Dor Vs Toupet Fundoplication After Laparoscopic Heller Myotomy: Long-Term Randomized Controlled Trial Evaluated by High-Resolution Manometry.

BACKGROUND: Laparoscopic Heller myotomy (LHM) with partial fundoplication is an effective treatment for achalasia. However, the type of fundoplication is still a subject of debate. AIM: The aim of the study is to identify which partial fundoplication leads to better control of acid exposure, manometric parameters, and symptoms scores. METHODS: A randomized controlled trial was performed to compare Dor vs Toupet fundoplication after LHM. The preoperative diagnosis was made by high-resolution manometry (HRM), upper endoscopy, and barium esophagogram. Preoperative and postoperative symptoms were evaluated with Eckardt, GERD-HRQL, and EAT-10 questionnaires. RESULTS: Seventy-three patients were randomized, 38 underwent Dor and 35 Toupet. Baseline characteristics were similar between groups. Postoperative HRM showed that the integrated relaxation pressure (IRP) and basal lower esophageal sphincter (LES) pressure were similar at 6 and 24 months. The number of patients with abnormal acid exposure was significantly lower for Dor (6.9%) than that of Toupet (34.0%) at 6 months, but it was not different at 12 or 24 months. No differences were found in postoperative symptom scores at 1, 6, or 24 months. CONCLUSION: There were no differences in symptom scores or HRM between fundoplications in the long term. A higher percentage of abnormal 24-h pH test were found for the Toupet group, with no difference in the long term.

[Therapeutic options for portal hypertensive biliopathy: case series and literature review]. / Opciones terapéuticas de la biliopatía por hipertensión portal: serie de casos y revisión de la bibliografía.

BACKGROUND: Portal hypertensive biliopathy is an underdiagnosed condition because only some patients have symptoms. The major clinical manifestations include cholestasis and cholangitis. The aim of this study is to present a series of cases evaluated, treated and followed at a tertiary-care public institution. CLINICAL CASE: Four patients with portal hypertensive biliopathy were exposed to different therapeutic approaches focused on the management of portal hypertension and biliary decompression. They were followed for ~5 years. Three cases achieved a favorable outcome with symptom remission, but one patient died while attempting dilatation of the bile duct. Finally, we carried out a literature review about actual portal hypertensive biliopathy therapeutics. CONCLUSIONS: There is currently no consensus on the optimal treatment for this condition. The goal is to decompress the biliary tree. Each case should be individually evaluated to choose the best treatment option.

Antecedentes: la biliopatía por hipertensión portal es poco diagnosticada debido a que sólo algunos pacientes experimentan síntomas. Las manifestaciones clínicas más importantes son la colestasis y la colangitis. Objetivo: comunicar una serie de casos evaluados, tratados y seguidos en una institución pública de tercer nivel. Casos clínicos: cuatro pacientes con biliopatía por hipertensión portal se expusieron a diferentes métodos para tratar la hipertensión portal y la descompresión de la vía biliar. Se realizó seguimiento durante casi cinco años. Tres casos mostraron adecuada evolución, con remisión de los síntomas; un paciente falleció al intentar dilatarle la vía biliar. Finalmente, se revisa la bibliografía en relación con la terapéutica de la biliopatía por hipertensión portal. Conclusiones: no existe consenso para el tratamiento óptimo de este padecimiento, aunque el objetivo es descomprimir la vía biliar; cada caso plantea particularidades que guían el tratamiento.

[Renal hemodynamics and its correlation with the Child-Pugh stage in cirrhotic patients and their controls]. / Hemodinámica renal y su correlación con el estadio de Child-Pugh en pacientes cirróticos y controles sanos.

