The keys to successful TIPS in patients with portal vein thrombosis and cavernous transformation. / Trombosis y cavernomatosis portal: las claves para el éxito de un TIPS.

Portal vein thrombosis is a common complication in patients with cirrhosis. Anticoagulation involves a high risk of bleeding secondary to portal hypertension, so placing transjugular intrahepatic portosystemic shunts (TIPS) has become an alternative treatment for portal vein thrombosis. Three strategies for TIPS placement have been reported: 1) portal recanalization and conventional implantation of the TIPS through the jugular vein; 2) portal recanalization through percutaneous transhepatic/transsplenic) access; and (3) insertion of the TIPS between the suprahepatic vein and a periportal collateral vessel without portal recanalization. We describe different materials that can be used as fluoroscopic targets for the TIPS needle and for portal recanalization. This article aims to show the success of TIPS implantation using different combinations of the techniques listed above, which is a good treatment alternative in these patients whose clinical condition makes them difficult to manage, and to show that portal vein thrombosis/cavernous transformation should not be considered a contraindication for TIPS.

Optimizing the management of patients with BCLC stage-B hepatocellular carcinoma: Modern surgical resection as a feasible alternative to transarterial chemoemolization.

OBJECTIVE: To analyse the impact of liver resection (LR) in patients with Hepatocellular Carcinoma (HCC) within the Barcelona-Clinic-Liver-Cancer (BCLC)-B stage. METHODS: Analysis of patients with BCLC-B HCC treated with LR or transarterial chemoembolization (TACE) between 2007 and 2012 in our hospital. Survival/recurrence analyses were performed by log-rank tests and Cox multivariate models. Further analyses were specifically obtained for the HCC subclassification (B1-2-3-4) proposed recently. RESULTS: Eighty patients were treated (44-TACE/36-LR). Number of nodules was [1.8(1.1)], being multinodular in 50% of cases. Although resected patients had a higher hospital stay than those who underwent TACE (14 ± 13 vs 7 ± 6; P = 0.004), the rate and severity of complications was lower measured by Dindo-Clavien scale (P < 0.05). Overall survival was 40% with a median follow-up of 29.5 months (0.07-96.9). Five-years survival rates were 62.9%, 28.1% and 15.4%, respectively (P = 0.004) for B1, B2 and B3-4 stages. Cox model showed that only total bilirubin [OR = 2.055(1.23-3.44)] and BCLC subclassification B3-4 [OR = 2.439(1.04-5.7)] and B2 [OR = 2.79(1.35-5.77)] vs B1 were independent predictors of 5-years-survival. In B1 patients, surgical approach led a significant decrease in 5-years recurrence-rate (25% vs 60%; P = 0.018). In the surgical subgroup analysis, better results were observed if well/moderate differentiation combined with no microvascular-invasion (VI) in 5-years-survival (84.6%; P = 0.001) and -recurrence (23.1%; P = 0.041), respectively. These survival and recurrence trends were remarkable in B1 stages. CONCLUSIONS: Management of Intermediate BCLC-B HCC stage should be more complex and include updated criteria regarding B-stage subclassifications, VI and tumour differentiation. Modern surgical resection would offer improved survival benefit with acceptable safety in selected BCLC-B stage patients.

Histologic study of the effects of chemoembolization with preloaded doxorubicin beads in patients with hepatocellular carcinoma.

OBJECTIVE: To determine the degree of tumor necrosis in surgical specimens of hepatocellular carcinomas treated with microspheres preloaded with doxorubicin and to analyze the relationship between the degree of necrosis and a) morphologic factors and b) imaging biomarkers. MATERIAL AND METHODS: We studied the livers of 21 patients who had undergone selective arterial chemoembolization with DC beads (Biocompatibles, UK) before receiving liver transplants. RESULTS: Imaging techniques detected 43 nodules (mean size, 25 mm). Angiography showed 25 hypervascularized nodules, 12 slightly vascularized nodules, and 6 avascular nodules. A total of 81 hepatocellular carcinomas (mean size, 15 mm) were detected in the specimens: two were capsular and two had vascular infiltration. The mean degree of necrosis after chemoembolization was 39%; necrosis was greater than 60% in 28 hepatocellular carcinomas and less than 60% in 52. The degree of necrosis correlated significantly with the time elapsed between the last chemoembolization treatment and liver transplantation (the degree of necrosis decreased as time increased), with the number of nodules in the specimen, and with capsular infiltration. When imaging techniques detected 1 or 2 nodules, there was a greater probability of achieving greater than 90% necrosis. No relation with the degree of necrosis achieved was found for the size of the nodules detected at imaging, the enhancement pattern, or the number of chemoembolization treatments. CONCLUSION: The degree of necrosis achieved depends on the time spent on the waiting list, on the number of nodules in the specimen, and on whether capsular infiltration is present.

