Living donor liver transplantation: usefulness of hemostatic and prothrombotic screening in potential donors.

Bleeding and thrombosis are serious complications of living donor liver transplantation (LDLT). The aim of this paper was to describe the results of a screening for coagulation disorders, including for thrombophilic factors, in potential living liver graft donors and to evaluate thrombotic and bleeding events in donors and recipients, during and after the procedure. From January 2001 to January 2007, 41 LDLTs were performed at our institution. We performed systematic screening for bleeding or prothrombotic states among 188 potential donors, 38 (20.2%) of whom showed at least one abnormality. We rejected potential donors with factor V Leiden, prothrombin mutation G20210A, and deficiencies in anticoagulant proteins (protein C, protein S, and antithrombin) or coagulation factors. Bleeding and thrombotic events in donors and recipients of the 41 LDLTs were evaluated during 7 days to 70 months follow-up. No major bleeding events were detected in the donors. Neither donor nor recipient experienced venous thrombosis or pulmonary embolism. Among all recipients, six suffered hepatic artery thrombosis including five in the first month probably related to surgery. Deep venous thrombosis and pulmonary embolism are well-known complications of hepatic surgery; Prothrombotic abnormalities in the donor can be transmitted to the recipient, leading to increased risk of serious postoperative events. Although the cost-effectiveness is not definitely established, we recommend systematic screening for hemostatic and prothrombotic disorders to prevent more morbidity of a procedure that already has high risks of bleeding and thrombosis.

Pancreatitis aguda, adenopatías mesentéricas y diarrea / No disponible

No disponible

[Prevalence of celiac disease in apparently healthy blood donors in the autonomous community of Madrid]. / Prevalencia de la enfermedad celiaca en donantes de sangre de la Comunidad de Madrid.

OBJECTIVE: The aim of this study was to determine the prevalence of celiac disease among the adult population of Madrid by measuring antibodies against tissue transglutaminase as serologic screening method. POPULATION AND METHODS: 2,215 subjects participated voluntarily in this study. All of them completed a clinical questionnaire. We determined the levels of total IgA and antibodies to tissue transglutaminase (tTG). An intestinal biopsy by endoscopy was proposed to all subjects who were tTG-positive. The histologic lesion was classified in accordance to Marsh. RESULTS: Three known CD cases were identified by the questionnaire. Eleven donors with tTG positivity were detected, all of them asymptomatic. Four subjects rejected the intestinal biopsy. Seven out of 11 positive subjects consented to undergo a duodenal biopsy -3 had villous atrophy and 4 had increased intraepithelial lymphocyte counts with normal villi. In our study the number of donors with biopsy-proven CD was 6, and the prevalence was 1/370. If we include the subcategories of gluten sensitive enteropathy (Marsh I), the prevalence would be 1/222. When we considered antibody positivity the prevalence of gluten sensitivity was 1 in 201, and it reached 1 in 158 when the three known CD cases were included. CONCLUSIONS: Data on CD prevalence in this study confirm that CD is a first-line healthcare problem that may warrant universal screening. We detected a high number of lymphocytic enteritis cases, and thus some sort of action is mandatory.

Prevalencia de la enfermedad celiaca en donantes de sangre de la Comunidad de Madrid / Prevalence of celiac disease in apparently healthy blood donors in the Autonomous Community of Madrid

