Estudio observacional multicéntrico español de primeros episodios sugestivos de esclerosis múltiple: cohorte PREM / Spanish multi-centre observational study of the fi rst attacks suggestive of multiple sclerosis: the PREM cohort

Introducción. Estudios recientes han demostrado la necesidad de optimizar el manejo de los pacientes tras un primer brote sugerente de esclerosis múltiple (EM). Nuestro objetivo es comprobar si los resultados de seguimiento de estos estudios son reproducibles en un contexto multicéntrico español. Pacientes y métodos. El estudio PREM (estudio multicéntrico español prospectivo observacional a 24 meses) incluyó a pacientes en los tres primeros meses tras un primer brote sugerente de EM con al menos dos lesiones típicas en una resonancia magnética. Se obtuvo la Expanded Disability Status Scale (EDSS) y se valoró la presencia de brotes basalmente y a los 3, 6, 9, 12, 18 y 24 meses; se realizó una resonancia magnética basalmente y a los 6 y 24 meses, para el cálculo del volumen cerebral y de volúmenes lesionales (T1, T2 y T1 tras la administración de gadolinio). Se valoraron los criterios de McDonald y Poser durante el seguimiento. Un subgrupo de pacientes fue seguido hasta completar cuatro años. Resultados. Se incluyó a 110 pacientes (un 67% mujeres) de edad media de 30,2 años; 22 pacientes abandonaron prematuramente el estudio. Un 19% y un 45% de pacientes cumplían criterios de Poser a los 6 meses y 24 meses, respectivamente; un 63% y un 71% en el caso de los criterios de McDonald. La EDSS descendió signifi cativamente (–0,94; p < 0,001) y se observó desarrollo de atrofi a (–1,2%; p < 0,001) a los 24 meses. Conclusión. Los resultados de seguimiento de pacientes con primeros brotes sugerentes de EM en un contexto multicéntrico español son superponibles a los de los ensayos clínicos internacionales realizados en estos pacientes (AU)

Introduction. Recent studies have shown the need to optimise the management of patients after a fi rst attack suggestive of multiple sclerosis (MS). Our aim is to determine whether the results from follow-ups in these studies are reproducible within a Spanish multi-centre context. Patients and methods. The PREM study (observational prospective Spanish multi-centre study at 24 months) included patients in the fi rst three months following a fi rst event suggestive of MS with at least two typical lesions in a magnetic resonance scan. The Expanded Disability Status Scale (EDSS) was obtained and the presence of attacks was evaluated basally and at 3, 6, 9, 12, 18 and 24 months; a magnetic resonance scan was performed basally and at 6 and 24 months so as to be able to calculate the brain volume and the volumes of the lesions (T1, T2 and T1 after administering gadolinium). McDonald and Poser criteria were evaluated during the follow-up. A subgroup of patients was followed up for a total eriod of four years. Results. Altogether 110 patients (67% females) with a mean age of 30.2 years were included in the study; 22 patients dropped out of the study before it fi nished. Poser criteria were met by 19% and 45% of patients at 6 months and 24 months, respectively; 63% and 71% satisfi ed McDonald criteria. The EDSS decreased signifi cantly (–0.94; p < 0.001) and development of atrophy was observed (–1.2%; p < 0.001) at 24 months. Conclusions. Results of the follow-up of patients with fi rst attacks suggestive of MS within a Spanish multi-centre context are wholly comparable with those from international clinical trials performed in these patients (AU)

[Multiple sclerosis epidemiological situation update: pertinence and set-up of a population based registry of new cases in Catalonia]. / Situación epidemiológica actual de la esclerosis múltiple: pertinencia y puesta en marcha de un registro poblacional de nuevos casos en Cataluña.