[Transjugular intrahepatic portosystemic shunting with covered stents in children: a preliminary study of safety and patency]. / TIPS recubierto en niños. Estudio preliminar sobre su seguridad y permeabilidad.

OBJECTIVE: To retrospectively analyze the safety and efficacy of transjugular intrahepatic portosystemic shunting (TIPS) using covered stents in children. MATERIAL AND METHODS: We present 6 children (mean age, 10.6 years; mean weight, 33.5kg) who underwent TIPS with 8mm diameter Viatorr(®) covered stents for acute (n=4) or recurrent (n=2) upper digestive bleeding that could not be controlled by endoscopic measures. Five of the children had cirrhosis and the other had portal vein thrombosis with cavernous transformation. We analyzed the relapse of upper digestive bleeding, the complications that appeared, and the patency of the TIPS shunt on sequential Doppler ultrasonography or until transplantation. RESULTS: A single stent was implanted in a single session in each child; none of the children died. The mean transhepatic gradient decreased from 16mmHg (range: 12-21mmHg) before the procedure to 9mmHg (range: 1-15mmHg) after TIPS. One patient developed mild encephalopathy, and the girl who had portal vein thrombosis with cavernous transformation developed an acute occlusion of the TIPS that resolved after the implantation of a coaxial stent. Three children received transplants (7, 9, and 10 months after the procedure, respectively), and the patency of the TIPS was confirmed at transplantation. In the three remaining children, patency was confirmed with Doppler ultrasonography 1, 3, and 5 months after implantation. None of the children had new episodes of upper digestive bleeding during follow-up after implantation (mean: 8.1 months). CONCLUSION: Our results indicate that TIPS with 8mm diameter Viatorr(®) covered stents can be safe and efficacious for the treatment of upper digestive bleeding due to gastroesophageal varices in cirrhotic children; our findings need to be corroborated in larger series.

[Radiofrequency ablation of renal tumors: Practical aspects and results]. / Ablación por radiofrecuencia de tumores renales. Aspectos prácticos y resultados.

OBJECTIVES: To report our experience in percutaneous radiofrequency ablation of renal tumors, emphasizing technical aspects and indications and analyzing our results. MATERIAL AND METHODS: We retrospectively analyzed 20 tumors in 13 patients (10 with a single kidney, 2 who had refused surgical treatment, and 1 with severe comorbidities). All procedures were carried out using the radiofrequency interstitial tumor ablation (RITA) technique under general anesthesia and CT guidance. All patients underwent follow-up CT examination with and without intravenous contrast administration; the absence of enhancement was considered complete necrosis. RESULTS: The mean size of the tumors was 2.8 cm. Complete necrosis was achieved in 17 tumors (85%); complete necrosis was achieved in 100% of the exophytic tumors and in 50% of the tumors with mixed growth after 14 months' follow-up. Complete ablation was achieved in 15 of the 16 tumors measuring < or =3.5 cm. In 9 of the 10 patients with a single kidney (four of whom had more than one tumor), renal function remained normal after the procedure; the other patient developed hydronephrosis after a urinary tract lesion and died. The patient who died also developed a subcapsular liver lesion that did not require transfusion when another tumor was treated transhepatically. CONCLUSION: In experienced hands and with careful selection of patients (exophytic tumors < or =3.5 cm), radiofrequency ablation of renal tumors can achieve excellent oncologic results with minimal morbidity and mortality.

[Therapeutic embolization of uterine leiomyomas: cases requiring surgery]. / Embolización terapéutica de leiomiomas uterinos; casos que requirieron cirugía.

OBJECTIVE: To retrospectively analyze the clinical, radiolgical, and histological findings in patients with uterine leiomyomas (LU) that required surgical intervention after embolization. MATERIAL AND METHODS: Between July 1999 and January 2006, we embolized 182 patients with LU. Eight of these patients subsequently required surgical resection of the tumor. We reviewed clinical data, imaging findings, embolization technique, and reasons for surgery, histological findings in the resected specimens, identification and location of the embolizing material, presence and type of necrosis in the LU, and associated pathology in adjacent organs. RESULTS: The 8 patients that required surgery represented 4.3% of all patients embolized for LU. Surgery was necessary due to technical failure in two patients (1.02%), complications in three (1.64%) and failed treatment in the remaining three 3 (1.64%). The mean maximum diameter of the LU was 9.8 cm (range: 4-17 cm). The mean volume of the LU was 491.88 ml (range: 30-1.365 ml) The mean age of the patients was 37.7 years (range: 28-48 years). Global necrosis was evident in 6 LU; necrosis was hyaline type in 3 and inflammatory in the remaining 3. The embolizing material was detected in the LU in one case, in the uterine myometrium in two cases, and in the ovary in one. CONCLUSION: Less than 5% of cases of LU required surgery after embolization; the risk of surgery after embolization was greater in large lesions. When the embolization technique was adequate, histological study confirmed global necrosis of the tumors, although this was not accompanied by clinical improvement.