INTRODUCTION: Portal hypertension is associated with splanchnic vasodilatation and baroreceptors activation with secondary renal vasoconstriction. OBJECTIVE: To measure the pulsatility and resistance index in the renal arteries: Segmentaries and arcuates of both kidneys in cirrhotic patients Child-Pugh A, B, C classes and compared them with healthy controls. PATIENTS AND METHODS: Thirty patients with cirrhosis were included: Ten patients Child A, 10 were Child B and 10 Child C class and 10 healthy patients, we measured the resistance index (RI = [systolic peak velocity-minimum diastolic velocity]/systolic peak velocity) and the pulsatility index (PI = [systolic peak velocity-minimum diastolic velocity]/medium velocity) with Doppler spectral analysis. RESULTS: The RI in controls had an average of 0.55 +/- 0.11. In child A: 0.79 +/- 0.114, in Child B 0.77 +/- 0.104 and in Child C 0.85 +/- 0.037. For the pulsatility index the values were: 0.98 +/- 0.21, 1.4 +/- 0.105, 1.72 +/- 0.206, and 2.04 +/- 0.346, respectively. The resistances and pulsatility index were higher in patients with cirrhosis at the time to be compared with healthy controls, which represent a diminishment in blood flow. At the time to compare each one of the Child stages with controls, both index resulted higher in cirrhotic patients, but when we compared the cirrhotic patients between them, only difference for RI in child B vs. C was evident. The differences in PI were evident between each one of the Child classes. DISCUSSION: The present study proved that a non invasive method like Doppler ultrasound is useful in the evaluation of the renal hemodynamic changes in cirrhotic patients with a good correlation between Child class and IP.

Early experience of Budd-Chiari syndrome treatment with transjugular intrahepatic portosystemic shunt.

The Budd-Chiari syndrome is a heterogeneous group of disorders characterized by obstruction of hepatic venous outflow at any level from the small hepatic veins to the junction of the inferior vena cava with the right atrium. We present two cases of Budd- Chiari syndrome with severe ascites associated with polycythemia vera in first case and protein C deficiency in the second, in both cases transjugular intrahepatic portosystemic shunt were placed, with excellent control of symptoms, no mortality were observed, and just one episode of pulmonary venous thrombosis was observed. To our knowledge this is the first time that transjugular intrahepatic portosystemic shunt are used and reported in Budd-Chiari syndrome in Mexico.

Pregnancy and portal hypertension a pathology view of physiologic changes.

The coexistent of pregnancy and liver disease represent a complex clinical situation, besides the liver complications that present in pregnancy with a previous health liver, like intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy or HELLP syndrome with bleeding disorders and viral hepatitis, the previous liver damage with portal hypertension associated represent a clear stated of hemodynamic changes which increased risk of variceal bleeding. The portal hypertension syndrome has a splanchnic blood flow increase. During pregnancy an hypervolemic stated developed as consequence there is an increased in portal flow that contributed to more portal pressure transmitted to the collaterals veins which increase variceal bleeding risk in this group of patients. The present review will focus on treatment options to prevent variceal bleeding in this clinical situation.

A 57 year old man with chronic renal failure and cardiac tamponade who developed ischemic hepatitis.

Ischemic hepatitis is an infrequent entity, usually associated with low cardiac out put. We present a case of a 57 year-old man with chronic renal failure and cardiac tamponade who developed elevation of serum alanine transferase level of 5,054 U/L, aspartate transferase level of 8,747 U/L and lactate dehydrogenasa level of 15,220 U/L. The patient developed hepatic encephalopathy and hypoglycemia. Liver Doppler ultrasound was normal. He was seronegative for HBV and HCV, drugs list was scrutinized for the names of known hepatotoxins. Ischemic hepatitis was diagnosed. The hypoglycemia and encephalopathy were solved and the patient was discharged with normal transaminase levels. Ischemic hepatitis is typically preceded by hypotension, hypoxemia, or both. As one would expect, the most common cause of sustained systemic hypotension is cardiovascular disease. Liver biopsy is usually not necessary. The best treatment is support measures and correct the underlying condition.