INTRODUCTION: The first epidemiological studies on multiple sclerosis (MS) around the world pictured a north to south latitudinal gradient that led to the first genetic and environmental pathogenic hypothesis. MS incidence seems to be increasing during the past 20 years based on recent data from prospective studies performed in Europe, America and Asia. This phenomenon could be explained by a better case ascertainment as well as a change in causal factors. The few prospective studies in our area together with the increase in the disease in other regions, justifies an epidemiological MS project in order to describe the incidence and temporal trends of MS. DEVELOPMENT: A prospective multicenter MS registry has been established according to the actual requirements of an epidemiological surveillance system. Case definition is based on the fulfillment of the McDonald diagnostic criteria. The registry setting is the geographical area of Cataluna (northeastern Spain), using a wide network of hospitals specialized in MS management. CONCLUSION: Recent epidemiological studies have described an increase in MS incidence. In order to contrast this finding in our area, we consider appropriate to set up a population based registry.

Situación epidemiológica actual de la esclerosis múltiple: pertinencia y puesta en marcha de un registro poblacional de nuevos casos en Cataluña / Multiple sclerosis epidemiological situation update: pertinence and set-up of a population based registry of new cases in Catalonia

Introducción. Los primeros estudios epidemiológicos de esclerosis múltiple (EM) de ámbito mundial caracterizaron un patrón geográfico latitudinal, con prevalencias más altas en las zonas más alejadas del ecuador. A raíz de esta distribución, se plantearon hipótesis causales de índole genética y ambiental. Según los datos de estudios prospectivos desarrollados en diversas regiones de Europa, América y Asia, la incidencia de la enfermedad ha aumentado a lo largo de los últimos 30 años, lo cual podría indicar una mejor detección de casos o un cambio en los factores causales subyacentes. Los escasos estudios prospectivos disponibles en nuestro entorno y el aumento de la enfermedad descrito en otras regiones justifican la pertinencia de un proyecto epidemiológico dirigido a conocer las tasas de incidencia y la tendencia temporal de EM. Desarrollo. De acuerdo con los requisitos actuales de un sistema de vigilancia epidemiológica, se ha establecido un registro prospectivo de carácter multicéntrico. Para la definición de nuevo diagnóstico se emplean los criterios establecidos por McDonald. El ámbito de aplicación es el territorio de Cataluña, a través una red de hospitales de referencia especializados en el manejo de EM, que notifican la información mediante un aplicativo informático conectado a internet. Conclusiones. Los estudios epidemiológicos de la EM de las últimas décadas han descrito un incremento de su incidencia. Para dimensionar este fenómeno en nuestro ámbito, creemos pertinente la puesta en marcha de un registro poblacional de la enfermedad en Cataluña (AU)

Introduction. The first epidemiological studies on multiple sclerosis (MS) around the world pictured a north to south latitudinal gradient that led to the first genetic and environmental pathogenic hypothesis. MS incidence seems to be increasing during the past 20 years based on recent data from prospective studies performed in Europe, America and Asia. This phenomenon could be explained by a better case ascertainment as well as a change in causal factors. The few prospective studies in our area together with the increase in the disease in other regions, justifies an epidemiological MS project in order to describe the incidence and temporal trends of MS. Development. A prospective multicenter MS registry has been established according to the actual requirements of an epidemiological surveillance system. Case definition is based on the fulfillment of the McDonald diagnostic criteria. The registry setting is the geographical area of Cataluña (northeastern Spain), using a wide network of hospitals specialized in MS management. Conclusion. Recent epidemiological studies have described an increase in MS incidence. In order to contrast this finding in our area, we consider appropriate to set up a population based registry (AU)

Intraoperative flow measurement of native liver and allograft during orthotopic liver transplantation in children.