Embolización terapéutica de leiomiomas uterinos; casos que requirieron cirugía / Therapeutic embolization of uterine leiomyomas: cases requiring surgery

Objetivo. Análisis retrospectivo clínico, radiológico y patológico de pacientes con leiomiomas uterinos (LU) que requirieron intervención quirúrgica tras el tratamiento con embolización. Material y métodos. Desde julio de 1999 hasta enero de 2006 se embolizaron 182 pacientes con LU. Del total de ellas, 8 precisaron intervención quirúrgica con extirpación del tumor. Revisamos retrospectivamente, en estas 8 pacientes, datos clínicos, hallazgos de pruebas por imagen, técnica de embolización y causas de la cirugía, hallazgos histológicos en las piezas extirpadas, identificación y localización del material embolizante (ME), presencia y tipo de necrosis en los LU y patología asociada en órganos adyacentes. Resultados. Las 8 pacientes intervenidas representan un 4,3% del total de pacientes embolizadas. La causa fue por fallo técnico en dos (1,02%), complicaciones en tres (1,64%) y fallo en el tratamiento en otras tres (1,64%). La media de los diámetros máximos de los LU fue de 9,8 cm (rango: 4-17 cm). El volumen medio de los LU fue de 491,88 ml (rango: 30-1,365 ml). La edad media de las pacientes fue de 37,7 años (rango: 28-48 años). Histológicamente se evidenció necrosis global en 6 de los LU, siendo de tipo hialino en 3 e inflamatorio en los otros 3. El ME se detectó en el LU (un caso), en el miometrio uterino (dos casos) y en un ovario (un caso). Conclusión. Los casos de LU que requieren cirugía posembolización son inferiores al 5%, existiendo mayor riesgo en los de gran tamaño. Cuando la técnica de embolización fue adecuada, el estudio histológico confirmó la necrosis global de los tumores, aunque este hecho no se acompañó de mejoría clínica (AU)

Objective. To retrospectively analyze the clinical, radiolgical, and histological findings in patients with uterine leiomyomas (LU) that required surgical intervention after embolization. Material and methods. Between July 1999 and January 2006, we embolized 182 patients with LU. Eight of these patients subsequently required surgical resection of the tumor. We reviewed clinical data, imaging findings, embolization technique, and reasons for surgery, histological findings in the resected specimens, identification and location of the embolizing material, presence and type of necrosis in the LU, and associated pathology in adjacent organs. Results. The 8 patients that required surgery represented 4.3% of all patients embolized for LU. Surgery was necessary due to technical failure in two patients (1.02%), complications in three (1.64%) and failed treatment in the remaining three 3 (1.64%). The mean maximum diameter of the LU was 9.8 cm (range: 4-17 cm). The mean volume of the LU was 491.88 ml (range: 30-1.365 ml) The mean age of the patients was 37.7 years (range: 28-48 years). Global necrosis was evident in 6 LU; necrosis was hyaline type in 3 and inflammatory in the remaining 3. The embolizing material was detected in the LU in one case, in the uterine myometrium in two cases, and in the ovary in one. Conclusion. Less than 5% of cases of LU required surgery after embolization; the risk of surgery after embolization was greater in large lesions. When the embolization technique was adequate, histological study confirmed global necrosis of the tumors, although this was not accompanied by clinical improvement (AU)

[Histological study of the effect of pre-transplant chemoembolization of hepatocellular carcinoma]. / Estudio histopatológico del efecto de la quimioembolización pretrasplante en el hepatocarcinoma.