Objetivo: conocer la prevalencia de enfermedad celiaca en la población adulta de la Comunidad de Madrid utilizando como método de despistaje los anticuerpos frente a la transglutaminasa tisular. Población y métodos: han participado de modo voluntario 2.215 donantes de sangre. Todos ellos rellenaron una encuesta. Se determinó la IgA sérica total y los anticuerpos antitransglutaminasa tisular. A los donantes con anticuerpos positivos, se les ofreció la realización de biopsia intestinal por endoscopia. La histología de la mucosa intestinal se graduó según los criterios de Marsh. Resultados: mediante la encuesta se identificaron tres celiacos diagnosticados previamente. Once donantes presentaban anticuerpos positivos, todos ellos asintomáticos. Cuatro rechazaron la biopsia intestinal. De los siete en los que se realizó, tres tenían atrofia vellositaria y cuatro infiltrado linfocitario con vellosidades normales. En nuestro estudio el número total de donantes con enfermedad celiaca confirmada por biopsia fue de seis, lo que supone una prevalencia del 1/370. Considerando el grado I de Marsh, la prevalencia de la enteropatía por gluten sería de 1/222. La respuesta inmunológica anómala al gluten medida por la positividad de los anticuerpos fue de 1/201 que alcanza valores de 1/158 si consideramos los tres celiacos diagnosticados previamente. Conclusiones: los datos de prevalencia hallados en este estudio confirman que la enfermedad celiaca constituye un problema sanitario de primer orden, que podría justificar la instauración de un programa de despistaje universal. Se ha detectado un alto número de casos de enteritis linfocitaria lo que obliga a plantearse la actitud a seguir

Objective: the aim of this study was to determine the prevalence of celiac disease among the adult population of Madrid by measuring antibodies against tissue transglutaminase as serologic screening method. Population and methods: 2,215 subjects participated voluntarily in this study. All of them completed a clinical questionnaire. We determined the levels of total IgA and antibodies to tissue transglutaminase (tTG). An intestinal biopsy by endoscopy was proposed to all subjects who were tTG-positive. The histologic lesion was classified in accordance to Marsh. Results: three known CD cases were identified by the questionnaire. Eleven donors with tTG positivity were detected, all of them asymptomatic. Four subjects rejected the intestinal biopsy. Seven out of 11 positive subjects consented to undergo a duodenal biopsy –3 had villous atrophy and 4 had increased intraepithelial lymphocyte counts with normal villi. In our study the number of donors with biopsy-proven CD was 6, and the prevalence was 1/370. If we include the subcategories of gluten sensitive enteropathy (Marsh I), the prevalence would be 1/222. When we considered antibody positivity the prevalence of gluten sensitivity was 1 in 201, and it reached 1 in 158 when the three known CD cases were included. Conclusions: data on CD prevalence in this study confirm that CD is a first-line healthcare problem that may warrant universal screening. We detected a high number of lymphocytic enteritis cases, and thus some sort of action is mandatory

First Spanish series of intestinal transplantation in adult recipients.

BACKGROUND: short-bowel transplantation has experienced a substantial growth worldwide following improved results from the late 1990's on, and its coverage by Medicare. According to the International Registry (1985-2005), a total of 1,292 intestinal transplants for 1,210 patients in 65 hospitals across 20 countries have been carried out thus far. OBJECTIVE: to know short-term (6 months) results regarding patient and graft survival from the first Spanish series of intestinal transplants in adult recipients. MATERIAL AND METHODS: we present our experience in the assessment of 20 potential candidates to short-bowel transplantation between June 2004 and October 2005. Of these, 10 patients were rejected and 4 were transplanted, which makes up the sample of our study. RESULTS: to this date 5 transplants have been carried out in 4 patients (2 retransplants, 2 desmoid tumors, 1 short bowel syndrome after excision as a result of mesenteric ischemia). Upon study completion and after a mean follow-up of 180 days (range 90-190 days) all recipients are alive, and all grafts but one (75%) are fully operational, with complete digestive autonomy. All patients received induction with alemtuzumab except one, who received thymoglobulin; in all induction was initiated with no steroids. CONCLUSIONS: intestinal transplantation represents a therapeutic option that is applicable in our setting and valid for recipients with an indication who have no other feasible alternative to keep their intestinal failure under control.

Primera serie nacional de trasplante de intestino en receptores adultos / First Spanish series of intestinal transplantation in adult recipients