Hepatic hemodynamic changes during liver transplantation (OLT) in children have not yet been studied. We measured intraoperative portal vein flow (PVF) and hepatic arterial flow (HAF) (mL/min) in 53 children and 58 grafts during OLT. Flows were measured in the native organ and in the allograft. In the native liver, PVF and HAF are similar; after transplantation they return to the physiological situation. No flow differences were seen between whole and partial grafts. Among the 8 (14%) portal vein thromboses, PVF was lower in both the native liver and the graft than in the no thrombosis group (P < .05). PVF <5 mL/min/kg was a risk factor to develop PV thrombosis. No graft loss occurred in 3 cases without PVF at the time of OLTs despite the observation that repermeabilization was not possible. In 4 patients with PVF <5 mL/min/kg, after tying a spontaneous spleno-renal shunt (n = 3) or performing a porto-renal vein anastomosis (n = 1), PVF reached >20 mL/min/kg, avoiding thrombosis. In conclusion, PVF and HAF measurements during pediatric OLT may predict patients at high risk for development of PV thrombosis.

Liver transplantation in childhood with more than 10 years of follow-up: analysis of a single-center experience.

UNLABELLED: We pioneered pediatric liver transplantation (OLT) in Spain (June 1985). The aim of this study was to evaluate the current status of our OLT recipients with more than 10 years follow-up. MATERIALS AND METHODS: The 50 patients with >10 years follow-up had a mean age at OLT of 5.6 years with 60% showing a main indication of biliary atresia. All but one (tacrolimus) received cyclosporine. RESULTS: No patient loss occurred among these patients. Eighteen patients had follow-up >15 years and 12 >20 years. The incidence of acute rejection was 56%; chronic rejection, 16%; and lymphoproliferative disorders, 12%. Seven (14%) required retransplantation at a mean of 4.2 years after the first OLT due in four instances to chronic rejection. After 10 years of follow-up, one patient developed portal vein thrombosis and three biliary strictures. All patients remain on immunosuppression. In 64% cyclosporine was switched to tacrolimus or another agent. One patient developed acute rejection at 19.2 years. In 14% of patients the liver function test is abnormal with serum creatinine is >1.5 mg/dL in 10%; one requires insulin and three, antihypertensive drugs. Noncompliance with medications was detected in 10%. Three recipients had offspring. CONCLUSIONS: OLT was an effective treatment with a good quality of life also on long-term follow-up.

Recurrence of hepatocellular carcinoma after liver transplantation.

Outcome after liver transplantation (OLT) clearly depends on recurrence of hepatocellular carcinoma (HCC). After recurrence, patient outcome will depend on the time and site of appearance. The aim of this study was to analyze the therapeutic implications of tumor recurrence behavior. From October 1988 to December 2005, 685 patients received OLT, including 202 due to HCC (32%). We analyzed 28 recurrences (15.2%) among 184 patients who survived at least 3 months (minimum follow-up 1 year). According to the time of recurrence, we divided the patients into early recurrence (ER < 12 months; n = 9; 32.1%) and late recurrence (LR > 12 months n = 19; 67.9%). Actuarial survivals at 1, 5, and 10 years were 82%, 65%, and 50% and disease-free survival, 80%, 58%, and 46%, respectively. Risk factors for recurrence were: vascular invasion (P < .01), bad differentiation (P < .01), and previous hepatectomy (P < .05). After OLT, ER presented at: 5.7 +/- 2.3 months (range 3-10) vs 33.5 +/- 24.3 months (range 12-103) for LR P < .001). Survival postrecurrence (SPR) was shorter: 3.1 +/- 2.4 (range 1-8) months vs 16.4 +/- 14.2 (range 1-5) months (P < .001). Treatment was offered to one ER (11%) and to eight LR (47.1%; P < .05), achieving in these cases longer SPR: 20.1 +/- 14 vs 6.9 +/- 9 months (P < .05). The most common sites of recurrence were liver (n = 7), lung (n = 7), bone (n = 5), adrenal gland (n = 2), peritoneum (n = 2), lymph node (n = 2), skin (n = 2) or cerebral (n = 1). Early recurrences showed short survivals; no treatment could be offered to these patients. Liver recurrence appeared early. In contrast, most lung recurrences appeared later with the possibility of treatment and longer SPR. Bone recurrence appeared later, usually associated with other locations. Treatment was palliative and prognosis was worse. Skin and lymph node recurrences can be treated curatively with prolonged survival. In conclusion, HCC recurrence was difficult to treat curatively and was only prevented by employing restricted criteria.

