hours and selective bowel decontamination, in 23 we used ganciclovir prophylactic. The incidence of infection was 73 for 100, 40 episodes of bacterial infection, eight fungal and ten viral. The direct relationship of infection and mortality was seen in six patients. We studied different risk factors of infection and we found a correlation between surgical time, prior operations and arterial thrombosis with infections.
Assuntos
Transplante de Fígado , Infecção da Ferida Cirúrgica/epidemiologia , Infecções Bacterianas/epidemiologia , Criança , Pré-Escolar , Seguimentos , Humanos , Terapia de Imunossupressão/métodos , Incidência , Lactente , Transplante de Fígado/estatística & dados numéricos , Micoses/epidemiologia , Fatores de Risco , Infecção da Ferida Cirúrgica/prevenção & controle , Viroses/epidemiologiaRESUMO
BACKGROUND: More than two thirds of all intestinal transplantations (ITx) performed around the world correspondent to recipients younger than 18. OBJECTIVE: To analyze our 5-year experience in pediatric ITx. PATIENTS: We assessed the outcome of the 19 children included in list out of 41 patients considered for ITx from 1997. The main cause of intestinal failure was short bowel syndrome (14) followed by intestinal motility disorders (3) and congenit disorders of intestinal epithelium (CDIE) (2). The median of age, at the moment of including in the list, was 0.9 years (range 0.4-17) and median of weight was 6.4kg (range 0.4-29.3). Ten children were included for liver and small bowel transplantation (LSBTx), 7 to isolated small bowel (SBTx), and 2 for multivisceral transplantation (MVTx). Indications for SBx were hepatic fibrosis/cirrhosis (10), hepatic fibrosis in evolution (5) (to avoid later LSBTx), intractable diarrhoea (1), recurrent line infections (1), lost of central vein access (1), and bad quality of life in one. RESULTS: Five children died in the waiting list, after a median time of 325 days (range 19-581). Seven remain in the waiting list (median 139 days, range 30-778). In 3 of these the indication changed from SBTx to LSBTx because of progression to end stage liver disease. Six children recieved seven grafts (1 MVTx, 4 LSBTx, 2 SBx) after a median time in the waiting list of 352 days (range 66-732). Six out of seven grafts achieved normal function and all survivals reached full digestive autonomy after Tx. We had to rejection episodes, one with good response to medical treatment and one that required removal of intestinal allograft and later LSBTx. Two children died 1 because of problem not related to the procedure (hemorrage following liver biopsy) and one girl died 29 months after transplant due to post-transplantation lymphoproliferative disease. CONCLUSIONS: ITx is a realistic alternative in our country for children with intestinal failure. The main problems are immunologic (rejection, lynphoproliferative and disease) Shortage of small weight donors is a dramatic limitation that prompts the discussion of surgical alternatives.
Assuntos
Enteropatias/cirurgia , Intestinos/transplante , Adolescente , Fatores Etários , Peso Corporal , Criança , Pré-Escolar , Feminino , Motilidade Gastrointestinal , Rejeição de Enxerto , Sobrevivência de Enxerto , Humanos , Terapia de Imunossupressão , Lactente , Masculino , Complicações Pós-Operatórias , Qualidade de Vida , Síndrome do Intestino Curto/etiologia , Síndrome do Intestino Curto/cirurgia , Espanha , Resultado do TratamentoRESUMO
UNLABELLED: We present the first case of intestinal transplant (IT) performed in Spacin. CASE REPORT: 28 months old boy with secretory diarrhea since the first month of life, diagnosed of microvillous inclusion disease (MID). He is on total parenteral nutrition (TPN) and had suffered of multiple episodes of catheter related sepsis with lost of standard venous access. An isolated small bowel transplant from a cadaveric donor was performed at the age of 3 years. The native ileocaecal valve and colon were not removed. RESULTS: Enteral feeding was started in the 2nd. week after the IT. On the 25th day he was off TPN. Since the 77th day, he eats regular foods by mouth. At the 6th month post IT the ileostomy was closed. Among the complications, he suffered a rotavirus infection on the 38th post IT day and an episode of mild rejection responsive to methil-prednisolone bolus. CONCLUSIONS: The IT is a therapeutic option that can be already offered with possibilities of success in our country. Although the colonic enterocytes express MVD, the recipient ileocaecal valve and colon can be preserved.
Assuntos
Intestinos/transplante , Pré-Escolar , Humanos , Masculino , EspanhaRESUMO
AIM: To analyze the outcome of children with intestinal failure (IF) included as candidates for intestinal transplantation (IT). Patients, Eight out of 23 children with IF assessed since July 1997 met criteria for IT and were included on the waiting list. The causes of IT were Short Bowel Syndrome (SBS) in 6 and Microvillus Inclusion Disease (MID) in 2. The indication of IT were end stage liver disease (ESLD) in 5 (related to total parenteral nutrition administration, TPN), progressive hepatic fibrosis in 2 and loss of venous access in 1. The patients with ESLD were included for combined liver-small bowel transplantation (LSBT) and the remaining for isolated intestinal transplantation (IIT). RESULTS: Two children died waiting for LSBT, 4 patients are on the waiting list, 2 for LSBT and 2 for IIT (length of stay: 4-11 months). Two children were transplanted, one with IIT in a 2.5 years old boy with MID, and one with LSBT in a 22 months girl with SBS and ESLD. Both patients recovered intestinal function after transplantation and are a live (follow-up of 19 and 10 months respectively). The LSBT's patient is under treatment for postransplant lymphoproliferative disease (PTLD). CONCLUSIONS: The lack of suitable donors for the small children candidate to IT explains the long period of stay on the waiting list and the high pretransplant mortality. Two strategies are possible; early referral of children with IF to a transplant center and surgical techniques like ex vivi-hepatic reductions of the LSB graft.