OBJECTIVE: To retrospectively evaluate the degree of necrosis brought about by chemoembolization of hepatocellular carcinoma by correlating the histological study of livers explanted in liver transplantations with morphological (number, size, histological type, encapsulation, and vascular invasion) and technical (angiographic patterns, number of sessions, and level of chemoembolization) factors of the tumors. MATERIAL AND METHODS: Seventeen cirrhotic patients that underwent chemoembolization of hepatocellular carcinoma prior to liver transplantation were studied. Chemoembolization consisted of introducing adriamycin, lipiodol, and particles of polyvinyl alcohol into the hepatic artery. The explanted livers were studied macroscopically and microscopically, evaluating the degree of necrosis achieved in each of the nodules found. RESULTS: A total of 32 nodules (26 hepatocellular carcinomas and 7 type II dysplastic nodules) were detected in 16 patients; the remaining patient had multiple hepatocellular carcinomas. The mean size of the hepatocellular carcinomas was 3.2 cms (range 0.4-7.5) and the mean size of the dysplastic nodules was 1.2 cm (range 1-1.7). Greater than 90% necrosis was achieved in 17 (68%) of the 25 hepatocellular carcinomas; 6 of these lesions were encapsulated and none had vascular infiltration. In the patient with multiple hepatocellular carcinomas (all were hypervascularized and had no capsule), the degree of necrosis achieved was < 30% in each lesion. In three patients with nodular vascular infiltration, multiple nodules were present; the necrosis achieved in these lesions ranged from 0%-70%, and extrahepatic metastases after transplantation. Eighteen of the hepatocellular carcinomas had a hypervascularized angiographic pattern and seven were hypovascular or avascular. In the seven type II dysplastic nodules (none of which was encapsulated), no necrosis was achieved. These nodules were found in three patients; all but one were avascular and coincided with simultaneous hepatocellular carcinomas in two patients. CONCLUSION: The greatest degree of necrosis was achieved in single, encapsulated, hypervascularized hepatocellular carcinomas without vascular infiltration. Chemoembolization fails to achieve necrosis in dysplastic nodules.

[Practical aspects in the percutaneous extraction of foreign bodies using a Goose-Neck Snare]. / Aspectos prácticos de la extracción percutánea de cuerpos extraños con lazo recuperador.

OBJECTIVE: To present our clinical experience in the extraction of different foreign bodies (from vascular or other sites) using a goose-neck snare in 13 patients, with emphasis on practical and technical aspects used during the procedures. MATERIAL AND METHODS: A total of 13 foreign bodies, including 9 intravascular objects and 4 in other locations, were included. The intravascular foreign bodies were stents (n = 2), coils (n = 2), fragments of broken central venous catheters (n = 3), and fragments of broken balloon catheters (n = 2). The nonvascular foreign bodies were fragments of broken double-J catheters (n = 2), one double-J catheter located entirely within the calyces of the kidney, and a fragment of a broken metallic guide wire in an intrahepatic bile duct. Goose-Neck Snares of different diameters (depending on the location) were used to extract the foreign bodies. Forceps were used as an auxiliary device in one patient with a fragment of double-J catheter, and in another case with a catheter fragment in a pulmonary vein, a pigtail catheter was also used to move the fragment and facilitate its extraction with the Goose-Neck Snare. RESULTS: All of the foreign bodies were successfully extracted except a transjugular intrahepatic portosystemic shunt that migrated to the right heart cavities and was correctly repositioned in the right brachiocephalic venous trunk. No complications of any kind were seen during the procedures. CONCLUSIONS: The Goose-Neck Snare is very useful, safe, and versatile for the extraction of different types of foreign bodies in different territories. Especially in vascular territories, it is necessary to have ample knowledge about and experience in the different techniques used for catheterization.

[Self-expanding metallic endoprostheses in the palliative treatment of biliary obstructions in nonresectable carcinoma of the head of the pancreas]. / Endoprótesis metálicas autoexpansivas en el tratamiento paliativo de la ictericia obstructiva en el carcinoma de cabeza de páncreas irresecable.

OBJECTIVE: A study of immediate and long-term results with the self-expandable metallic stent (Wallstent), in the treatment of biliary obstruction in 25 patients with non resectable carcinoma of the head of the pancreas was carried out. Stent placement was successful in all patients. RESULTS: Complication rate was 4% (n = 1); one patient had venous bleeding after percutaneous catheter placement. There was no procedure related mortality (30-day mortality); hospital stay was 6, 7 days (2-12). Average survival was 6 months (+/- 2.97). Average patency of the initial stent lasted 5 months (+/- 2.01); comfort index was 83%. Five patients required re-admission. Late complications were cholangitis in 2 and stent occlusion in 4. Disimpaction in one patient and placement of additional stent (PAL-MAZ) in the remaining 3 patients were performed. One patient required surgical treatment; hepaticojejunostomy was performed. Elapse time between prostheses placement and stent occlusion was 3.4 months (2-4.5). CONCLUSIONS: We conclude that metallic stent placement has low morbidity without mortality and provide good quality of live. The most frequent late complication was prostheses obstruction.

The relationship between the perception of alcohol and drug harmfulness and alcohol consumption by university students.

University students find themselves at a stage when many attitudes and habits undergo change and consolidation, and it is during this period when patterns of consumption of toxic substances are partially or definitively established. A group of 955 university students (328 medical students, 347 students of veterinary medicine, and 280 law students) were studied. Sex and religion played a decisive role in determining the relation between the use of toxic substances and the subjects' attitude toward consumption in our sample. Also, the three campuses were found to differ significantly with regard to students' assessment of harmfulness and patterns of consumption.