[Peripheral cholangiocarcinoma: results of surgical treatment]. / Colangiocarcinoma periférico: resultados del tratamiento quirúrgico.

INTRODUCTION: Peripheral cholangiocarcinoma (PC) is an uncommon primary hepatic tumor that represents 10% of hepatic resections for primary malignant tumors in our experience. PATIENTS AND METHODS: From 1988 to 2004, 29 patients with a diagnosis of PC were treated in our unit. One patient was treated with chemoembolization and the remainder underwent surgery. In 7 patients, hepatectomy was not performed due to the presence of an extrahepatic tumor or massive hepatic invasion. The resectability index was 75%. Twenty-one patients underwent radical excision of PC and comprised the study group. RESULTS: The mean age was 60 years with a slight predominance of women. Sixty-two patients were symptomatic and tumoral markers were elevated in 58%. PC developed in normal liver in 15 patients, in cirrhotic liver in 2 patients and in the context of chronic hepatitis in 4 patients. The mean tumoral size was 7 cm (between 1.6 and 13 cm). Multiple tumors were found in 3 patients, invasion of the hepatic hilum lymph nodes was found in 8 patients and vascular invasion was observed in a further 8 patients. Major hepatectomy was performed in 90% of the patients; radical lymphadenectomy of the hepatic hilum was performed in 15 patients and excision of the extrahepatic biliary tract followed by Roux-en-Y hepaticojejunostomy in 4 patients. Operative mortality occurred in 3 patients (14%); one cirrhotic patient died 4 days after surgery from cardiovascular causes and 2 patients died from liver failure after extensive hepatectomies that included resection of the inferior vena cava and suprahepatic veins. Complications occurred in 33% of the patients. Ten patients (47%) died. Of these, 6 died from tumoral recurrence. Tumoral recurrence occurred in 9 patients (5 hepatic and 4 extrahepatic). Hepatic recurrences were treated with radiofrequency ablation in 2 patients and chemotherapy in 5 patients. The median survival was 11 months. Actuarial survival at 1, 3 and 5 years was 60%, 47% and 47% respectively. Disease-free survival at 1, 3 and 5 years was 50%, 31% and 31% respectively. In univariate analysis, significant risk factors for mortality were lymphatic invasion and a resection margin of less than 1 cm. In multivariate analysis, negative factors for tumoral recurrence were lymphatic invasion, satellitosis, and poor tumoral delimitation. CONCLUSION: Surgical treatment of PC through radical hepatic resection with margins of more than 1 cm in patients without nodal invasion provides good results with a 5-year survival of 79%.

Colangiocarcinoma periférico: resultados del tratamiento quirúrgico / Peripheral cholangiocarcinoma: results of surgical treatment

