Aristóteles y los traslados forzosos / Aristotle and compulsory transfers

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Valoración de la válvula mucosa intestinal en la atresia de las vías biliares / Valuation of intestinal valve in biliary atresia

Con el objeto de evitar los episodios de colangitis luego de la portoenteroanastomosis de Kasai, se han desarrollado diferentes tipos de válvulas intestinales. El motivo de este trabajo es analizar la utilidad de la válvula intestinal mucosa simple en el conducto bilioentérico en un grupo de niños con atresia de vías biliares y tratados entre 1990 y 1993 con la intervención de Kasai sin derivación externa, 16 enfermos consecutivos fueron incluidos en un protocolo prospectivo y randomizado. Los paciente fueron divididos en dos grupos: grupo 1, pacientes tratados con la intervención de Kasai (n=10) y grupo 2 pacientes tratados con la intervención de Kasai mas válvula mucosa yeyunal. En ambos grupos analizamos la edad de interveción flujo biliar episodios de colangitis , función hepática y evolución clínica.En este estudio no encontramos diferencias significativas en ninguno de los parámetros estudiados, por lo cual creemos que la válvula no aporta beneficios ni perjuicios en cuanto a la prevención de las colangitis

Valoración de la válvula mucosa intestinal en la atresia de las vías biliares / Valuation of intestinal valve in biliary atresia

Con el objeto de evitar los episodios de colangitis luego de la portoenteroanastomosis de Kasai, se han desarrollado diferentes tipos de válvulas intestinales. El motivo de este trabajo es analizar la utilidad de la válvula intestinal mucosa simple en el conducto bilioentérico en un grupo de niños con atresia de vías biliares y tratados entre 1990 y 1993 con la intervención de Kasai sin derivación externa, 16 enfermos consecutivos fueron incluidos en un protocolo prospectivo y randomizado. Los paciente fueron divididos en dos grupos: grupo 1, pacientes tratados con la intervención de Kasai (n=10) y grupo 2 pacientes tratados con la intervención de Kasai mas válvula mucosa yeyunal. En ambos grupos analizamos la edad de interveción flujo biliar episodios de colangitis , función hepática y evolución clínica.En este estudio no encontramos diferencias significativas en ninguno de los parámetros estudiados, por lo cual creemos que la válvula no aporta beneficios ni perjuicios en cuanto a la prevención de las colangitis

Our first 100 consecutive pediatric liver transplants.

Orthotopic liver transplantation (OLT) is nowadays accepted as the best therapy for end-stage liver disease. The difficulties involved are even greater in children than in adults, and it is debatable whether exclusively pediatric programs are warranted. The aim of this paper is to analyze our experience at the Children's Hospital "La Paz", with the first consecutive 100 OLT in children, 61% of whom weighed less than 20 kg. Since 1986, 220 pediatric patients were evaluated as candidates, 100 OLT were performed in 78 patients and 13 died on the waiting list, currently maintained below 15 cases. Indications were: cholestasis (45), metabolic disease (18), fulminant hepatic failure (3), primary liver tumors (2) and cirrhosis (10). Mean age was 66 months (range = 7 to 216) with a mean weight of 21 kg (range = 6 to 60), twenty patients weighed less than 13 kilograms. OLT was performed by standard technique. Reduced or segmental grafts were necessary in 8 instances. Twenty-two patients were retransplanted and 2 received three grafts. Indications for retransplantation were: hepatic artery thrombosis (8), primary nonfunction (4), chronic rejection (7), portal thrombosis (2) and Budd-Chiari recurrence (1). Acute rejection was observed in 52 patients, and eight cases developed a chronic rejection. These episodes were treated with "bolus" of steroids, monoclonal antibodies (OKT-3) and FK-506. Surgical complications included: hepatic artery thrombosis 12%, portal vein thrombosis 3% and biliary fistula or stenosis 13%. The incidence of primary non-function was 7%. Actuarial survival rate at 5 years was 75%.(ABSTRACT TRUNCATED AT 250 WORDS)

Liver transplantation in small babies.

Pediatric liver transplantation is an effective treatment for end-stage liver disease with 1- and 5-year survivals approaching 90% and 70%, respectively. Survival is influenced by the recipient's age, weight, primary disease, vascular malformations, and nutritional status. Younger patients weighing less than 13 kg are considered to be a high-risk group. The aim of this article is to evaluate the impact of this group of patients on the overall results of our pediatric liver transplant program. From January 1986 through January 1992 we performed 76 liver transplants in 59 pediatric patients. Sixteen received a second graft and a third was required in one. Fourteen patients weighed less than 13 kg (mean, 11 kg; range, 6 to 13 kg). Their mean age was 12 months, with a range of 8 to 36 months. Indications for transplantation were: biliary atresia (9), Byler's disease (1), tyrosinemia (3), and alpha 1-antitrypsin deficiency (1). The incidence of rejection in this group (52%) was not significantly different from that in other patients (61%). Ten episodes of acute rejection required only steroids: in one monoclonal antibodies were added. Five patients had a new graft implanted, four for hepatic artery thrombosis and one for primary liver nonfunction. Nine patients are alive (64%) with the follow-up time ranging from 2 to 56 months (mean, 31). Five patients died of multiorgan failure (3), portal vein thrombosis (1), and primary liver nonfunction (1). Four-year graft and patient survival rates were 47% and 64%, respectively. Small babies are a high-risk group in a pediatric liver transplant program.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hepatic artery thrombosis in the pediatric liver transplant]. / La trombosis de la arteria hepática en el trasplante hepático pediátrico.

The hepatic artery thrombosis (HAT) is the most serious complication after pediatric liver transplantation. Most of the cases will need a retransplantation. Multiple factors are keeping in discussion as causes of this complication: Rejection, two or more arteries, complex vascular reconstruction, etc. This article describes our experience with this complication and the prophylactic treatment. From January 1986 through April 1991, 62 orthotopic liver transplants were performed on 48 pediatric patients with a mean age of seven years. The incidence of hepatic artery thrombosis was 19 per 100, increasing when recipients were less than three years and less than 15 kg (23.8 per 100). Forty six cases were rearterialized with end-to-end anastomoses, ten were rearterialized by directly anastomosing them to the recipient aorta and six with iliac artery graft. We use in the last 38 consecutive patients prophylactic heparin during two weeks after transplantation (300 u/kg/d) following with antiaggregants. There were eleven patients with hepatic artery thrombosis, one of them had two episodes in both grafts. We perform a retransplantation in eight patients, two died waiting a new graft and one exceptional patient is out of the clinic with normal liver function and without regraft. Seventeen grafts had two or more arteries from aorta, ten with branches from superior mesenteric artery and five from gastric artery. One graft had a triple hepatic artery and another one was a common hepatic artery from superior mesenteric artery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Infection as a complication of the liver transplant]. / La infección como complicación del trasplante hepático.

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.

[The pediatric liver transplant. The surgical aspects]. / Trasplante hepático pediatrico. Aspectos quirurgicos.

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)