Introducción: el trasplante de intestino, con la mejoría en los resultadosdesde finales de los años 90 y desde su cobertura por el Medicare,ha experimentado un crecimiento sustancial a nivel internacional.En la actualidad, según el Registro Internacional (1985-2005),se han realizado un total de 1.292 trasplantes de intestino en 1.210pacientes en 65 hospitales distribuidos por 20 países.Objetivo: conocer los resultados a corto plazo (6 meses) entérminos de supervivencia del paciente y del injerto de la primeraserie nacional de trasplante de intestino en receptores adultos.Material y métodos: presentamos nuestra experiencia en laevaluación de 20 potenciales candidatos a trasplante intestinal entrejunio de 2004 y octubre de 2005. De ellos, fueron desestimadosun total 10 pacientes y fueron trasplantados 4, lo que constituyela muestra de nuestro estudio.Resultados: hasta la fecha se han realizado 5 trasplantes en 4pacientes (2 retrasplantes, 2 tumores desmoides, y 1 síndrome deintestino corto tras exéresis por isquemia mesentérica). Al final delestudio y tras un seguimiento medio de 180 días (rango, 90-190días), todos los receptores están vivos, y todos los injertos, a excepciónde uno (75%), están funcionando plenamente, con autonomíadigestiva completa. Todos los pacientes recibieron induccióncon alemtuzumab excepto uno que recibió timoglobulina y entodos se inició la inducción sin esteroides.Conclusiones: el trasplante intestinal constituye una opciónterapéutica aplicable en nuestro medio y válida en receptores enquienes está indicado y que no tienen otra alternativa válida paracontrolar su insuficiencia intestinal

Background: short-bowel transplantation has experienced asubstantial growth worldwide following improved results from thelate 1990s on, and its coverage by Medicare. According to the InternationalRegistry (1985-2005), a total of 1,292 intestinal trasplantsfor 1,210 patients in 65 hospitals across 20 countries have been carriedout thus far.Objective: to know short-term (6 months) results regardingpatient and graft survival from the first Spanish series of intestinaltransplants in adult recipients.Material and methods: we present our experience in the assessmentof 20 potential candidates to short-bowel transplantationbetween June 2004 and October 2005. Of these, 10 patientswere rejected and 4 were transplanted, which makes up thesample of our study.Results: to this date 5 transplants have been carried out in4 patients (2 retransplants, 2 desmoid tumors, 1 short bowelsyndrome after excision as a result of mesenteric ischemia).Upon study completion and after a mean follow-up of 180days (range 90-190 days) all recipients are alive, and all graftsbut one (75%) are fully operational, with complete digestiveautonomy. All patients received induction with alemtuzumabexcept one, who received thymoglobulin; in all induction wasinitiated with no steroids.Conclusions: intestinal transplantation represents a therapeuticoption that is applicable in our setting and valid for recipientswith an indication who have no other feasible alternative tokeep their intestinal failure under control

Preliminary experience with living donor liver transplantation in adults and children.

INTRODUCTION: Living donor liver transplantation (LDLT) is becoming a widespread technique with good results. Its use may sharply decrease waiting list mortality. However, donor safety is of primary concern. The aim of this work was the preliminary evaluation of the LDLT program initiated in our institution in 1995. PATIENTS AND METHODS: Among 875 liver transplants (LT) performed from 1986 12 are LDLT in nine adults (50.0+/-10.0 years) and three children (1.9+/-1.1 years). All donors were relatives: son/daughter (six), brother (three), and father/mother (three). RESULTS: Donor right lobe graft weight was 758.3+/-137.4 g; left liver 525.3+/-97.1 g; and left lobe 293.3+/-30.5 g, with a graft weight/recipient weight ratio of 0.91+/-0.21 (0.64-1.36) in adults. Complications in five donors (42%) included biliary fistula in the first three cases, two pleural effusions and one intra-abdominal collection. Mean hospital stay was 16.9+/-15.2 days (median 12). Recipient indications for adults were: four HCV cirrhosis (+ alcoholic in one), one HBV cirrhosis, one cryptogenic, one alcoholic, one PBC, and one retransplant due to cholangiopathy. In children, the etiologies were two biliary atresia and one liver fibrosis. The first case was the only mortality (8.3%). Two patients were retransplanted (16.6%) due to arterial thrombosis (AT) and graft dysfunction. Actuarial survival at 1 year was 91.7%+/-8.0% for patients and 83.3%+/-10.8% for grafts. Complications in the recipients included AT (two), Acinetobacter sepsis, jaundice and upper digestive hemorrhage (due to a "small-for-size" graft), biliary fistula after T-tube removal, volvulus around the T tube, and intra-abdominal collection. CONCLUSIONS: Our experience suggests that good results can be achieved with LDLT. Standardization of the technique will allow refinement of the operation and decrease waiting list mortality. However, donor safety remains a fearful threat.