Introducción: El colangiocarcinoma periférico (CP) es un tumor hepático primario poco frecuente, que supone el 10% de las resecciones hepáticas por tumor maligno primario en nuestra experiencia. Pacientes y métodos: Desde 1988 a 2004 tratamos en nuestra unidad a 29 pacientes diagnosticados de CP. Uno se trató con quimioembolización y el resto fueron intervenidos, aunque en 7 casos no se realizó hepatectomía por presencia de tumor extrahepático o invasión hepática masiva. El índice de resecabilidad fue del 75%. A 21 pacientes se les practicó una exéresis radical del CP y son los que forman el grupo de estudio. Resultados: La edad media de los 21 pacientes era de 60 años, entre ellos había un ligero predominio femenino, 62 eran sintomáticos y los marcadores tumorales estaban elevados en el 58%. El CP apareció en un hígado normal en 15 casos, 2 eran cirróticos y 4 presentaban hepatitis crónica. El tamaño tumoral medio fue de 7 cm (rango: 1,6-13), 3 eran múltiples, se halló invasión de los ganglios del hilio hepático en 8 casos e invasión vascular en otros 8. Se realizó hepatectomía mayor en el 90% de los casos, linfadenectomía radical del hilio hepático en 15 casos y exéresis de la vía biliar extrahepática seguida de hepaticoyeyunostomía en Y de Roux en 4 ocasiones. La mortalidad operatoria fue del 14%. El 33% de los pacientes presentó complicaciones. Fallecieron 10 pacientes (47%), 6 de ellos por recidiva tumoral. Nueve pacientes presentaron recidiva tumoral (5 hepática y 4 extrahepática). Las recidivas hepáticas se trataron con ablación por radiofrecuencia en 2 casos y 5 pacientes recibieron quimioterapia. La supervivencia mediana fue de 11 meses y la supervivencia actuarial al año, 3 y 5 años fue del 60, el 47 y el 47%, respectivamente. La supervivencia libre de enfermedad al año, 3 y 5 años fue del 50, el 31 y el 31%, respectivamente. La invasión linfática y el margen de resección inferior a 1 cm fueron factores de riesgo de mortalidad significativos en el estudio univariado, mientras que la invasión linfática, la satelitosis y la mala delimitación tumoral fueron factores negativos de recidiva tumoral en el estudio univariado. Conclusión: El tratamiento quirúrgico del CP mediante resección hepática radical con márgenes superiores a 1 cm en los pacientes que no presentan invasión ganglionar obtiene unos buenos resultados, con una supervivencia del 79% a los 5 años

Introduction: Peripheral cholangiocarcinoma (PC) is an uncommon primary hepatic tumor that represents 10% of hepatic resections for primary malignant tumors in our experience. Patients and methods: From 1988 to 2004, 29 patients with a diagnosis of PC were treated in our unit. One patient was treated with chemoembolization and the remainder underwent surgery. In 7 patients, hepatectomy was not performed due to the presence of an extrahepatic tumor or massive hepatic invasion. The resectability index was 75%. Twenty-one patients underwent radical excision of PC and comprised the study group. Results: The mean age was 60 years with a slight predominance of women. Sixty-two patients were symptomatic and tumoral markers were elevated in 58%. PC developed in normal liver in 15 patients, in cirrhotic liver in 2 patients and in the context of chronic hepatitis in 4 patients. The mean tumoral size was 7 cm (between 1.6 and 13 cm). Multiple tumors were found in 3 patients, invasion of the hepatic hilum lymph nodes was found in 8 patients and vascular invasion was observed in a further 8 patients. Major hepatectomy was performed in 90% of the patients; radical lymphadenectomy of the hepatic hilum was performed in 15 patients and excision of the extrahepatic biliary tract followed by Roux-en-Y hepaticojejunostomy in 4 patients. Operative mortality occurred in 3 patients (14%); one cirrhotic patient died 4 days after surgery from cardiovascular causes and 2 patients died from liver failure after extensive hepatectomies that included resection of the inferior vena cava and suprahepatic veins. Complications occurred in 33% of the patients. Ten patients (47%) died. Of these, 6 died from tumoral recurrence. Tumoral recurrence occurred in 9 patients (5 hepatic and 4 extrahepatic). Hepatic recurrences were treated with radiofrequency ablation in 2 patients and chemotherapy in 5 patients. The median survival was 11 months. Actuarial survival at 1, 3 and 5 years was 60%, 47% and 47% respectively. Disease-free survival at 1, 3 and 5 years was 50%, 31% and 31% respectively. In univariate analysis, significant risk factors for mortality were lymphatic invasion and a resection margin of less than 1 cm. In multivariate analysis, negative factors for tumoral recurrence were lymphatic invasion, satellitosis, and poor tumoral delimitation. Conclusion: Surgical treatment of PC through radical hepatic resection with margins of more than 1 cm in patients without nodal invasion provides good results with a 5-year survival of 79%

Analysis of discarded livers for transplantation.

The aims were to study the causes of nonacceptance of a liver for transplantation after exploration by the donor surgical team and to compare donor characteristics of transplanted and discarded livers. All donor harvesting procedures performed by our unit from 1988 to 2004 were retrospectively studied. Donors were divided in those accepted and transplanted and those discarded by the donor surgical team. The causes of rejection were classified as hepatic and nonhepatic. Donor characteristics of accepted, transplanted livers were compared with those rejected for hepatic reasons. Seven hundred fifty four donor liver procurements were performed: 628 livers were accepted and transplanted (TL), 126 (17.5%) were discarded owing to extrahepatic (n = 16) or hepatic causes (n = 110). Extrahepatic causes were: technical (5.6%), and incidental tumors infection (7.2%). Hepatic causes were: chronic disease or cirrhosis (26.4%), ischemic or septic liver (16.8%), and steatosis (44%). Univariate analysis of donor characteristics showed a significant difference in older age, diabetes, alcohol intake, arterial hypertension, abnormal liver ultrasound (US) exam, and abnormal liver function tests in the group of discarded livers. Obesity and the finding of steatosis in US exam were the only two factors that maintained statistical significance upon multivariate analysis.

Portacaval shunt and inferior vena cava preservation in orthotopic liver transplantation.

The aim was to study the advantages of the use of a temporary portacaval shunt (PCS) with inferior vena cava (IVC) preservation during the piggyback technique for the anhepatic phase of orthotopic liver transplantation (OLT) performed in cirrhotic patients. Two groups of cirrhotic patients who underwent OLT with piggyback technique were compared; one with a PCS (n = 57) and the other, without PCS (n = 54). Patients with fulminant hepatitis, retransplantation, portal thrombosis, and previous portosystemic shunts were excluded. In both groups graft reperfusion was achieved by simultaneous arterial and venous revascularization. Donor, recipient, and surgical characteristics were similar in both groups. The PCS group had a significantly higher portal venous flow (PVF) than the no-PCS group (773 +/- 402 mL/min vs 555 +/- 379 mL/min, P = .004). Therefore, two subgroups were studied; the high PVF subgroup A (>800 mL/min), mean 1099 +/- 261 mL/min, and the low PVF subgroup B (<800 mL/min), mean 433 +/- 423 mL/min. Subgroup A, who were treated with PCS, required fewer blood transfusions and displayed better postoperative renal function; whereas, no differences were observed among subgroup B patients with versus without PCS. In conclusion, the use of a temporary PCS with piggyback technique during OLT in cirrhotics has advantages in patients who still maintain a high portal venous flow.

Outcome of 28 split liver grafts.

UNLABELLED: Our aim is to present our experience with split liver transplantation. From 1992-2002, 14 livers were split to obtain 28 grafts that were transplanted to 12 adults and 16 children. Ex situ splitting was performed in all cases. The left graft consisted of the left lateral segment (segments II-III) in 11 cases and the left lobe in three, depending on the size of the pediatric recipient. Pediatric recipients were of mean age 3, 4 years; mean weight 13 kg; six emergency cases for fulminant hepatic failure or urgent retransplantation and seven of 10 elective cases for biliary atresia. Postoperative mortality rate was 31% (five cases), including four of six emergency cases and one elective case (10%). The main cause was multiorgan failure. Technical complications were: one arterial thrombosis, one portal vein thrombosis, and four biliary complications. Eleven patients are alive and well. Adult recipients were of mean age 53 years. The indications were hepatocellular carcinoma in six cases, liver cirrhosis of various etiologies in five, and one recurrence of hepatitis C in a graft. Two patients died during the postoperative period from sepsis after retransplantation for primary nonfunction of the split graft and multiorgan failure with sepsis. One-year actuarial survival was 84%. CONCLUSIONS: The results of split liver transplantation in elective cases are similar to whole liver transplantation, whereas patient survival among emergency cases is low due to the critical condition of the patients.