[Celiac disease and Bud-Chiari syndrome: an uncommon association]. / Enfermedad celíaca y síndrome de Budd-Chiari: una asociación infrecuente.

Celiac disease can present great clinical heterogeneity. Its association with a series of intestinal and non-intestinal diseases, whether immunologically mediated or otherwise, presents a higher than normal frequency. We present a patient with celiac disease and Budd-Chiari syndrome of unknown cause. This association has previously been described only in isolated cases in northern Africa. The appearance of this case in Spain reveals that the coexistence of both processes in a single patient is unlikely to be due to environmental or geographical factors.

Trombosis de las venas porta y mesentérica superior asociada a déficit de proteína S / Portal and mesenteric thrombosis and protein "S" deficiency

No disponible

Diffuse fatty liver in familial heterozygous hypobetalipoproteinemia.

A 34-year-old man had asymptomatic hepatomegaly, slightly increased serum alanine aminotransferase and gamma-glutamyl transpeptidase levels, and a sonographic pattern suggesting diffuse hepatic steatosis. Liver biopsy revealed fatty change in 25% to 50% of hepatocytes. The patient also had low serum levels of cholesterol and triglycerides and met clinical, biochemical, and familial diagnostic criteria of heterozygous hypobetalipoproteinemia. We could not relate his hepatic steatosis to any already known cause of fatty liver and could only attribute it to heterozygous hypobetalipoproteinemia. Familial heterozygous hypobetalipoproteinemia should be ruled out in patients with unexplained hepatic steatosis.

[Eosinophilic cholecystitis: an infrequent cause of cholecystectomy]. / Colecistitis eosinofílica: una causa poco frecuente de colecistectomía.

Eosinophilic cholecystitis is a rare form of cholecystitis. Histologically, it is characterized by a dense, transmural leukocyte infiltrate composed of more than 90% eosinophils. The etiology remains obscure, although it had been associated with allergies, parasites, hypereosinophilic syndromes, eosinophilic gastroenteritis, cholelithiasis, and acalculous cholecystitis. Here we report an eosinophilic cholecystitis gallstone-associated case, the only one with this histopathologic diagnosis among 5,537 cholecystectomies made in our hospital in the last years.

[A comparative study of 2 technics of percutaneous endoscopic gastrostomy]. / Estudio comparativo de dos técnicas de gastrostomía endoscópica percutánea.

OBJECTIVE: To compare the two most frequently used methods of percutaneous endoscopic gastrostomy: Pull-string Ponsky-Gauderer type and Push-over-wire Sachs-Vine gastrostomy. PATIENTS AND METHODS: Forty-four patients with oral feeding incapacity were prospectively randomized to one of the two methods of percutaneous endoscopic gastrostomy. In 22 patients the Ponsky-Gauderer type were used and in the other 22 the Sachs-Vine gastrostomy were employed. In every case the gastrostomy tube was replaced 4-5 months after its placement by a Flexiflo tube. The mean follow-up of the patients was 7.3 months (range: 4-18). RESULTS: Gastrostomy was successful in every case. No differences were found between the two procedures in technical difficulties or complications during gastrostomy placement. Wound infection occurred in 6 patients (13%), 3 in each group, and in all cases it was cured with topic antibiotic treatment administered through the gastrostomy. Tube dislodgement was observed in 3 patients in the Ponsky-Gauderer group (soft internal with-holder). The only significant difference between the two procedures was found at the removal of the gastrostomy tube. In the Sachs-Vine type the removal of the tube was always endoscopically performed (due to the presence of a rigid internal with-holder), while the Ponsky-Gauderer type was always done by traction (soft internal with-holder). No related procedure mortality was found with any of the two techniques. CONCLUSION: Both percutaneous endoscopic gastrotomy techniques are similar in efficacy, safety and morbidity and they prove to be a valid alternative to surgical gastrostomy in patients with oral feeding incapacity.