Duodenopancreactectomía cefálica por recidiva local de hipernefroma / Pancreatoduodenectomy by local recurrent renal cell carcinoma

Los autores aportan un caso de recidiva duodenal por hipernefroma que cursó con clínica digestiva alta en forma de úlcera gigante duodenal hemorrágica, cuya biopsia endoscópica informó de tejido neoplásico de origen renal. Como tratamiento se pudo realizar una duodenopancreatectomía cefálica en cuya pieza de resección se objetivó una afectación duodenopancreática por tumor de células claras compatible con hipernefroma (AU)

Coledocotomía y coledocorrafia sobre el tubo en "T" de Kehr. Morbilidad y mortalidad en una serie de 243 pacientes operados / Choledochotomy and closure of the choledochus with "T"-tube drainage. Morbidity and mortality in a series of 243 surgical patients

Objetivo. Se presenta nuestra experiencia en el manejo de los pacientes sometidos a exploración quirúrgica de la vía biliar con drenaje sobre el tubo de Kehr. Pacientes y métodos. Estudio retrospectivo sobre 243 pacientes (1985-1997), a quienes se les practicó apertura de la vía biliar principal por presentar enfermedad o sospecha de enfermedad litiásica y en los que la intervención finalizó con colocación de un tubo de Kehr. Resultados. La morbilidad fue del 28,3 por ciento. Aparecieron complicaciones de tipo biliar en el 14,8 por ciento de los casos, todas resueltas en el mismo ingreso, sin necesidad de reintervención (19 litiasis residuales y 17 fugas biliares). La presentación de complicaciones de tipo biliar no supuso un aumento de la morbilidad general (p < 0,05). La colangiografía trans-Kehr intraoperatoria (CTK) disminuyó de forma significativa el riesgo de presentar litiasis residual (p < 0,001), al detectar casi la mitad en el quirófano. Apareció un 33,3 por ciento (3/9) de fugas cuando el Kehr se retiró el séptimo día y un 3,0 por ciento (7/230) cuando se retiró a partir del octavo día (p < 0,01). Fallecieron 4 pacientes (1,6 por ciento), pero ninguno de ellos presentó complicaciones de tipo biliar. Conclusiones. La CTK intraoperatoria redujo de forma significativa la incidencia de litiasis residual. Si la CTK de control es normal, el Kehr puede ser retirado de forma segura a partir del octavo día. En caso de litiasis residual, si no se prevé su expulsión espontánea, estará indicada su extracción mediante colangiopancreatografía retrógrada endoscópica (CPRE) tan pronto como se diagnostique (AU)

Oral ulcerations as the first sign of a foramen magnum meningioma.

We report the case of a patient with oral ulcerations that were likely traumatic in origin caused by biting of the tongue. Physical examination showed only deviation, fasciculations, and hemiatrophy of the right side of the tongue. Neurologic examination disclosed an isolated XII nerve palsy. A magnetic resonance image showed a lesion in the posterior fossa displacing the brain stem at a bulbar level. This was consistent with the diagnosis of a meningioma, later confirmed by the histopathologic study. It is very unusual that a meningioma produces a selective involvement of the XII nerve. Early diagnosis of a foramen magnum meningioma is important, both to improve prognosis and to avoid neurologic sequelae.

Paraganglioma extraadrenal retroperitoneal. Presentación de dos nuevos casos / Retroperitoneal extraadrenal paraganglioma. Report of two new cases

Presentamos 2 casos de paraganglioma retroperitoneal extraadrenal no diagnosticados preoperatoriamente, ya que simularon una tumoración hepática y pancreática, respectivamente. La ausencia de preparación preoperatoria adecuada y de diagnóstico originó en uno de nuestros pacientes importante labilidad tensional durante las maniobras de extirpación, que fue controlada de manera adecuada. Analizamos los principales aspectos clínicos, diagnósticos, terapéuticos y pronósticos de estos tumores poco frecuentes y realizamos una revisión de la bibliografía (AU)